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Monthly   Cyclopedia 

AND 

Medical  Bulletin 


(Published  thk  Last  of  Each  Month) 


Monthly  Cyclopaedia  Section 


Vol.  II.  PHILADELPHIA,  JANUARY,  1909.  No.  1. 


Original  Articles 


Department  in  charge  of  J.  MADISON  TAYLOR,  A.M.,  M.D. 


PRACTICAL  SUGGESTIONS  IN  THE  ADMINISTRATION  OF  TUBERCUUN, 

TOGETHER  WITH  A  DISCUSSION  OF  THEORY  UPON 

WHICH  ITS  ACTION  IS  BASED.' 

By  F.  M.  POTTENGER,  A.M.,  M.D. 

MONROVIA,    CALIFOBNIA. 

The  term  tuberculin,  as  it  was  originally  applied,  meant  the  culture  fluid 
upon  which  tubercle  bacilli  had  been  artificially  grown,  concentrated  by  heat 
to  one-tenth  of  its  original  quantity  after  the  bacilli  had  been  removed  by 
careful  filtration.  This  was  Koch's  lymph.  It  was  given  to  the  world  in 
1890,  and  almost  lost  to  the  world  at  the  same  time.  Except  by  a  few,  who 
saw  its  virtues  in  spite  of  its  reckless  employment,  it  was  cast  aside  as  one  of 
the  greatest  therapeutic  failures  of  the  age;  and  the  name  of  Robert  Koch 
who,  because  of  his  great  contributions  to  modem  science  can  claim  the  dis- 
tinction of  being  the  world's  greatest  physician  and  humanity's  greatest  bene- 
factor,2  was  for  the  time  coupled  with  failure  and  dishonor.  Koch  had  not 
failed;    but  the  medical  profession  had   failed   to  grasp   the  nature  of  his 


1  Read  by  invitation  before  the  Homoeopathic  Medical  Society  of  the  County  of 
Kew  York,  New  York  Academy  of  Medicine,  October  8,  1908. 

2  The  editors  cannot  sustain  the  claim  of  their  distinguished  contributor  that  Koch 
occupies  so  exalted  a  position  in  the  Annals  of  Medicine.  Had  Pasteur  never  existed, 
Koch,  Lister  and  many  other  modern  celebrities  would  never  have  become  such.  Koch 
is  a  brilliant  bacteriologist  and  a  great  benefactor  in  the  field  of  tuberculosis,  but 
Pasteur  is  by  far  "humanity's  greatest  benefactor." — Ed. 

(1) 
3 


2  SUGGESTIONS  IN  THE  USE  OF  TUBERCULIN. 

remedy  and  failed  to  follow  his  instructions,  and,  as  a  result,  misiortune 
followed. 

A  few  cautious  workers  continued  the  employment  of  the  remedy  in  spite 
of  its  apparent  failure,  and,  after  a  few  years,  were  able  to  report  to  the  world 
that  tuberculin  is  of  value,  and  to-day  it  is  all  but  universally  recognized  by 
those  who  are  treating  tuberculosis. 

Aside  from  the  original  tuberculin  there  have  been  many  other  prepara- 
tions made;  Koch  himself  has  given  us  two:  T.  E.,  which  contains  those 
toxins  of  the  tubercle  bacillus  which  are  not  readily  soluble  in  distilled  water, 
and  T.  E.,  which  is  an  emulsion  of  dead  tubercle  bacilli. 

The  watery  extract  of  tubercle  bacilli,  von  Euck,  is  made  by  pulverizing 
the  bodies  of  the  bacilli  in  an  agate  mortar  and  extracting  them  with  distilled 
water  after  the  fats  have  first  been  removed  by  extraction  with  alcohol  and 
ether. 

Denys'  tuberculin  is  the  filtered  broth  upon  which  the  bacilli  have  been 
grown,  and  difi;ers  from  Koch's  old  tuberculin  in  that  it  has  not  been  subjected 
to  heat. 

Beraneck's  tuberculin  contains  both  the  soluble  toxins  which  will  yield 
readily  to  distilled  water,  and  the  insoluble  ones  v/hich  he  extracts  by  means 
of  orthophosphoric  acid. 

C.  Spengler  has  also  produced  several  preparations  which  are  made  from 
both  the  bovine  and  human  type  of  bacillus. 

The  term  tuberculin  has  now  come  to  mean  any  preparation  made  from 
the  culture  fluid  on  which  tubercle  bacilli  grow  or  any  preparation  made  from 
the  bacilli  themselves.  Unless  this  is  understood  much  confusion  will  arise, 
for  the  preparations  vary  a  great  deal  in  their  dosage,  and  somewhat  in  their 
action.  All  are  of  value  in  the  treatment  of  tuberculosis,  although  different 
clinicians  have  their  own  special  preferences,  sometimes  depending  on  their 
conception  of  the  action  of  the  difiierent  preparations,  and  sometimes  depend- 
ing on  the  fact  that  they  know  one  better  than  the  others.  Tuberculin  is  very 
often  erroneously  spoken  of  as  a  serum.  Serums  are  those  products  which 
are  made  from  the  serum  of  animals  which  have  been  subjected  to  doses  of 
some  of  the  products  of  the  tubercle  bacillus,  and  so  far  have  not  found  a  very 
extensive  use  in  the  treatment  of  tuberculosis.  There  should  be  no  confusion 
between  tuberculin  and  serums.     They  are  entirely  different  products. 

The  question  arises,  what  claim  has  tuberculin  to  therapeutic  considera- 
tion? To  answer  this  question,  we  must  discuss  the  nature  of  cure  in  tuber- 
culosis. 

Tuberculosis  is  an  infectious  disease,  and  like  all  infectious  diseases,  its 
cure  consists  in  establishing  immunity  on  the  part  of  the  afllicted  organism 
to  the  infecting  germ  and  its  toxins.  This  is  what  always  occurs  if  a  cure 
results. 

The  meaning  of  cure  can  best  be  studied  by  recalling  the  phenomena 
which  take  place  at  the  time  of  infection.  The  animal  organism  is  naturally 
endowed  with  resistance  or  protective  substances  which  ward  off  infections  by 
various  micro-organisms.     If  we  consider  tuberculosis,  the  following  is  what 


SUGGESTIONS  IN  THE  USE  OF  TUBERCULIN.  3 

happens  when  bacilli  gain  entrance  into  the  tissues.  If  they  are  few  in  num- 
ber they  are  acted  upon  by  the  protective  substances  of  the  blood  and  destroyed. 
It  is  very  important  to  know,  however,  that  when  these  protective  substances 
act  upon  the  bacilli,  they  themselves  are  used  up,  and  for  the  time  the  organism 
is  left  with  its  defensive  forces  weakened.  But  this  does  not  last  long  if  the 
cells  of  the  organism  are  able  to  react,  for  the  bacilli  undergo  destruction, 
liberate  their  toxins,  which  are  nothing  more  than  tuberculias,  and  these  stim- 
ulate the  body  cells  to  the  production  of  more  protective  substances;  thus  the 
defensive  forces  of  the  body  are  again  renewed  ready  for  the  next  attack. 

Now  let  us  go  a  step  further  and  suppose  that  the  number  of  the  infect- 
ing micro-organisms  or  their  virulence  is  such  that,  for  the  time  being,  the 
protective  forces  of  the  body  are  overcome  and  an  infection  results.  Whether 
or  not  it  will  heal  and  a  cure  be  brought  about,  or  whether  it  will  spread, 
depends  on  whether  the  organism  will  produce  sufficient  protective  bodies  to 
destroy  the  bacilli  contained  in  the  focus  of  disease  and  those  which  attempt 
to  invade  new  tissues. 

Thus  it  can  be  seen  that  there  are  two  factors  in  cure,  the  cells  and  the 
stimulating  toxin.  If  the  cells  should  fail  to  respond  in  the  production  of 
protective  substances,  no  matter  how  much  toxin  is  present,  the  infection 
would  not  heal;  and  if  the  toxin  is  wanting,  we  must  conceive  of  the  cells 
lacking  the  stimulus  necessary  for  their  excitation. 

In  treating  tuberculosis,  then,  the  indications  are  for  first  keeping  the 
body  cells  in  such  a  state  of  health  that  they  will  respond  to  stimulation  when 
the  proper  toxins  are  thrown  into  the  tissues;  second,  if  for  any  reason  the 
toxin  from  the  focus  of  infection  fails  to  cause  the  necessary  stimulation,  it 
must  be  supplied  artificially.  The  latter  we  are  attempting  to  do  when  we 
use  tuberculin  therapeutically. 

But  the  question  must  still  be  answered,  why  is  there  not  sufficient  tubercle 
toxins  always  present  to  stimulate  the  cells? 

The  answer  must  lead  us,  in  part,  into  theorizing.  In  a  latent  focus  we 
can  understand  how  the  toxin  would  fail  to  be  thrown  out,  but  in  active  foci 
where  toxins  are  being  continuously  elaborated,  we  must  assume  that  large 
quantities  are  being  brought  into  contact  with  the  body  cells  more  or  less  con- 
stantly. In  such  cases,  however,  we  know  that  the  artificial  injection  of  tuber- 
culin will  improve  the  case;  therefore,  we  assume  that  the  effect  of  the  toxin 
is  spent  on  the  cells  at  the  seat  of  the  infection,  and  that  they  are  so  injured 
that  they  fail  to  respond,  and  that  when  the  toxin  is  artificially  introduced  into 
the  tissues  at  a  distance  from  the  focus  of  disease,  the  local  cells  around  the 
site  of  injection  produce  the  protective  substances. 

Based  upon  this  somewhat  technical  but  necessary  discussion,  we  have  a 
foundation  not  only  for  tuberculin  therapy,  but  we  have  an  explanation  of  the 
principles  which  underlie  all  therapy  in  tuberculosis.  We  can  see  that  the 
scientific  treatment  of  tuberculosis  consists  in  both  building  up  and  strength- 
ening the  body  cells  by  bringing  the  afflicted  individual  to  the  highest  state  of 
physical  strength  consistent  with  his  condition,  to  which  end  such  well- 
recognized  measures  as  open  air,  good  food,  hydrotherapy,  rest,  change  of 


4  SUGGESTIONS  IN  THE  USE  OF  TUBERCULIN, 

environment,  climatic  change  and  suitable  tonics  have  been  directed;  and 
artificially  supplying  the  toxin  necessary  for  the  stimulation  of  the  cells,  so 
that  they  will  respond  in  the  production  of  the  specific  protective  substances 
which  are  necessary  to  the  cure,  to  which  end  tuberculin  is  successfully 
employed. 

It  seems  folly,  then,  to  speak  of  the  tuberculin  treatment,  or  the  open 
air,  or  dietetic,  or  hydrotherapeutic  treatment  of  tuberculosis,  because  no 
treatment  is  complete  without  both  factors.  The  tuberculin  may  not  be 
administered  artificially,  reliance  may  be  placed  in  the  supply  furnished  by 
the  focus  of  infection;  but  tuberculin,  furnished  somehow,  is  an  important, 
if  not  absolutely  necessary,  factor  in  the  cure.  On  the  other  hand,  patients 
may  get  well  without  any  tonic  measures  being  applied,  yet  we  all  recognize 
how  much  better  the  chances  are  when  such  measures  are  applied. 

Those  who  would  treat  so  complex  a  disease  as  tuberculosis  should  not 
become  faddists.  They  need  the  constant  presence  of  a  good  balancing  wheel. 
They  should  learn  first  what  they  are  attempting  to  do,  then  keep  that  con- 
stantly in  mind.  If  they  do  this,  they  will  not  go  far  wrong.  They  will  not 
use  one  measure  to  the  exclusion  of  others,  but  they  will  see  that  the  most 
successful  results  can  be  obtained  only  by  a  careful  combination  of  various 
measures,  and  especially  of  tuberculin  combined  with  general  tonic  measures. 
The  next  practical  question  to  be  answered  is,  how  sliall  tuberculin  be 
administered?  I  would  first  call  attention  to  the  fact  that  tuberculosis  heals 
slowly;  even  what  appears  on  physical  examination  to  be  a  very  slight  lesion 
requires  from  four  to  six  months  to  heal.  Therefore,  if  one  will  judge 
whether  or  not  tuberculin  is  helping  his  patient,  he  must  be  able  to  examine 
the  chest  with  a  fair  degree  of  skill,  and  to  recognize  slight  changes  that  occur. 
I  deem  a  careful  charting  of  the  chest  once  a  month,  with  a  comparison  of 
findings  as  necessary  in  tuberculin  treatment.  If  one  is  not  able  to  examine 
with  such  skill,  he  will  have  to  depend  on  the  general  condition  of  the  patient 
to  guide  him  in  his  therapy.  I  will  say,  however,  that  this  is  unsatisfactory 
and  liable  to  lead  to  error. 

Whoever  would  employ  tuberculin  should  be  thoroughly  conversant  with 
its  action.  He  should  know  the  symptoms  which  it  will  produce  when  admin- 
istered in  various  doses.  He  should  also  know  that  the  symptoms  produced 
by  a  dose  of  tuberculin  are  almost  identical  with  tliose  produced  by  activity 
in  a  tuberculous  focus;  therefore,  in  treating  cases  which  are  at  all  active, 
careful  discrimination  is  often  necessary  in  order  to  determine  whether  the 
symptoms  produced  are  those  of  a  tuberculin  reaction  due  to  the  dose  adminis- 
tered therapeutically,  or  whether  they  are  due  to  the  activity  of  the  disease 
process.  One  must  remember  that  tuberculosis  runs  an  uneven  course,  now 
quiescent  for  a  time  without  symptoms  and  with  steady  temperature,  and  then 
active  with  s}Tnptoms  and  variable  temperature.  If  such  a  patient  is  receiving 
therapeutic  doses  of  tuberculin  all  such  symptoms  must  not  be  attributed  to 
the  remedy.  On  the  other  hand,  if  produced  by  it,  the  fact  must  be  recognized 
and  the  dosage  modified  or  withheld,  so  that  no  harm  will  be  done. 

Eecognizing  this  character  of  active  tuberculosis,  those  who  are  beginning 


SUGGESTIONS  IN  THE  USE  OF  TUBERCULIN.  5 

the  use  of  tuberculin  should  avoid  such  cases,  and  treat  only  early  cases  which 
are  showing  no  active  signs.  Not  until  thoroughly  conversant  with  the  remedy 
should  the  treatment  of  the  more  advanced  cases  be  undertaken.  I  am  not  an 
advocate  of  the  idea  that  tuberculin  is  applicable  only  in  incipient  or  early 
inactive  tuberculosis,  but  I  am  thoroughly  convinced  that  it  is  relatively  of 
much  greater  value  to  the  patient  in  more  advanced  cases  where  ordinary 
hygienic  measures  so  often  fail;  but  I  feel  that  I  cannot  impress  too  strongly 
the  advisability,  I  might  say  the  absolute  necessity,  of  those  who  are  beginning 
the  use  of  the  remedy  confining  their  efforts  to  early  non-active  cases. 

"Wlien  it  has  been  determined  to  treat  a  given  patient  with  tuberculin,  the 
first  thing  the  physician  should  do  is  to  make  a  thorough  examination,  record- 
ing his  findings  carefully,  as  mentioned  above.  He  should  then  keep  the 
patient  under  observation  for  a  period  of  three  or  four  days,  and  have  him 
keep  a  two-hourly  chart  of  his  temperature  and  pulse.  The  amoimt  of  cough, 
sputum,  the  condition  of  the  patient's  appetite,  and  his  weight  should  also  be 
noted. 

This  preliminary  period  of  observation  is  very  important,  for  it  enables 
the  physician  to  become  acquainted  with  the  patient  and  his  disease,  and  fur- 
nishes a  period  without  treatment  which  can  be  compared  with  that  after 
treatment  has  begun. 

As  to  the  particular  preparation  to  be  employed,  I  shall  only  say  that  all 
are  of  value,  and  leave  the  choice  to  the  physician. 

It  is  impossible  to  suggest  the  beginning  dose,  because  it  varies  with  the 
preparation  and  the  condition  of  the  patient.  No  amount  can  be  established 
as  an  initial  dose  to  be  used  in  all  cases,  nor  can  any  given  scheme  of  increase 
or  spacing  of  doses  be  given.  In  the  administration  of  tuberculin,  above  all 
other  remedies,  we  must  individualize.  The  dosage  is  given  entirely  according 
to  the  patient.  It  is  important  to  make  the  initial  dose  so  small  that  there  is 
no  likelihood  of  a  reaction  occurring;  for  example,  if  we  were  going  to  treat 
an  early  non-active  case  with  Koch's  old  tuberculin  we  could  give  as  the  first 
dose  %o  of  a  milligram,  or,  if  we  chose  to  use  T.  E.,  we  could  begin  with  %ooo 
or  M.0000  of  a  milligram  of  the  solid  substances,  which  would  be  (remembering 
the  product  as  sold  to  the  trade  represents  one  per  cent,  of  solid  extract  of 
tubercle  bacilli)  34o  or  %oo  of  a  milligram  of  the  original  solution. 

The  increase  of  dosage  after  the  initial  injection  has  been  given  is  impor- 
tant. Experience  seems  to  show  that  very  small  doses  with  too  long  intervals 
between  them  is  a  factor  in  producing  a  hypersensitiveness  on  the  part  of  the 
patient;  therefore,  it  seems  best  to  give  the  small  dose,  and  if  there  is  no 
indication  of  reaction,  to  increase  the  amount  at  each  succeeding  dose  until  the 
point  of  reaction  is  found. 

Two  days  is  a  very  common  interval  between  the  smaller  doses ;  this  to  be 
lengthened  to  three,  four,  or  a  week,  and  even  a  month  as  the  doses  become 
larger.  The  amount  can  be  increased  according  to  the  patient,  the  preparation 
and  the  initial  dose  from  %o  to  twice  or  even  ten  times  the  previous  dose. 
This  is  a  common  scheme  for  old  tuberculin:  Initial  dose  Yio  milligram,  then 
following  with  two-day  intervals  as  near  as  allowable  with  one  milligram,  two 


6  SUGGESTIONS  IN  THE  USE  OF  TUBERCULIN. 

milligrams,  three  milligrams,  four  milligrams,  five  milligrams,  etc.,  providing 
no  s}Tnptoms  of  reaction  occur. 

I  have  cautioned  against  a  reaction.  A  tuberculin  reaction  is  that  group 
of  s}Tiiptoms  which  is  produced  by  the  toxins  made  from  the  tubercle  bacillus 
when  acting  upon  the  organism.  These  symptoms  vary  according  to  the 
amount  of  tuberculin  employed  and  the  tolerance  of  the  individual. 

The  therapeutic  effect  of  tuberculin  is  obtained  short  of  any  unpleasant 
subjective  or  objective  signs  or  symptoms.  It  consists  in  a  stimulation  of  the 
physiological  process  of  immunity.  The  body  cells  are  confronted  by  a  toxin, 
and  if  the  dose  be  suitable  they  respond  by  the  production  of  immunizing 
bodies;  and,  according  to  nature's  law,  not  only  do  they  produce  sufficient  to 
overcome  the  injected  toxin  (tuberculin),  but  they  produce  an  excess  which 
goes  to  protect  the  organism  against  the  toxins  produced  in  the  focus  of  dis- 
ease. This  is  the  aim  of  therapy,  and  it  is  accomplished  short  of  toxic  symp- 
toms. The  patient  often  notes  a  feeling  of  well-being  and  an  improvement  in 
his  general  condition  coincident  with  the  proper  administration  of  tuberculin. 

If  the  dose  be  in  excess  of  the  amount  necessary  for  the  proper  stimula- 
tion of  the  body  cells,  toxic  symptoms  manifest  themselves,  and  we  have  what 
is  known  as  a  tuberculin  reaction.  This  manifests  itself  in  several  ways,  and 
appears,  as  a  rule,  from  four  to  twenty-four  hours  after  the  injection;  first, 
there  may  be  a  slight  infiltration  at  the  point  of  injection;  second,  there  may 
be  certain  subjective  symptoms,  varying  with  the  dosage,  such  as  slight  nerv- 
ousness or  languor,  if  the  toxic  effect  is  slight,  and  aching  of  the  head,  back 
and  limbs  if  it  is  greater,  and  even  nausea,  vomiting  and  severe  prostration 
when  pronounced;  third,  there  is  a  local  hyperaemia  or  congestion  caused  at 
the  seat  of  the  tuberculous  infection  which  may  be  seen  when  the  lesion  is 
visible,  as  in  the  larynx,  or  may  be  detected  by  careful  auscultation  by  an 
expert  examiner  when  the  lesion  is  in  the  lungs ;  fourth,  a  rise  of  temperature 
which  may  show  as  a  rise  of  a  few  tenths  of  a  degree  with  only  slight  or  no 
subjective  symptoms,  or  it  may  rise  to  102  or  even  higher,  and  may  be  accom- 
panied by  severe  constitutional  symptoms.  Such  temperature  reactions  are 
rarely  obtained  at  the  hands  of  those  who  are  conversant  with  the  use  of  tuber- 
culin, and  should  be  aroided. 

The  symptoms  of  a  reaction  will  usually  disappear  in  from  twenty-four  to 
seventy-two  hours,  although  occasionally  a  reaction  will  last  for  several  days. 

No  further  dosage  should  be  administered  as  long  as  signs  of  a  reaction 
are  present.  And  it  is  wise  to  wait  until  two  or  three  days  have  elapsed  after 
all  signs  of  reaction  have  passed  away  before  administering  another  dose.  It 
is  not  wise  to  increase  the  dosage  after  a  reaction  until  the  dose  which  caused 
it  fails  to  produce  signs  of  reaction,  and  it  is  often  best  to  reduce  the  first 
dose  after  a  reaction. 

Tuberculin  should  be  administered  hypodermically.  The  site  of  the  injec- 
tion should  be  cleansed  by  careful  washing,  either  with  alcohol  or  ether,  and 
the  syringe  and  needle  should  be  handled  with  the  usual  antiseptic  precautions. 

The  injections  should  be  made  preferably  subcutaneously  and  not  deep 
into  the  tissue.     This  affords  opportunity  for  watching  the  local  reaction  at 


NEUROSES  CURED  BY  TREATMENT  OF  NASAL  AFFECTIONS.      7 

the  point  of  injection.  I  prefer  the  extensor  surface  of  the  forearm  because 
of  its  convenience,  although  the  region  of  the  triceps,  the  loins  or  the  back 
may  be  used. 

Tuberculiu  must  not  be  looked  upon  as  a  sure  cure  for  tuberculosis, 
neither  must  it  be  expected  to  remove  the  dead  and  dying  tissue  which 
is  always  present  in  advanced  cases.  It  is,  however,  nature's  own  remedy  for 
tuberculosis.  It  is  what  she  uses  to  stimulate  the  defense  of  the  organism.  If 
we  use  it  intelligently  we  can  supplement  nature  and  greatly  fortify  her  in  her 
struggle  against  the  tubercle  bacillus;  but  with  it  we  must  employ  measures 
directed  toward  building  up  and  strengthening  the  patient. 


SOME  REFLEX  NEUROSES  CURED  BY  TREATMENT  OF  CO-EXISTENT 

NASAL  AFFECTIONS. 

By  MARGARET  F.  BUTLER,  M.D., 

Clinical  Professor  of  Rhinology  and  Laryngology,  Woman's  Medical  College  of  Penn- 
sylvania;   Laryngologist  to  the  Woman's  Hospital  of  Philadelphia. 

The  following  cases  are  reported,  not  because  they  are  unique  nor  of 
unusual  interest,  but,  for  the  reason,  that  all  had  undergone  long  courses  of 
treatment  without  the  nasal  origin  of  the  disease  having  been  suspected.  To 
the  rhinologist  such  cases  are  of  frequent  occurrence,  but  there  must  be  a  few 
practitioners  who  slight  the  nose  and  throat  as  factors  in  the  physiological 
economy.  I  have  an  acquaintance,  a  woman  of  about  fifty-five  years,  who  has 
been  an  invalid  all  her  life  on  account  of  asthma,  and  she  is  a  marked  victim 
of  aprosexia.  She  has  been  under  the  constant  care  of  a  physician  of 
the  highest  standing  in  his  school.  She  has  never  breathed  through  her  nose, 
she  does  not  know  that  she  should  breathe  through  it,  and  her  speech  indicates 
that  there  is  partial  or  complete  nasal  obstruction.  Notwithstanding  all  these 
signs,  a  nasal  examination  has  never  been  suggested. 

I  have  in  mind  a  case  of  facial  chorea  in  a  child  eight  years  old,  in  which 
at  least  two  physicians  have  recommended  that  she  be  "saved  from  jars,"  with 
the  hope  that  she  would  grow  out  of  the  habit.  The  faucial  tonsils  almost 
meet  in  the  middle  line,  yet  this  throat  condition  has  been  given  no  considera- 
tion as  an  etiological  factor  in  the  disease. 

Doubtless  there  has  been  considerable  reaction  from  the  enthusiasm  of  the 
time  to  which  Michael  refers  in  his  lines  written  in  1890, 

"Dann  wird  die  Nase  ausegebrannt, 
Denn  das  hilft  immer  wie  bekannt," 

yet  it  is  possible  to  give  too  much  importance  to  the  theory  of  lowered  nerve 
resistance  and  a  neurotic  habit  of  the  patient  in  symptoms  which  have  become 
so-called  "constitutional."  I  have  not  found  the  victims  of  these  reflex  symp- 
toms of  an  especially  nervous  type,  but  most  of  them  were  exhausted  from  the 
long-continued  suffering. 


8      NEUROSES  CURED  BY  TREATMENT  OF  NASAL  AFFECTIONS. 

Unless  it  be  iu  the  eye,  there  is  probably  no  other  mucous  membrane  in 
the  body  in  which  the  reflex  tendency  is  more  conspicuous  than  in  the  nose. 
It  is  only  necessary  to  touch  certain  hyperssthetic  areas  very  lightly  to  elicit 
such  reflex  phenomena  as  sneezing,  coughing,  lachrymation,  pain  in  the  ear,  etc. 
Momentary  cessation  of  respiration  and  of  the  heart's  action  may  be  caused  by 
irritation  of  the  nasal  fossae.  A  few  of  the  reflex  neuroses  of  nasal  origin 
given  by  various  authors  are  lachrymation,  discomfort  in  the  eyes,  glaucoma, 
hay  fever,  enuresis,  chorea,  headache,  trigeminal  neuralgia,  spasm  of  the  fauces 
and  Iar}Tigismus  stridulus. 

The  book  by  Dr.  A.  Kuttner,  of  Berlin,  entitled  "Die  nasalen  Eeflexneu- 
rosen  und  die  nonnalen  Nasenreflexe,"  is  a  very  comprehensive  contribution 
on  this  subject.    His  catalogue  of  the  literature  is  quite  extensive. 

I  shall  report,  briefly,  a  few  illustrative  cases  that  have  come  to  my 
attention : 

Case  I. — Mrs.  S.  P.,  age  thirty-two  years,  a  resident  of  one  of  our  south- 
ern States,  was  brought  to  my  ofiice  in  the  fall  of  1905,  complaining  of  pain 
in  her  left  ear,  which  had  persisted  with  but  slight  intermission  for  two  years. 
The  ear  ached  constantly,  and  the  pain  increased  on  yawning,  eating  or  sing- 
ing high  notes.  The  trouble  had  originated  in  the  following  manner:  The 
patient  had  been  in  a  hospital  six  weeks  for  an  appendectomy.  Five  days 
after  returning  home  she  was  awakened  in  the  night  by  a  sharp  pain  in  the 
left  ear.  She  was  referred  to  an  ear  specialist  in  her  home  town,  who  treated 
her  for  catarrh  of  the  ear,  but  the  pain  was  not  relieved.  When  I  examined 
her  I  found  the  drumhead  of  the  affected  side  normal  in  appearance,  the  tests 
for  hearing  gave  no  indications  of  middle  nor  inner  ear  disease,  there  was  no 
tenderness  over  the  mastoid,  and  the  teeth  were  in  good  condition.  Examina- 
tion of  the  nose,  however,  showed  the  middle  turbinal  of  the  side  corresponding 
to  the  afl'ected  ear  pressing  against  the  septum,  the  contact  extending  well  back 
toward  the  sphenoid.  There  was  no  indication  of  any  involvement  of  the 
accessory  sinuses.  I  asked  Professor  B.  Alexander  Eandall  to  see  the  case, 
and  he  advised  removal  of  the  intra-nasal  pressure.  The  middle  turbinal  was 
removed  its  entire  length,  and  the  patient  was  relieved  almost  immediately. 

Case  IT. — Mr.  C.  B.,  age  forty-five  years,  came  to  my  office  in  Novem- 
ber, 1906,  complaining  of  sneezing  and  lachrymation.  The  s^^mptoms  were 
limited  to  the  right  side  of  the  nose.  The  history  showed  that  he  had  suffered 
since  about  twelve  years  of  age  with  frequent  headaches,  limited  to  the  right 
supra-orbital  and  temporal  regions.  Several  noted  ophthalmologists  of  London 
had  examined  his  eyes,  but  he  had  received  no  relief.  There  was  a  history  of  a 
gun-shot  wound  near  the  right  eye,  and  it  was  supposed  that  a  grain  of  shot 
might  have  lodged  somewhere  in  the  deep  tissues,  but  no  attempt  had  been  made 
to  discover  it.  Lately  the  snpra-orbital  pain  has  become  so  much  worse  as  to 
be  almost  unendural)le.  On  examining  the  nose  I  found  the  upper  part  of  the 
septum  in  the  right  fossa  flexed  sharply,  pressing  upon  the  middle  turbinal. 
The  frontal  sinus  was  found  free  from  disease.  The  deviated  septum  was 
straightened  by  submucous  resection  of  the  crooked  bone  and  cartilage,  and  the 
attacks  of  headache  and  catarrh  ceased. 


NEUROSES  CURED  BY  TREATMENT  OF  NASAL  AFFECTIONS.      9 

Case  III. — Miss  C,  age  about  twenty-three  years,  had  suffered  for  five 
years  with  an  intense  supra-orbital  neuralgia  on  the  left  side.  In  my  estima- 
tion she  could  not  have  been  considered  of  a  nervous  type.  She  had  taken  a  great 
deal  of  medicine;  indeed,  had  been  under  constant  treatment  for  the  neuralgic 
trouble  with  no  relief.  Finally,  a  choroiditis  developed  on  the  same  side. 
The  ophthalmologist.  Dr.  Mary  Getty,  asked  for  an  examination  of  the  nose. 
The  middle  turbinal  was  found  pressing  against  the  septum.  Operation  gave 
immediate  and  permanent  relief,  both  to  the  eye  and  to  the  neuralgic  s}TQp- 
toms.     Six  years  have  now  elapsed  since  the  operation. 

Lennox  Bro^voie  reports  a  case  of  glaucoma  not  benefited  by  iridectomy, 
but  cured  by  removal  of  a  nasal  polyp. 

Every  nose  and  throat  specialist  has  so  many  cases  of  supra-orbital  head- 
ache relieved  by  intra-nasal  operation  that  it  would  be  tiresome  to  repeat  cases. 

Case  IV. — Miss  H.  H.  came  to  my  clinic  at  the  Woman's  Hospital  in 
January,  1903,  on  account  of  a  nasal  catarrh  which  she  had  had  since  child- 
hood. There  was  crusting  in  the  nose,  odor,  and  general  discomfort.  She 
had  suffered  much  from  asthma  at  the  same  time,  but  she  had  concluded  that 
this  was  incurable.  Her  mother  had  had  it  all  her  life,  and  had  died  of  it, 
and  she  was  quite  resigned  to  do  likewise.  Examination  of  the  nose  showed 
the  right  fossa  occluded  by  a  deviated  septum,  the  left  was  very  roomy  and 
lined  with  crusts.  The  naso-pharynx  and  post-pharyngeal  wall  were  dry  and 
contained  much  thick  secretion.  The  deviated  septum  was  broken  and  retained 
in  the  median  line  by  a  splint  which  had  to  be  worn  for  a  month.  The  opera- 
tion precipitated  such  a  severe  attack  of  asthma  that  I  was  obliged  to  keep  the 
patient  in  the  hospital  for  four  weeks,  and  during  the  spring  months  which 
followed  she  was  astlmiatic.  During  the  summer,  however,  she  quite  recov- 
ered, and  last  week  she  wrote  me  that  she  had  been  well  ever  since,  and  rarely 
has  any  return  of  her  asthmatic  trouble. 

Case  V. — Miss  J.,  age  fifty  years,  came  to  me  in  April,  1906,  on  account 
of  a  nasal  catarrh  which  had  existed  since  childhood.  For  the  last  few  years 
there  had  been  an  abundant  discharge  of  blood  and  pus.  She  had  had  asthma 
since  eight  years  old.  Examination  of  the  nose  showed  both  nares  to  be 
occluded  with  nasal  polyps.  These  were  removed,  and  the  patient  has  only 
had  one  of  her  %ad,  old-fashioned"  asthmatic  attacks  since,  and  that  occurred 
eighteen  months  ago. 

Another  patient,  age  48  years,  has  almost  ceased  to  have  asthmatic  attacks 
since  the  straightening  of  a  deviated  septum  and  the  removal  of  some  small 
pol}TDs  in  October,  1906.  She  has  returned  twice,  complaining  of  wheezing, 
and  both  times  I  have  found  small  polyps  high  up  in  the  nose.  By  pinching 
these  off  or  by  cauterizing  intumescent  tissue  the  attacks  have  been  aborted.  ^ 

Maurice  Schmidt  tells  of  a  patient  who  would  occasionally  return  to  him, 
saying  he  thought  he  must  have  another  polyp  for  he  had  been  feeling 
asthmatic  again.  The  polyp  was  duly  found  and  removed,  and  the  patient  was 
relieved. 


1  Since   reporting   this   case   the   middle   turbinals   have   been   removed   from   both 
sides  with  still  further  relief  of  the  symptoms. 


10  THE  USE  OF  TOBACCO  BY  THE  IMMATURE. 

Hay  fever  is  not  an  incurable  disease.  I  have  a  patient  who  has  prac- 
tically escaped  three  summers.  Last  summer  she  recklessly  went  into  a  field 
of  new  mown  hay  and  precipitated  a  short  attack,  but  aside  from  that  she  has 
had  no  trouble.  She  was  a  mouth-breather  from  habit,  there  being  no  nasal 
obstruction.  Deep  breathing  exercises  developed  the  alte  of  the  nose  and 
inspiratory  muscles.  Aside  from  this  she  had  no  other  treatment  that  I  con- 
sidered of  any  benefit.  Another  patient  was  kept  free  from  attacks  last 
summer  by  cauterizing  the  middle  turbinals  and  the  tubercle  of  the  septum 
with  tri-color  acetic  acid,  according  to  the  method  described  by  Professor 
Killian. 


THE  USE  OF  TOBACCO  BY  THE  IMMATURE. 

Bt  JOHN  B.  HUBER,   A.M.,  M.D., 

NEW    YORK    CITT. 

Professor  of  Pulmonary  Diseases,  the   Fordham  University  Medical   School;     Lecturer, 

the  New  York  State  Department  of  Health;    Visiting  Physician  to  St.  Joseph's 

Hospital  for   Consumptives,   etc. 

Several  years  ago  the  late  Dr.  I.  N.  Love  declared:  "The  numerous 
mental  wrecks,  youths  who  have  come  under  my  care  during  the  last  ten  years, 
whose  lives  were  failures,  or  who  fill  suicides'  graves,  impress  me  that  to-day 
tobacco  stands  as  the  gravest  danger  confronting  the  new  century;  and  the 
medical  profession  has  a  fearful  responsibility  in  educating  young  men  and 
their  parents  to  appreciate  this  danger."^  These  observations,  and  others  of 
a  like  tenor,  have  been  quite  widely  concurred  in;  they  have  stimulated  the 
production  of  no  little  literature  on  the  subject,  some  of  which  has  been  rather 
hysterical  than  scientific;  and  they  have  occasioned  the  activities,  not  always 
perhaps  well-advised,  of  legislatures  and  of  anti-tobacco  leagues,  Neverthe- 
less, the  general  trend  of  this  sentiment  against  the  use  of  tobacco  by  the 
immature  has  certainly  been  sound;  wherefore  it  seems  apropos  to  note  the 
conclusions  arrived  at  by  Dr.  G.  L.  Meylan,  the  Medical  Director  of  Columbia 
University,  in  an  article  on  "Columbia  and  Nicotine,"  which  recently  appeared 
in  the  New  York  Evening  Post.  Meylan  compared  the  students  in  that  insti- 
tution who  smoke  with  the  non-smokers.  He  found  that  among  the  former 
tobacco  does  not  tend  to  stunt  the  growth,  nor  impair  lung  capacity;  that  the 
physical  condition  of  the  smokers — their  weight,  height,  lung  capacity  and 
total  strength — averaged  rather  better  than  in  the  non-smokers.  Among  his 
statistics  we  find  that  his  smokers  averaged  in  age  twenty  years  and  ten 
months;  his  non-smokers  nineteen  years  and  eight  months.  And  his  smokers 
bested  the  others  by  1.17  centimeters  in  height;  1.51  kilograms  in  weight; 
.08  litres  in  lung  capacity,  and  18  kilograms  in  strength. 

Here  one  immediately  scents  a  fallacy;  and  is  quite  receptive  for  the  very 
cogent  criticism  which  the  writer,  "S.  B.  J.,"  submitted  in  the  issue  of  April 


1  Journal  of  the  American  Medical  Association,  March  2,   1901. 


THE  USE  OF  TOBACCO  BY  THE  IMMATURE.  H 

21,  1908,  of  that  same  newspaper:  "How  much  gain  may  the  nineteen-year- 
old  men  ordinarily  be  expected  to  make  during  the  year  and  two  months  that 
must  elapse  before  they  are  as  old  as  the  smokers  with  whom  they  are  com- 
pared ?''  Eecords  of  Professor  Hitchcock,  of  Amherst,  are  cited  which  show 
the  average  gain  in  heighth  of  students  between  nineteen  and  twenty  years  to 
be  .732  inch;  in  weight  2.67  pounds;  in  lung  capacity  5.56  cubic  inches. 
Converting  Meylan's  metric  data  into  English  weights  and  measures,  the  result 
would  show  that  by  the  time  the  non-smokers  are  as  old  as  the  smokers  they 
may  expect  to  be  one-fourth  inch  taller,  to  have  two-thirds  cubic  inch  more 
lung  capacity,  and  to  be  of  about  the  same  weight.  Professor  Seaver's  records 
of  Yale  students  would  give  the  non-smokers  an  advantage  in  height  of  .94 
inch;  in  weight  of  7.69  pounds;  in  chest  capacity  of  14.36  cubic  inches. 
From  these  and  a  number  of  other  considerations,  one  must  conclude  that  Dr. 
Meylan's  presentment  was  unfortunate. 

Among  the  baneful  effects  of  nicotine  (or  the  pyridine  compounds  into 
which  it  is  converted)  are  those  upon  the  nervous  system,  as  evidenced  by 
vertigo,  tremor,  giddiness,  leg  weariness,  pains  in  various  nerve-centres; 
amnesia,  aphasia,  psychic  aberration,  due  to  spinal  or  cerebral  irritation;  and 
especially  such  vaso-motor  paralyses  as  cold  extremities,  pallor,  clammy  hands 
and  excessive  sweating.  Brunton^  has  found  that  at  first  nicotine  powerfully 
increases  the  blood-pressure  and  slows  the  heart;  the  arterioles  are  contracted, 
partly  because  the  vaso-motor  centres  in  the  medulla  are  stimulated,  and  partly 
because  of  the  local  action  upon  the  arterioles  themselves.  This  slowing  is 
presently  followed  by  the  rapid  pulse  in  consequence  of  the  paralysis  of  the 
heart  ganglia.  In  both  frogs  and  mammals  tobacco  produces  first  convulsions 
and  then  paralysis.  The  symptoms  referable  to  the  cardio-vascular  system  are 
palpitation,  irregular  and  rapid  pulse,  precordial  pain,  oftentimes  sharp  and 
severe,  and  very  like  angina.  The  myocardium  may  become  impaired  by  con- 
stant contraction  of  the  coronaries;^  this  and  the  rise  of  blood-pressure  may 
lead  to  arteriosclerosis  ;4  a  true  angina  may  develop,  as  also  a  fatty  heart. 

Digestion  is  often  impaired;  much  saliva  is,  perhaps  subconsciously, 
swallowed  by  smokers  who  do  not  spit,  and  by  chewers  of  tobacco  this  occasions 
nausea,  vomiting,  flatulence  and  gastralgia,  especially  in  the  neophyte.  It  is 
likely  also^  that  the  gastric  secretions  are  thus  diminished,  hyperchlorhydria 
induced,  and  muscular  tone  in  the  digestive  tract  impaired.  "A  peculiar 
susceptibility  to  the  influence  of  tobacco  is  shown  when  a  lesion  arises  in  pre- 
viously healthy  epithelium;  and  this  may  even  induce  a  cancer  at  an  espe- 
cially early  age;^  susceptibility  to  such  a  malignant  growth  may  play  an 
important  part  when  a  chancre,  or  some  sore  caused  by  biting  the  tongue  or 

2 "The  Effect  of  Tobacco  in  Health  and  Disease,"  by  Brunton  and  others:  Tlie 
Practitioner,  July,  1905.  Also  Clark  (L.  P.):  "The  Experimental  Effects  of  Tobacco 
on  the  Nervous  System,"  Medical  Record,  June  29,  1907. 

3Larrahee,  R.  C:  Tobacco  Ref.  Handbk.  Med,  Sc,  Vol,  VII,  p.  791, 

4Huchard:  Maladies  du  Coeur,  Paris,  1889, 

BDalton:  The  Practitioner,  July,  1905. 

8  Spencer :  Ibid. 


12  THE  USE  OF  TOBACCO  BY  THE  IMMATURE. 

cheek,  or  by  the  irritation  of  a  tooth,  is  aggravated  by  tobacco.  Tobacco  may 
affect  the  nose  and  throat,  either  by  irritation  (especially  when  the  stronger 
forms  are  used),  or  indirectly  from  dyspepsia  or  other  constitutional  disturb- 
ances; it  should  not,  however,  be  blamed  entirely  for  the  "relaxed"  or  "gouty" 
throat,  in  the  production  of  which  alcohol  oftentimes  plays  a  part.'''  Tobacco 
may,  moreover,  unfairly  be  held  accountable  for  a  catarrh  dependent  upon  some 
such  well-defined  lesion  as  a  suppuration  in  an  accessory  sinus.  And  yet 
tobacco  will  often  enough  aggravate  such  a  lesion,  as  it  will  also  a  pre-existent 
Inflammation  of  the  whole  respiratory  tract.  Asthma  is  not  rare  among 
smokers;  the  respirations  are  quickened  and  deepened,  so  that  dyspnoea  is  the 
result.  Smoking  in  an  unventilated  room  is  much  more  injurious  than  in  the 
open;  and  non-smokers  might  as  well  indulge  if  they  must  breathe  an  atmos- 
phere laden  with  tobacco  fumes.  When  the  smoke  is  inhaled  much  nicotine 
is  absorbed  by  the  sensitive  pulmonary  surfaces,  and  thus  must  be  explained 
the  prostration  which  so  often  follows  upon  this  practice.  Our  colleagues  who 
work  upon  the  nose  and  throat  have  foimd  that  no  treatment  will  avail  so  long 
as  the  patient  will  persist  in  the  use  of  tobacco.  The  "weed"  produces,  by 
local  irritation,  a  catarrhal  conjunctivitis;  or  the  nicotine,  when  slowly  and 
continually  absorbed  from  the  alimentary  tract,  may  induce  amblyopia,  either 
acute  or  chronic.  The  acute  form  has  resulted  even  from  the  application  of 
tobacco  to  a  hollow  tooth ;  and  in  a  patient  who  took  snuff  during  ten  days 
to  cure  a  cold.  The  chronic  form  occurs  in  heavy  smokers  of  strong  tobacco; 
dyspepsia,  bad  feeding,  poverty,  overwork,  worry  and  insomnia  predispose  by 
lowering  the  nervous  resistance  to  such  toxic  influences.  If  amblyopia  is  to 
be  treated,  tobacco  must,  of  course,  be  entirely  withheld;  the  results  are  better 
in  the  young  than  in  men  over  fifty.  Among  other  evils  ascribed  to  the  misuse 
of  tobacco  is  impotence.  Those  who  work  in  tobacco  suffer  greatly  from 
anaemia,  respiratory  diseases  and  digestive  disturbances.  As  we  are  here  con- 
cerned mainly  with  the  immature  it  seems  relevant  to  consider  the  experiments 
of  Vas^  upon  puppies.  By  means  of  this  substance  he  induced  antemia;  the 
haemoglobin  and  the  red  blood  corpuscles  decreased  over  one-half;  the  solid 
residue  and  the  alkalinity  of  the  blood  decreased  a  little,  whilst  the  leucocytes 
were  decidedly  augmented.  The  use  of  tobacco  has  been  observed  to  induce 
a  diminution  of  the  therapeutic  effects  of  medicines,  and  to  retard  the  healing 
of  wounds.  Unquestionably  tobacco  predisposes  to  pulmonary  tuberculosis, 
and  when  diseases  of  respiration  have  developed  the  tobacco  habit  certainly 
aggravates  them. 

The  most  injurious  form  of  smoking  is  the  cigarette,  largely  because  the 
fumes  are  inhaled,  and  also  because  of  the  temptation  to  smoke  many 
cigarettes;  next  comes  the  pipe;  the  least  injurious  is  the  cigar.  Tobacco 
used  in  chewing  and  snuffing  contains  very  little  nicotine,  wherefore  poisoning 
by  these  means  is  comparatively  rare.  Other  things  being  equal,  the  more 
excessive  the  indulgence,  the  more  the  smoke  is  inhaled,  and  the  younger  the 
patient,  the  more  likely  are  ill  effects  to  be  manifested. 

7  Lack :   Ibid. 

SArehiv.  f.  Exp.  Pathol.,  XXXIII,  141. 


CONGENITAL  UNILATERAL  HYPERTROPHY— REPORT  OF  CASE.  13 

Tobacco  has  its  analogue  among  perhaps  every  people  or  tribe  that  has 
ever  been  visited  by  civilized  man.  It  is  one  of  the  "paratriptics,"  the  sav- 
ings banks  of  the  tissues,  which  seem  to  retard  tissue  waste;  such  also  are  the 
Calabar  bean,  coca,  arsenic,  strychnine,  cinchona,  gentian,  Indian  hemp, 
coffee,  tea,  alcohol.  The  best  reason  for  saying  that  these  things  are  beneficent 
when  judiciously  used  is  that  the  demand  for  them  is  imperative  and  not  to  be 
denied — their  worldwide  prevalence  demonstrates  that.  They  are  used  to 
tide  an  exhausted  or  a  misused  organism  over  physical  crises.  To  the 
beginner  in  their  use  the  most  of  them  are  unpalatable,  or  even  poisonous; 
and  it  is  not  likely  they  would  be  taken  to  any  degree  were  it  not  that  the 
moderate  use  of  them  has,  on  the  whole,  been  found  salutary,  or  at  least 
necessary.  As  a  paratriptic,  tobacco  has  established  itself  immovably  in  the 
regard  of  a  very  large  contingent  of  the  race.  In  the  East  they  say  of  it  that 
to  some  there  can  be  no  greater  blessing;  to  others  no  greater  curse.  I  am 
here,  however,  not  concerned  vsdth  the  adult;  I  but  enounce  the  general  prin- 
ciple that  the  use  of  tobacco  should  be  debarred  the  child,  the  growing  lad  and 
the  youth.  For  them  it  is  unquestionably  deleterious  and  poisonous;  and 
their  bodies,  which  are  fresh  and  rich  in  reserve  forces,  need  no  stimulant, 
this  or  any  other.  One  must  surely  conclude  that  a  substance  which  can, 
when  persisted  in,  so  profoundly  affect  the  youthful  organism  in  the  ways  here 
indicated,  is  likely  to  work  destructive  and  permanent  changes  in  the  tissues. 


CONGENITAL  UNILATERAL  HYPERTROPHY— REPORT  OF  CASE.' 

Bt  C.  H.   MUSCHLITZ,  M.D., 

Demonstrator  of  Orthopoedic  Surgery  in  Jefiferson  Medical  College;  Assistant  Orthopcedic 
Surgeon  to  Jefferson,  Philadelphia,  and  St.  Agnes'  Hospitals. 

The  following  case  is  rather  an  unusual  type  of  congenital  abnormality, 
and  I,  therefore,  have  considered  it  worthy  of  permanent  record. 

The  patient,  S.  E.  M.,  a  male  infant,  age  four  months,  of  American  par- 
entage, was  first  seen  at  the  Orthopcedic  Dispensary  of  the  Jefferson  Hospital, 
November  9,  1907,  and  the  following  history  was  obtained  from  the  family 
physician,  Dr.  L.  C.  "Williams,  of  Lambertville,  N.  J.,  who  referred  the  case. 
The  patient  was  a  first  and  only  child,  born  full  term,  breech  presentation  with 
forceps  delivery  of  the  head.  The  infant  was  breast-fed,  always  healthy,  and 
teething  began  a  short  time  before  the  visit  to  the  dispensary.  The  family 
history  presents  some  evidence  of  tuberculosis  on  the  paternal  side.  The 
motiaer,  before  and  during  her  gravidity,  was  in  excellent  condition,  there 
being  no  history  of  nervous  or  mental  disturbance,  trauma  or  uterine  disorder. 
When  the  child  was  one  and  one-half  months  old  the  mother  noticed  an 
inequality  of  the  legs,  the  left  being  the  larger,  both  equally  active,  but  she 


1  Read  before  Philadelphia  Pediatric  Society,  March  10,   1908. 


14  CONGENITAL  UNILATERAL  HYPERTROPHY— REPORT  OF  CASE. 

thought  the  larger  one  the  stronger.     There  was  no  evidence  of  pain,  tender- 
ness or  restlessness  at  any  time. 

Examination  revealed  a  well-nourished  and  developed  infant  with  a  rather 
square  shaped  head,  which  was  found  to  be  symmetrical.  The  most  noted 
abnormalities  were  the  enlargement  of  the  left  arm  and  left  leg,  the  measure- 
ments of  which  are  as  follows: — 

Measurements    of    Legs.  Left.  Right. 

Circumference  of  thigh  at  groin 23.1     cm.  22.5     cm. 

Circumference  of  thigh  at  middle 23.25  cm.  20.       cm. 

Circumference  of  thigh  above  knee 18.11  cm.  15.5     cm. 

Circumference  of  calf 18.1     cm.  15.5     cm. 

Circumference  of  ankle 13.1     cm.  11.25  cm. 

Circumference  over  dorsum  of  foot 13.5     cm.  11.25  cm. 

Length  of  leg  from  ant.  sup.  spine  to 

int.  mall 47.5     cm.  48.1     cm. 

Measurements   of   Arms.  Left.  Right. 

Circumference  at  biceps 13.5     cm.  12.8     cm. 

Circumference  at  forearm 13.       cm.  12.5     cm. 

Circumference  at  wrist 9.25  cm.  9.       cm. 

Circumference  at  hand 9.25  cm.  9.       cm. 

The  temperature,  sensations  and  reflexes  were  normal  in  both  arms  and 
legs.  The  tissue  seemed  equally  firm  in  all  the  extremities.  There  was  no 
evidence  of  unilateral  facial,  cranial  or  chest  involvement.  The  contour  of 
the  extremities  seemed  undisturbed.  There  was  no  impairment  of  the  move- 
ments of  any  part  of  the  body. 

The  radiogram  (by  Dr.  W.  F.  Manges)  shows  slight  enlargement  of  the 
body  structure  and  clearly  demonstrates  that  the  muscular  structures  are  the 
principal  tissues  involved. 

In  supplementing  the  report  of  this  case  with  a  review  of  the  literature, 
I  find  that  Greig  (in  1898),  Fowler  and  Johnston  (in  1900),  have  ably  dis- 
cussed and  considered  tlie  subject  in  well-written  articles. 

The  terms  that  have  been  applied  most  commonly  to  designate  this 
anomaly  are  congenital  hemi-hypertrophy,  congenital  lateral  hypertrophy, 
congenital  unilateral  enlargement,  and  Taruffi  has  used  the  term  macrasomia 
lateralis.  Probably  no  better  term  could  be  used  than  that  of  unilateral 
hypertrophy  or  unilateral  enlargement  to  cover  the  subject  as  a  whole,  for  in 
the  classifications  subdivisions  are  quite  numerous,  and  as  a  result  various 
terms  might  be  applied  indicating  tlic  part  of  tissue  involved. 

Greig  classifies  these  conditions  first,  according  to  the  tissues  affected,  and 
secondly,  according  to  the  anatomical  part  involved.  The  tissue  classification 
is  as  follows:  (1)  Bone  only  afTcctcd,  (2)  soft  part  only  affected,  (3)  bone 
and  soft  parts  affected  conjointly.  The  anatomical  division  is:  (1)  Head  and 
face  alone  are  involved,  (2)  not  limited  to  the  head  and  face,  (3)  not  involving 
head  and  face.     Fowler  classifies  these  as  true  and  false.     The  true,  he  says, 


CONGENITAL  UNILATERAL  HYPERTROPHY— REPORT  OF  CASE.  15 

are  always  congenital  and  non-progressive,  but  in  which  the  tissues  uniformly 
participate  in  the  overgrowth.  In  Wittelshafer's  collection  of  46  cases,  only 
2  cases  were  true  hypertrophy,  according  to  Fowler,  and  only  two  cases 
involved  the  arms  and  legs. 

Etiologically  nothing  definite  has  been  recorded.  Tiehl,  Passauer,  and 
Adams  have  reported  maternal  impressions  as  causes  in  their  cases.  Tellat 
and  Monad  mention  incomplete  paralysis  of  the  vaso-motor  nerves  causing 
congestion  and  hypertrophy,  and  Greig  suggests  meningitis,  cerebritis  or  some 
involvement  of  the  cord. 

Of  the  cases  recorded  about  twenty  per  cent,  of  those  involving  the  head 
and  face  have  been  mentally  deficient,  while  no  signs  of  idiocy  or  imbecility 
were  noted  in  those  involving  parts  other  than  the  head  and  face.  We  might, 
therefore,  almost  conclude  that  the  origin  of  these  conditions  may  differ  quite 
materially,  depending  on  the  part  as  well  as  the  tissue  involved. 

Little  is  known  of  the  pathological  findings  in  the  congenital  or  true 
variety,  for  the  reason  that  so  few  have  come  to  autopsy  or  under  the  surgeon's 
knife.  We  are  indebted  to  Hornstein,  who  found  in  one  case,  whose  tissues 
were  subjected  to  microscopic  examination,  that  hypertrophy  in  the  muscle, 
subcutaneous  tissues,  and  in  the  skin  existed,  the  septa  and  muscle  bundles 
being  increased.  In  another  case,  quoted  by  the  same  writer,  thickening  of 
the  bones  at  the  epiphyses,  increase  of  fat  and  increase  in  the  connective  tissue 
in  the  peripheral  nerves  were  noted.  Maschke  reports  a  unilateral  enlarge- 
ment of  the  leg  with  congenital  displacement  of  muscle  tissues  in  the  foot  and 
bone  enlargement. 

Adams  reported  a  case  as  unilateral  hypertrophy  which  later  developed 
telangiectatic  spots  all  over  the  surface  of  the  hypertrophied  side.  Several  of 
the  cases  of  this  type  are  recorded  in  Greig's  collection. 

Of  the  clinical  findings  noted  in  some  cases  are  those  of  increased  activity 
of  the  sweat  and  sebaceous  glands,  early  eruption  of  the  teeth,  rapid  growth  of 
hair  and  nails.  The  temperature  is  often  higher  on  the  affected  side.  French 
writers  have  observed  a  difference  in  the  pulse.  It  is  not  unusual  to  find  in 
these  congenital  cases  that  they  have  remained  unnoticed  until  rather  late 
dates.  Fischer's  case  was  noticed  at  youth,  Devouge's  case  at  five  months, 
McGregor's  case  at  two  years,  while  Blodgett's  case  was  marked  and  noted  on 
the  third  day. 

The  diagnosis  of  these  cases,  as  a  rule,  present  little  or  no  difficulty, 
though  atrophy  of  the  opposite  side  is  a  condition  which  has  sometimes  been 
noted.  Milne  reports  a  case  in  which  the  diagnosis  was  doubtful,  but,  after 
carefully  studying  the  case,  concluded  that  atrophy  of  one  side  and  hypertrophy 
of  the  other  existed  in  the  same  patient.  By  the  exclusion  of  palsies,  mus- 
cular dystrophies  and  bone  affections,  together  with  a  clear  history,  the  diag- 
nosis should  not  be  difficult. 

The  prognosis  of  these  cases,  so  far  as  life  and  use  of  the  part  is  concerned, 
is  favorable.  Johnston  and  Fowler  claim  that  they  rarely  increase  in  size  out 
of  proportion.  Adams'  case,  however,  is  an  exception.  Ahfield,  Mobius  and 
Wagner  found  in  one  case  that  the  relative  measurement  remained  the  same 


16  THE  HUMAN  BODY  AND  AN  AUTO-PROTECTIVE  MECHANISM. 

between  the  ages  of  three  and  fourteen  years.  Mental  deficiency,  as  was  stated 
before,  is  rare,  save  in  facial  and  cranial  cases. 

The  congenital  cases  require  no  treatment,  as  they  rarely  interfere  with 
function.  Exceptional  cases,  however,  require  partial  removal,  amputation 
and  vessel  ligation. 

The  case  which  I  have  described  in  the  beginning  of  my  paper  could  well 
be  classed  as  a  form  of  hypertrophy  involving  the  soft  parts  only,  not  involving 
the  head  and  face,  and,  according  to  Johnston  and  Fowler,  classed  as  a  true 
hypertrophy  which  is  the  least  common  variety.  My  case,  too,  presented  an 
unusually  early  eruption  of  the  teeth,  but  the  afore-mentioned  clinical  findings 
were  absent.  In  Greig's  tabulation  of  42  cases,  not  limited  to  the  head  and 
face,  only  two  cases  involved  the  arms  and  legs  alone,  both  being  right-sided. 
Nearly  all  of  them  show  bone  enlargement.  The  case  I  have  reported  shows 
slight  bone  enlargement,  and  is  the  only  left-sided  case  involving  only  the  arm 
and  leg  that  the  writer  is  able  to  find  record  of. 

BlBLIOGEAPHY. 

Adams:  Archives  Ped.,  N.  Y.  Vol.  XI,  1894. 

Gbeig:   Edinburgh   Hosp.   Reports,    1900. 

FowLEB  and  Johnston:  Edinburgh  Hosp.  Reports,  1898. 

Hutchinson:  Report  of  Soc.  of  Diseases  of  Children,  Vol.  Ill,  1903. 

Maschke:   Cleveland  Medical   Journal,  May,    1907. 

Blodgett:  American   Journal  of   Orthopoedic   Surgery,   January,   1907. 


IS  THE  HUMAN  BODY  SUPPLIED  WITH  AN  AUTO-PROTECTIVE  MECHAN- 
ISM ?     A  NEW  THEORY  OF  IMMUNITY  BASED  ON  THE 
DUCTLESS  GLANDS/ 

Bt  CHARLES  E.  de  M.  SAJOUS,  M.D. 

PHILADELPHIA. 

Hippocrates  400  years  before  the  Christian  era,  taught  that  the  physician 
should  look  to  the  efforts  of  Nature  for  guidance.  The  best  work  of  our  day, 
that  upon  Immunity,  has  the  same  trend.  Is  the  human  body  supplied  with 
a  mechanism  which  governs  the  production  of  the  defensive  substances  that 
appear  in  the  blood  after  certain  infections  and  intoxications?  My  researches 
have  shown  that  such  a  mechanism  exists  and  that  the  organs  constituting  it 
are  (as  I  suggested  in  1903  in  the  first  volume  of  "Internal  Secretions")  the 
adrenals,  the  thyroid  and  the  pituitary  body. 

The  immunizing  process  ig  intimately  related  with  and  dependent  upon 
the  functions  of  these  organs : — 

Adrenals. — These  organs  supply  a  secretion  which  on  reaching  the  lungs 
absorbs  the  oxygen  of  the  air  and  becomes  a  constituent  of  hsemoglobin — its 

1  Abstract  of  address  read  by  invitation,  before  the  Toronto  (Canada)  Academy 
of  Medicine,  January  5,  1909.  To  be  published  in  extenso,  with  illustrations  and 
evidence,  in  the  'N&w  York  Medical  Journal. 


THE  HUMAN  BODY  AND  AN  AUTO-PROTECTIVE  MECHANISM.  17 

albuminous  constituent.  It  is,  as  such,  taken  up  by  the  red  corpuscles^  and 
secreted  by  these  cells  as  droplets  (the  so-called  "blood-platelets")  in  all  parts 
of  the  body  including  the  hlood-plasma  itself.  The  purpose  of  this  albuminous 
hsemoglobin  (which  I  have  termed  "adrenoxidase")  is  to  supply  oxygen  to  the 
tissues  and  to  the  blood.  Important  in  this  connection,  however,  is  that  this 
adrenoxidase  gives  the  reactions  and  presents  other  characteristics  of  a  familiar 
agent  in  the  immunizing  process,  the  immune  body  or  amhoceptor. 

Thyroid  and  parathyroids. — These  organs  supply  secretions  which  on  pass- 
ing out  of  the  lymphatics  (into  which  they  are  secreted)  enter  the  left  sub- 
clavian vein,  and  become  merged  into  a  single  substance.  Passing  then  into  the 
blood  of  the  superior  vena  cava,  this  secretion  is  carried  to  the  lungs,  and  on 
reaching  the  air-cells  is  taken  up  by  the  red  corpuscles — along  with  the  oxy- 
genized adrenal  secretion.  A  salient  feature  of  the  immunizing  process  appears 
in  this  connection,  viz.,  the  thyro-parathyroid  product  is  also  secreted  by  the 
red  corpuscles  into  the  blood  and  tissues,  and  by  acting  directly  upon  the 
phosphorus  which  the  nuclei  of  all  tissue  cells,  pathogenic  organisms,  etc., 
contain,  increases  their  inflammability,  i.e.,  their  sensitiveness  to  oxidation. 
As  such,  it  proved  to  be  both  opsonin^  and  agglutinin. 

Pituitary. — Considered  from  the  standpoint  of  immunity  only,  this  organ 
contains  a  sensitive  organ,^  the  "immunizing  center"  located  between  the 
anterior  and  posterior  lobe  (the  pars  intermedia)  and  connected  with  the 
adrenals  and  the  thyro-parathyroid  glands  by  nerves.  Through  these  nerves 
the  immunizing  center  governs  the  functional  activity  of  these  two  sets  of 
organs  (and,  therefore,  the  production  of  amboceptor,  opsonin  and  agglutinin), 
and  through  them,  therefore,  general  oxidation.  As  such  it  is  the  heat  or  fever 
center.  While  irritation  at  intervals  along  the  paths  of  the  nerves  from  the 
pituitary  to  the  adrenals  and  thyroid  causes  a  marked  increase  of  temperature, 
division  of  these  same  paths  renders  impossible  the  production  of  fever  even  by 
the  injection  of  putrid  substances. 

The  "immunizing  center"  I  found  to  be  the  developed  "test-organ"  or 
"osphradium"  described  by  zoologists  in  several  invertebrates.  While  in  these 
animals  its  purpose  is  to  test  the  purity  of  the  sea-water  from  which  they  obtain 
their  oxygen,  in  the  higher  animals  including  man,  it  tests  the  qualitative 
homologue  of  sea-water,  his  blood.  When  the  latter  contains  certain  poisons, 
the  "immunizing  center"  is  excited  by  it  and  the  functions  of  the  adrenals  and 


2  Among  the  facts  which  have  confirmed  the  view  I  advanced  in  the  first  volume 
of  "Internal  Secretions"  (1903)  that  the  red  corpuscles  were  the  distributors  of  the 
adrenal  secretion  to  the  tissues,  is  the  obsei'vation  of  Mulon,  of  Paris,  that  these 
corpuscles  give  the  chemical  reactions  of  adrenalin. — S. 

8  I  pointed  out  in  th«  second  volume  of  "Internal  Secretions"  ( first  edition,  1907 ) 
that  the  secretion  of  the  thyro-parathyroids  was  Wright's  opsonin;  Marb6,  of  the  Pasteur 
Institute,  has  since  found  that  thyroid  preparations  increase  markedly  the  opsonic  power 
of  the  blood. — S. 

4  Since  I  suggested,  in  1903,  that  the  pituitary .  body  contained  a  sensitive  organ 
which  was  influenced  by  drugs  and  poisons,  Gent^s,  Boeke,  Gemelli  and  others  have 
found  such  a  structure  in  the  pituitary  of  various  animals. — S. 
4 


Ig  THE  HmiAN  BODY  AND  AN  AUTO-PROTECTIVE  IklECHANISM. 

thyro-paratliyroid  glands  being  stimulated,  the  immunizing  process  (as 
manifested  by  fever  when  marked)  is  initiated. 

The  identity  of  the  immunizing  process  itself  (a  new  theory  of  immunity, 
the  various  phases  of  which,  I  have  found,  can  be  readily  discerned  by  the 
phj'sician  and  governed  by  appropriate  remedies),  based  on  the  functions  of 
these  various  organs,  is  as  follows : — 

There  occurs,  at  first,  what  might  be  termed  the  preparatory  stage,  the 
purpose  of  which  is  to  increase  the  defensive  constituents  of  the  blood  and  other 
body  fluids: — The  toxic  (whether  a  toxin,  wastes,  drugs,  etc.)  excites  the 
immunizing  center.  This  center  in  turn  stimulates  the  thyro-parathyroid 
glands  and  the  adrenals,  thus  causing  them  to  supply  the  blood  (and  to  a 
certain  extent  the  l}Tnph  and  serous  fluids)  with  an  excess  of  thyroiodase  and 
adrenoxidase.  Metabolism  being  enhanced  in  all  tissues  by  these  substances, 
the  pancreas  also  secretes  an  excess  of  trypsic  ferment,^  while  the  leucocytogenic 
tissues  (bone-marrow,  lymph  glands,  etc.)  produce  an  increased  number  of 
leucocytes,  mainly  finely  granular  oxypliiles  and  phagocytes. 

The  blood  and  other  body  fluids  being  now  provided  with  all  the  active 
agents  of  the  defensive  mechanism  the  active  stage  of  the  process  itself  is 
started.    It  is  briefly  as  follows : — 

The  thyroiodase  (opsonin,  agglutinin)  sensitizes  and  softens  the  pathogenic 
agent  while  the  adrenoxidase  (amboceptor)  oxidizes  the  phosphorus  of  the 
nucleo-proteid  granulations,  liberating  heat.  The  activity  of  the  digestive  fer- 
ments (plasmatic  and  phagocytic  complement)  being  increased  by  heat  energy, 
the  pathogenic  agents  are  digested  and  converted  into  eliminable  products. 

Not  only  is  this  conception  of  immunity  based  on  ample  experimental, 
chemical  and  clinical  evidence,  but  it  harmonizes  with  the  general  trend  of 
modem  thought.  Its  functions  sustain  the  views  of  the  modern  biochemist 
who  has  found  that  increased  metabolism  is  a  characteristic  of  the  febrile  pro- 
cess; they  also  coincide  with  the  observations  of  the  bacteriologist  that  while 
most  pathogenic  bacteria  thrive  at  the  normal  temperature  of  the  body,  they 
promptly  die  when  it  is  raised  several  degrees.  They  account  for  the  teaching 
of  clinical  experience  that  a  higher  mortality  occurs  in  apyretic  cases  than 
among  those  in  which  the  febrile  process  has  been  active.  They  explain  the 
harmful  influence  of  hyperpyrexia,  since  excessive  immunizing  activity  means 
proteolytic  destruction  of  the  blood-cells  (haemolysis)  and  even  of  tissue-cells 
(autolysis)  besides  the  pathogenic  agents  themselves. 

In  the  practical  field,  personal  experience  sustained  by  that  of  colleagues 
who  have  carefully  studied  my  doctrines,  has  shown  clearly  that  these  embody 
the  lever  through  which  we  can  overcome  infections.  We  need  only  analyze  the 
beneficial  action  of  vaccine  therapy,  of  antitoxine,  of  drugs  such  as  mercury, 


5  In  the  first  volume  of  "Internal  Secretions,"  pages  367  to  420,  I  have  sub- 
mitted evidence  to  the  effect  that  this  ferment  is  secreted  by  the  pancreas  as  a  true 
internal  secretion  into  the  splenic  vein.  On  reaching  the  portal  system,  it  is  taken  up 
by  leucocytes,  both  for  their  own  use  as  phagocytes  and  for  the  plasma  and  tissue  cells, 
where  they  secrete  this  and  other  pancreatic  ferments. — S. 


ADRENAL  GLAND. 


ALBUMINURIA. 


19 


the  iodides  and  other  so-called  "alteratives"  to  recognize  that  their  tendency, 
in  therapeutic  (non-toxic)  doses,  is  to  raise  the  temperature — proof  that  the 
immunizing  process  is  active.  Here  a  warning  imposes  itself,  however,  for, 
as  stated  above,  this  process  may  surpass  salutary  bounds,  and  destroy  blood 
and  tissue-cells.  This  affords  clues  to  the  pathogenesis  of  many  admittedly 
obscure  diseases.  In  arteriosclerosis,  endocarditis,  hepatic  cirrhosis,  acute 
yellow  atrophy  of  the  liver,  acute  chorea,  acute  rheumatism  and  many  other 
disorders,  one  can  readily  discern  the  pernicious  influence  of  an  excessive 
defensive  reaction.  Again,  the  Widal  test,  in  view  of  the  thyroid  origin  of 
agglutinin,  finds  a  normal  explanation  while  the  free  production  of  antibodies 
this  indicates  accounts  for  the  relatively  low  mortality  of  the  disease  to  which 
it  applies,  typhoid  fever.  This,  moreover,  explains  the  sero-diagnostic  and 
sero-prognostic  tests  of  Arloing  and  Courmont  in  tuberculosis.  Agglutination 
is  deemed  by  these  investigators  an  index  of  the  defensive  power  of  the  organism 
in  this  disease;  this  suggests — agglutinin  and  opsonin  being  identical — a 
simpler  and  more  exact  opsonic  index  than  that  now  available  for  all  diseases, 
as  will  be  shown  later  in  the  columns  of  this  journal. 


Cvjclopecdia  of  Current  literature 


ADRENAI  GLAND,  LESIONS  OF. 

Hji-perplasia  of  the  adrenal  is  an  al- 
most constant  lesion  in  arteriosclerosis 
associated  with  chronic  interstitial  neph- 
ritis and  left-sided  hypertrophy,  and  it 
occurs  with  almost  equal  frequency  in 
arteriosclerosis  with  chronic  nephritis  of 
the  parenchjTuatous  type;  it  is  also  a 
frequent  lesion  of  arteriosclerosis  with- 
out nephritis  and  of  nephritis  without 
arteriosclerosis.  Adrenal  hyperplasia  is, 
consequently,  probably  the  result  of  some 
factor  active  in  a  period  of  life  in  which 
these  affections  are  most  frequent.  The 
adrenal  lesion  consists  of  increase  of  con- 
nective tissue,  round  cell  infiltration,  in- 
crease in  the  thiclcness  of  the  vascular 
wall  and  hyperplasia  of  the  adrenal  cells 
proper.  Pearce  (Journal  of  Experi- 
mental Medicine,  November,  1908). 


ALBUMINURIA,  INTERMITTENT,  OF 
CHILDHOOD  CONSIDERED  IN  ITS 
RELATION  TO  HEREDITARY  TUBER- 
CULOSIS. 

Hereditary  tuberculosis  may  attack  the 
kidney  in  the  child  or  in  the  adult  in 
one  of  three  ways : 

1.  Certain  individuals  present  a  more 
or  less  abundant  albuminuria,  which  is 
preferably  intermittent,  and  which  may 
affect  one  of  the  well-lmo"\vn  classic 
cycles ;  but  it  disappears  as  the  pulmon- 
ary localization  becomes  established,  or 
gives  rise  to  general  lesions,  and  may, 
therefore,  be  termed  pretuberculous  albu- 
minuria. 

This  form  of  albuminuria  does  not 
necessarily  imply  the  existence  of  renal 
tuberculosis ;  but,  on  the  contrary,  seems 
to  have,  a  toxic  origin,  and  resembles  the 
bacteriolysis  which  is  an  expression  of 


20 


ANTHRAX. 


BIER'S  METHOD  OF  PASSIVE   CONGESTION. 


the  spontaneous  defensive  forces  of  the 
organism.  As  soon  as  this  spontaneous 
destruction  ceases,  tuberculosis  develops 
and  the  albuminuria  comes  to  an  end. 

3.  The  second  form  of  tuberculosis  has 
been  scored  out  by  the  author. 

3.  Finally,  there  is  a  third  series  of 
cases  which  are  much  more  numerous. 
The  kidney  is  affected  in  a  peculiar  man- 
ner, which  we  have  been  able  by  a  long 
series  of  similar  observations  to  deter- 
mine almost  with  certainty :  the  kidney 
reacts  very  slowly  and  sluggishly  to  the 
action  of  the  tuberculous  toxin  trans- 
mitted by  the  parent,  and  a  slight  degree 
of  latent  nephritis  is  produced  which  re- 
sults in  a  very  relative  impermeability, 
relieving  itself  in  a  moderate  diminution 
of  the  total  molecular  diuresis,  an  in- 
crease in  the  co-efficient  of  Korany,  and 
also  in  a  slight  elevation  of  the  blood- 
pressure;  a  moderately  severe  albumin- 
uria, usually  intermittent,  either  of  the 
matinal  (morning)  type,  or  frankly  or- 
thostatic (present  during  the  active  hours 
of  the  day)  ;  and  finally — as  the  hall- 
mark of  its  tuberculous  origin — a  well- 
defined  d'Arloing-Courmont  serum-reac- 
tion, often  exceeding  ^5.  These  cases, 
which  make  up  more  than  34  per  cent,  of 
our  statistics  of  intermittent  albuminuria 
in  young  subjects,  do  not  eventuate  in 
actual  tuberculosis.  For  this  reason  they 
seem  to  justify  the  term  paratuberculous 
albuminuria,  and  many  of  these  cases  be- 
long to  the  category  of  spontaneous  im- 
munization, to  which  Professor  Cour- 
mont  has  recently  called  attention.  J. 
Teissier  (Transactions  Congress  of  Tu- 
berculosis, September  29,  1908). 

ANTHRAX,  TREATMENT  OF. 

Under  expectant  treatment  three  died 
out  of  ten  patients  with  anthrax,  while 
none  died  in  the  nine  cases  between  1900 
and  1905  in  which  active  treatment  was 


undertaken.  Since  1905  the  author  has 
been  using  a  method  that  seems  to 
shorten  the  course  of  the  affection  still 
more,  and  there  has  been  no  mortality  in 
the  23  cases,  and  no  disfiguring  scars. 
The  first  principle  in  treatment  is  to 
avoid  further  injury.  Especially  inju- 
rious is  any  pressure  on  the  pustule, 
which  forces  the  bacilli  out  into  the 
blood.  It  is  important,  therefore,  for  the 
patient  to  lie  quietly  in  bed.  In  mild 
cases  it  is  sufficient  to  cover  the  pustule 
and  its  vicinity  with  an  antiseptic  moist 
dressing;  mercury  bichloride  or  alu- 
minum acetate  can  be  used  for  the  pur- 
pose. The  strictly  local  lesion  rapidly 
heals  under  the  treatment,  but  in  the 
severer  cases  a  crucial  incision  is  made 
and  the  actual  cautery  is  used  to  make 
a  groove  of  deep  punctures  around  the 
lesion.  This  groove  forms  a  scab  which 
renders  it  difficult  for  the  anthrax  bacilli 
to  penetrate  into  the  surrounding  tissues. 
This  crucial  incision  and  the  ring  of  cau- 
terization around  the  lesion  are  simple 
and  can  scarcely  be  considered  an  actual 
operation.  The  pain  is  so  slight  that  it 
seems  to  indicate  that  the  sensibility  in 
the  pustule  is  much  reduced.  The  writer 
adds  that  the  effect  of  this  treatment  is 
invariably  so  good  that  it  has  scarcely  a 
parallel  in  therapeutics,  except  antitoxin 
in  diphtheria.  Barlach  (Medizinische 
klinik,  November  1,  1908;  Journal  of 
the  American  Medical  Association,  De- 
cember 19,  1908). 

BIER'S    METHOD     OF    PASSIVE    CONGES- 
TION. 

Bier  recommends  both  active  hyper- 
semi  a  and  passive  congestion,  according 
to  the  condition  to  be  treated.  He  first 
used  passive  congestion  for  tubercle  in 
1890,  being  influenced  by  the  frequency 
of  phthisis  in  those  whose  lungs  were 
ancemic  from  stenosis  of  the  pulmonary 


CHOLECYSTITIS. 


CHOREA,  TREATMENT  OF. 


21 


cardiac  orifice,  or  other  cause.  Hyper- 
semia  and  inflannnation  are  beneficial  to 
a  certain  extent,  being  nature's  reaction 
to  and  metliod  of  counteracting  injurious 
influences.  Conditions  brought  about  by 
congestion  are  relief  of  pain,  abatement 
of  fever,  prevention  of  stiffness,  destruc- 
tion of  bacteria,  promotion  of  the  absorp- 
tion of  fluids,  resolution  of  thickenings 
in  joints  and  tendons,  and  a  certain  de- 
gree of  trophic  action.  In  some  cases  it 
will  produce  a  decidedly  beneficial  auto- 
inoculation.  It  may  be  brought  about  by 
means  of  a  bandage  proximal  to  the  area 
to  be  congested  or  by  a  suction  apparatus. 
Before  treatment  by  congestion  is  com- 
menced it  is  most  important  to  determine 
the  nature  of  the  disease,  and  to  vary  the 
technique  accordingly.  A  proper  method 
of  congestion  in  one  case  might  be  very 
improper  in  another.  A.  W.  ^Yakefield 
(Practitioner,  October,  1908). 

CHOLECYSTITIS. 

During  the  attack  of  cholecystitis  the 
patient  should  rest  in  bed,  and  should 
have  warm  Priessnitz  compresses  over  the 
upper  half  of  the  abdomen.  Opiates 
should  be  given  to  relieve  pain,  if  neces- 
sary. The  diet  should  be  exceedingly 
limited  during  the  first  few  days,  and 
all  cathartic  drugs  are  contraindicated. 
After  the  swelling  of  the  gall-bladder  has 
subsided  and  the  local  soreness  has  dis- 
appeared, the  patient  may  be  out  of  bed 
most  of  the  day.  The  diet  should  con- 
sist largely  of  cereals,  meat,  simple  vege- 
tables, bread  and  butter.  Alcoholic 
drinks,  acid  foods,  and  fruits  should  be 
prohibited.  The  use  of  salines  should  be 
begun  early.  Sodium  sulphate,  sodium 
phosphate,  sodium  bicarbonate,  and  so- 
dium salicylate  may  be  given  in  various 
mixtures.  They  are  best  administered 
dissolved  in  plenty  of  hot  water,  one-half 
to  one  hour  before  each  meal.    The  writer 


does  not  believe  there  is  any  special  vir- 
tue in  sodium  salicylate,  not  possessed  by 
the  other  drugs  mentioned ;  nor  does  he 
think  it  advisable  for  the  patient  to  eat 
more  than  the  three  regular  meals  a  day. 
It  is  possible  that  urotropin,  or  other 
drugs,  may  prove  to  have  unusual  value. 
Under  this  simple  treatment,  continued 
for  months,  or  if  need  be  for  years,  pa- 
tients are  given  an  excellent  chance  to 
escape  recurrence  of  inflammation,  and, 
in  fact,  all  s}-niptoms  referable  to  the 
gall-bladder.  H.  W.  Bettmann  (Medical 
Eecord,  November  28,  1908). 

CHOREA,  TREATMENT  OF  BY  INTRA- 
SPINAL  INJECTIONS  OF  MAGNESIUM 
SULPHATE. 

Four  cases  of  severe  chorea  are  re- 
ported by  the  author,  in  which  the  dura- 
tion of  the  affection  was  shortened  and 
there  has  been  no  recurrence  since  the 
treatment,  which  was  by  intraspinal  in- 
jection of  3.5  cubic  centimeters  of  a  25- 
per-cent.  solution  of  magnesium  sulphate. 
The  patients  were  girls  between  twelve 
and  twenty-two  years  old,  and  the  seda- 
tive action  of  the  drug  was  apparent  in  a 
few  hours,  the  symptoms  subsiding  com- 
pletely in  some,  but  requiring  a  second 
injection  in  the  others.  Slight  by-effects 
were  noted,  but  they  were  transient  in  all, 
and  in  the  forty  cases  on  record  in  which 
the  magnesium  sulphate  has  been  admin- 
istered in  intraspinal  injections,  apnoea 
was  observed  only  in  one  case,  and  it  was 
Ijrief  and  transient.  The  tendency  to 
headache  and  pain  in  the  limbs  after  the 
injection  can  be  reduced  by  a  preliminary 
injection  of  morphine.  In  future  the 
writer  intends  to  use  an  isotonic  solution, 
that  is,  one  with  a  freezing  point  at  0.56 
below  zero  C.  This  treatment  may  be 
found  effectual  also  in  major  chorea,  and 
in  the  chorea  of  pregnant  women.  G. 
Marinesco    (Semaine  mddicale,   ISTovem- 


22  EXAMINATION  OF  TUBERCULOUS  EFFUSIONS. 


DIPHTHERIA,  HEART  IN. 


ber  18,  1908;  Journal  of  the  American 
Medical  Association,  December  19, 
1908). 

CYTOLOGIC  EXAMINATION  OF  TUBER- 
CULOUS EFFUSIONS  IN  THE  VARI- 
OUS CAVITIES,  DIAGNOSTIC  VALUE 
OF. 

The  cytology  of  effusions  (Widal)  re- 
quires a  very  simple  and  very  easy 
method  of  examination,  and  is  of  consid- 
erable aid  in  determining  the  nature  of 
a  pleurisy.  A  great  predominance  of 
lymphocytes  is  a  strong  argument  in 
favor  of  tuberculosis.  There  is  no  danger 
of  making  a  mistaken  diagnosis  of  tuber- 
culosis on  the  strength  of  the  cytologic 
findings  in  a  pleural  effusion;  the  only 
risk  is  that  the  condition  may  be  mis- 
taken for  something  else,  as  abnormal 
formulas  are  by  no  means  exceptional. 
The  anomalies  of  the  cytologic  formula 
are  susceptible  of  various  explanations, 
but  some  of  these  anomalies  are  still  quite 
mysterious. 

The  cytology  of  tuberculous  effusions 
in  other  serous  cavities  has  a  very  ques- 
tionable semeiologic  value. 

The  great  predominance  of  lympho- 
cytes in  tuberculous  ascites  must  be  ex- 
cepted, an  occurrence  which,  however,  is 
by  no  means  a  very  common  one. 

In  general,  cytologic  findings  must  be 
interpreted  with  caution ;  they  often  need 
to  be  controlled  by  other  laboratory  ex- 
aminations, and  should  always  be  com- 
pared with  the  data  obtained  by  clinical 
observation.  A.  Cade  (Transactions 
Congress  of  Tuberculosis,  October  2, 
1908). 

DIPHTHERIA,  HEART  IN. 

The  two  chief  cardiac  lesions  in  diph- 
theria are  the  parenchymatous  and  the 
interstitial.     Patty  degeneration  is  ex- 


tremely frequent,  varying  widely  in 
degree,  and  always  accompanying  the 
severer  lesions.  It  may  occur  at  any 
time  in  the  disease.  A  much  severer  de- 
generation, both  focal  and  general,  which 
affects  all  parts  of  the  muscle  fiber,  the 
contractile  elements,  the  protoplasm  and 
the  nucleus,  and  which  leads  to  the  for- 
mation of  granular  detritis  and  large 
irregular  hyaline  masses,  also  occurs. 
This  is  only  found  late  in  the  course  of 
the  disease,  rarely  earlier  than  the  sev- 
enth day.  The  interstitial  changes  are 
of  two  types.  In  one  there  are  focal  col- 
lections of  l}Tnphoid  and  plasma  cells. 
In  the  other,  there  is  the  invasion  of  the 
degenerated  and  necrotic  muscle  cells 
with  endothelial  cells  and  polymorphonu- 
clear leucocytes.  These  are  all  essentially 
late  changes.  Only  fatty  degeneration  is 
seen  before  the  sixth  or  seventh  day.  The 
early  circulatory  disturbance  is  extraordi- 
narily severe,  but,  thanks  to  antitoxin,  is 
rarely  seen  at  present.  Eomberg  and 
Passler's  experiments  show  that  this  is 
due  to  failure  of  the  vasomotor  center, 
though  undoubtedly  the  heart  itself  is  af- 
fected. The  late  circulatory  disturbances 
may  appear  at  any  time  from  the  second 
to  the  fifth  week.  The  first  symptoms 
are  usually  to  be  found  in  the  pulse, 
which  drops  with  the  temperature,  often 
to  below  normal,  remaining  there  or  ris- 
ing and  falling  again.  In  a  certain  per- 
centage of  cases  it  may  be  persistently 
high,  but  either  of  these  means  almost 
certainly  myocarditis.  At  other  times 
the  first  symptom  is  irregularity  in  the 
force  or  rhythm,  and  the  former  is  con- 
stantly present,  and  may  last  for  months. 
The  worst  prognosis  is  given  in  cases 
with  low  and  constantly  falling  rate. 
Heart  examination  reveals  the  same  ab- 
normalities, together  with  murmurs  and 
evidences  of  dilatation,  and  here  the  per- 
sonal equation   of  the  examining  phy- 


ENDOCARDITIS. 


FLIES  AND  KOCH'S  BACILLUS. 


23 


sician  has  played  a  considerable  part  in 
their  interpretation. 

Accurate  deductions  cannot  be  drawn 
at  present  as  to  the  severity  of  the 
lesions  from  the  murmurs,  and  it  is  the 
author's  personal  opinion  that  dilatation 
has  been  diagnosed  too  frequently,  though 
it  would  be  wrong  to  say  that  it  is 
unusual.  A  sign  of  mild  cardial  disease 
of  greater  value  on  account  of  its  con- 
stancy is  the  alteration  in  character  of 
the  first  sound  of  the  heart,  consisting  in 
the  more  or  less  complete  disappearance 
of  the  muscular  element  of  the  first 
sound,  making  it  weak  and  short,  and 
what  is  usually  called  "valvular"  in 
quality.  Studies  in  regard  to  blood- 
pressure  are  incomplete  and  unsatis- 
factory. It  is  generally  somewhat  sub- 
normal, and  when  below  75  millimeters 
always  means  a  serious  condition,  and 
below  70  millimeters  great  danger.  A 
progressive  fall  should  excite  more  con- 
cern. General  symptoms,  such  as  pallor, 
apathy  or  irritability  and  vomiting, 
are  often  much  in  evidence.  Loss  of 
weight  is  common,  even  in  convales- 
cence. The  cause  of  death  has  not  been 
determined  by  experiment,  but  the  clini- 
cal evidence  is  conclusive  that  it  is  due 
to  myocarditis.  Eest  and  general  man- 
agement are  of  more  importance  in  the 
treatment  than  drugs,  from  which  little 
permanent  effect  can  be  expected,  as  the 
myocardial  lesions  require  days  and 
weeks,  and  not  hours  for  their  cure. 
The  so-called  pneimio-gastric  paralysis  is 
discussed,  and  the  writer  thinks  that  the 
post-mortem  findings  almost  completely 
dispose  of  the  nerve  as  a  factor  in  pro- 
ducing the  symptoms  referred  to,  as  it 
seems  to  be  generally  degenerated,  and 
these  symptoms  are  not  common.  The 
symptoms,  he  thinks,  could  be  better  ex- 
plained by  metabolic  disturbance  from 
the  action  of  the  toxin  on  the  viscera. 


referring  the  slow  heart  and  other  circu- 
latory symptoms  to  the  concomitant  myo- 
carditis. J.  Howland  (Journal  of  the 
American  Medical  Association,  December 
19,  1908). 


ENDOCARDITIS,  INFECTIVE  OR  ULCERA- 
TIVE. 
The  diagnosis  of  this  serious  disease  is 
often  very  difficult.  As  seen  in  practice 
it  does  not  always  correspond  with  the 
description  in  books.  In  a  series  of  nar- 
rated cases  the  most  prominent  symptom 
was  oscillation  of  the  temperature,  with 
rigor  or  evidence  of  infarction.  Other 
symptoms  were  petechise  of  the  extremi- 
ties, vomiting,  ashy  discoloration  of  the 
skin,  and  heart  murmurs.  A  murmur  is 
not  always  present;  when  present  it 
may  be  loud  and  persistent,  if  added  to 
pre-existing  chronic  valvular  lesion,  or  it 
may  be  soft,  and  finally  become  inau- 
dible. Attention  is  called  to  the  fact 
that  the  deposits  upon  the  heart  valves 
are  invariably  on  the  side  over  which  the 
blood  passes  in  its  onward  flow,  and  that 
the  vegetations  are  soft  and  spongy.  As 
they  do  not  prevent  closure  of  the  valves, 
an  absence  of  cardiac  murmur  is  not 
necessarily  strange.  The  vomiting  and 
retching,  which  may  follow  a  succession 
of  rigors,  without  any  discoverable  gas- 
tric, hepatic,  or  cerebral  change,  may  be 
considered  as  analogous  to  the  vomiting 
of  uraemia,  or  of  cholaemia.  The  septic 
cerebral  and  typhoid  types  of  symptoms 
are  probably  due  to  the  presence  of  a 
toxine  in  the  circulation.  N.  Tirard 
(Practitioner,  November,  1908). 

FLIES    AS    AGENTS   IN   THE   DISSEMINA- 
TION OF  KOCH'S  BACILLUS. 

Flies  are  active  agents  in  the  dissemi- 
nation of  Koch's  bacillus  because  they 
are  constantly  going  back  and  forth  be- 


24        GRAVES'S  DISEASE. 


HAEMORRHAGES  INTO  THE  VITREOUS  BODY. 


tween  contagious  sputa  and  iseces,  and 
food  stuffs,  especially  meat,  fruit,  milk, 
etc.,  which  they  pollute  by  contact  with 
their  feet,  and  especially  with  their  ex- 
cretions. 

The  experimental  researches  of  the  au- 
thor show  the  following : 

1.  Flies  caught  in  the  open  air  do  not 
contain  any  acid-fast  bacilli  that  could  be 
mistaken  for  the  bacillus  of  Koch. 

2.  Flies  that  have  been  fed  on  sputum 
evacuate  considerable  quantities  of  bacilli 
in  their  excretions.  The  bacilli  appear 
six  hours  after  ingestion  of  the  sputum, 
and  some  may  be  found  as  long  as  five 
days  later.  These  flies,  therefore,  have 
plenty  of  time  to  carry  these  bacilli  to  a 
great  distance,  and  to  contaminate  food 
in  houses  apparently  protected  from  con- 
tagion, because  not  inhabited  by  a  con- 
sumptive. 

3.  Food  polluted  by  flies  that  have  fed 
on  sputa  contains  infective  bacilli  and 
produces  tuberculosis  in  the  guinea  pigs. 

4.  Flies  readily  absorb  bacilli  con- 
tained in  dry  dust. 

5.  Flies  caught  at  random  in  a  hospi-. 
tal  ward  produce  tuberculosis  in  the 
guinea  pig. 

Practical  Conclusions. — The  sputa  and 
fffices  of  tuberculous  subjects  must  be  dis- 
infected; flies  should  be  destroyed  as 
completely  as  possible;  food  stuffs  should 
be  protected  by  means  of  covers  made  of 
wire  gauze.  Ch.  Andre  (Transactions 
Congi-ess  of  Tuberculosis,  September  30, 
1908). 

GRAVES'S  DISEASE,  PATHOLOGICAL 
CHANGES  IN  THE  THYROID  AS  RE- 
LATED TO  THE  VARYING  SYMPTOMS 
IN. 

Very  early  acute  cases  show  patho- 
logically hyperiemia  and  cellular  hyper- 
plasia in  more  or  less  of  the  gland,  if 


the  more  enlarged  lobe  has  been  removed. 
Later  acute  cases  show  greater  paren- 
chyma increase  and  increased  absorbable 
secretion.  The  increase  in  parenchyma 
is  in  proportion  to  the  severity  of  the 
symptoms.  Cases  in  which  there  is  re- 
mission of  toxic  S3^nptoms  show  evidence 
of  decreased  function,  or  of  probably  de- 
creased absorption.  Those  who  have 
recovered  from  toxic  sjTuptoms,  but  still 
suffer  from  heart  or  nerve  lesions,  or 
from  myxoedema,  show  exfoliated  epithe- 
lium and  thick  non-absorbable  colloid. 
The  mild  cases,  of  long  duration,  show 
increase  of  parenchAina  by  the  multipli- 
cation of  alveoli,  but  no  increase  of 
functional  power  of  the  individual  par- 
enchyma cells.  Simple  goiters  should  be 
regarded  as  multiple  retention  cysts, 
filled  with  non-absorbable  secretion,  cell 
detritus,  etc.  L.  B.  Wilson  (American 
Journal  of  the  Medical  Sciences,  Decem- 
ber, 1908). 

HEMORRHAGES     INTO     THE     VITREOUS 
BODY  IN  THE  ADOLESCENT. 

Iloimorrhages  into  the  vitreous  body 
during  adolescence  is  quite  frequent,  and 
owing  to  the  danger  of  recurrence,  and 
tissue  changes  in  the  eye,  is  a  dangerous 
condition,  worthy  not  only  of  patient, 
careful,  and  exhaustive  treatment  after 
the  occurrence,  but  also  of  prophylactic 
measures.  The  too  rapid  development  of 
cliildren  should  cause  solicitude.  Eapid 
changes  of  temperature  and  prolonged 
exposures  to  heat  or  cold  are  etiological 
factors.  ]\Ienstrual  disturbances,  undue 
sexual  excitement  and  abuse,  cardiac  dis- 
ease, dyscrasias,  malnutrition,  errors  of 
refraction,  all  causes  of  eye-strain,  hered- 
itary diseases  and  tendencies,  vascular 
diseases,  anosmias,  abnormal  (prema- 
ture?) development  or  malformations, 
all  mental  and  physical  causes  of  sudden 
and    rapid    fluctuations    of    the    blood- 


HEMORRHAGES  OF  ADRENALS. 


HEART  IN  TUBERCULOSIS 


25 


stream  and  tension,  are  causative  factors 
in  intraocular  hasmorrhages. 

The  origin  of  hgemorrhages  may  be 
from  the  retinal  vessels  or  from  the  ves- 
sels in  the  region  of  the  ciliary  body,  not 
from  the  sheath,  etc.,  of  the  optic  nerve. 
Glaucoma  is  rather  the  result  than  a 
causative  factor  of  these  haemorrhages. 
The  treatment  should  be  medicinal,  if 
possible,  the  knife  to  be  used  only  as  a 
dernier  resort.  Attacks  in  women 
usually  follow  menstrual  disturbances. 
Where  there  is  a  tendency  to  epistaxis, 
and  this  suddenly  ceases,  we  have  a  dan- 
ger signal  of  haemorrhage.  Males  are 
more  liable  to  intraocular  hasmorrhage 
than  women;  normal  menstruation  is 
seemingly  a  safeguard.  The  age  from 
puberty  through  womanhood,  or  man- 
hood, is  a  danger  period.  Antemic  con- 
ditions are  predisposing.  J.  A.  Gehrung 
(New  York  Medical  Journal,  December 
19,  1908). 

H.a:MOIlRHAGE    OF    THE    ADRENALS    IN 
INFANTS. 

It  has  been  observed  by  the  authors 
that  haemorrhage  of  the  suprarenal  cap- 
sules is  more  common  than  haemorrhage 
in  other  viscera.  This  is  due  primarily 
to  the  close  relation  of  the  adrenals  to 
the  vena  cava,  making  congestion  easy, 
and  to  the  peculiar  anatomical  construc- 
tion which  favors  hemorrhage.  A  weak- 
ness of  the  vessel  walls,  either  normal 
delicacy  or  pathological  alteration,  favors 
the  rupture.  The  place  of  election  of 
the  haemorrhage  is  usually  in  the  inter- 
nal cortical  zone,  because  of  its  vascular- 
ity and  the  anastomotic  arrangement  of 
the  vessel.  The  bleeding  always  follows 
active  or  passive  congestion.  Passive 
congestion  may  be  caused  by  difficult 
labors,  obstetric  operations,  thrombosis, 
or,  in  short,  anything  that  would  favor 
venous  stasis.     Active  congestion  is  in- 


duced by  infection  or  any  toxaemia  which 
incites  hyperaemia  by  a  superactivity  of 
the  gland.  The  findings  of  the  pneumo- 
bacillus  of  Friedliinder  in  the  author's 
two  cases  and  other  bacteria  in  five  addi- 
tional cases  proves  beyond  question  that 
infection  is  a  cause  of  adrenalin  hemor- 
rhage. Death  results  either  from  loss  of 
blood  or  an  interference  with  the  phy- 
siologic functions  of  the  gland.  J.  C. 
Litzenberg  and  S,  M.  White  (Journal  of 
the  American  Medical  Association,  De- 
cember 5,  1908). 

HEART  IN  PULMONARY  TUBERCULOSIS. 

The  importance  of  study  of  the  heart 
in  pulmonary  tuberculosis  with  reference 
to  diagnosis,  prognosis,  and  treatment  is 
emphasized  by  the  writer.  The  heart  it- 
self may  be  diseased  or  not  diseased  in  a 
given  case.  In  considering  the  latter 
situation  the  author  regards  the  position 
of  the  heart,  its  size,  dilatation  with  the 
area  of  cardiac  dullness,  auscultatory 
phenomena,  the  pulse,  including  blood- 
pressure  and  palpitation. 

The  position  of  the  heart  in  patients 
with  pulmonary  tuberculosis  depends 
directly  upon  the  pathological  changes 
that  have  taken  place  in  the  lungs;  in 
other  words,  it  may  be  displaced  upward, 
downward,  to  right  or  left.  In  size  the 
heart,  with  tuberculous  lungs,  may  be 
large,  small,  or  normal.  Dilatation  of 
the  heart  occurs  far  less  frequently  than 
would  be  supposed,  and  then  only  late  in 
the  disease.  Careful  auscultation  of  the 
heart  reveals,  in  a  certain  portion  of  pa- 
tients with  pulmonary  tuberculosis,  ac- 
centuated second  pulmonic  sound,  func- 
tional murmurs,  etc.  The  frequency  and 
tension  of  the  pulse  are  changed  early 
and  often  permanently.  Palpitation  is 
an  accompaniment  at  puberty  and  the 
menopause;  it  may  precede  haemoptysis, 
and    accompany   dyspepsia.     L.    Brown 


26 


LOCOMOTOR  ATAXIA. 


OPHTHALMO-REACTION  TO  TUBERCULIN. 


(American  Journal  of  the  Medical  Sci- 
ences, December,  1908). 

LOCOMOTOR  ATAXIA,  TREATMENT  OF, 

The  writer  deprecates  the  general 
tendency  to  give  an  unfavorable  prog- 
nosis in  cases  of  locomotor  ataxia,  which 
has  a  tendency  to  send  the  patients  to 
the  pretentious  quacks,  of  course,  to  be 
disappointed  in  the  end.  Two  classes  of 
cases  are  recognized  by  the  writer,  one 
including  about  60  per  cent,  of  all  pa- 
tients, and  in  which  the  disease  is  a 
paras3'philitic  affection,  progressive  and 
usually  incurable,  though  subject  to  fa- 
vorable modifications,  and  even  arrest  by 
intelligent  treatment;  the  other  40  per 
cent,  includes  patients  who  are  not  only 
capable  of  being  greatly  helped,  but 
often  of  being  cured.  Of  course,  evi- 
dences of  destructive  neural  disease  is  of 
unfavorable  signification.  Considering 
the  larger  proportion  of  luetic  cases, 
specific  treatment  is  suggested,  and  it  is 
found  that  in  about  20  per  cent,  the  use 
of  mercurials  is  of  advantage,  especially 
the  bichloride.  The  treatment  of  special 
symptoms  is  of  great  importance,  and 
attention  is  called  to  the  effect  of  baro- 
metric conditions  on  the  ataxic  pains 
which  are  for  this  reason  often  consid- 
ered rheumatic.  If  this  influence  can  be 
determined,  the  use  of  the  salicylates 
and  hydrotherapy  are  often  of  value,  and, 
with  the  judicious  control  of  the  phy- 
sician, the  use  of  morphine  is  compara- 
tively safe.  Dietetic  regulation  should 
be  instituted  for  the  gastric  crises,  which 
are  often  associated  with  intestinal  dis- 
turbances and  autointoxication.  The  use 
of  counter-irritation  is  also  mentioned. 
For  the  ataxia,  the  Fraenkel  systematic 
exercises  may  do  much  good  in  cases  in 
which  there  is  not  too  much  pain,  gastric 
crises  or  excessive  friability  of  the 
bones.     Overexercise  and  fatigue,  how- 


ever, should  be  avoided.  When  there  is 
plantar  anaesthesia,  perhaps  causing  the 
ataxia,  the  author  has  found  surprising 
benefit  from  the  high-frequency  current 
applied  directly  to  the  sole  by  means  of 
a  spark  electrode.  He  has  no  faith  in 
other  forms  of  electricity  for  this  pur- 
pose. For  the  urinary  difficulties  occur- 
ring in  about  half  the  cases,  lavage  of  the 
bladder  at  regular  intervals,  used  for  a 
long  period,  is  important.  A  warm  win- 
ter climate  is  useful  in  tabetic  cases,  and, 
preferably,  dry  climates.  Cases  due  to 
shock,  trauma  or  hysteria  are  often  cur- 
able by  very  simple  means,  if  there  is  no 
syphilitic  basis.  A.  McL.  Hamilton 
(Journal  of  the  American  Medical  Asso- 
ciation, December  5,  1908). 

OPHTHALMO-REACTION  TO  TUBERCULIN. 

In  this  communication  the  author  has 
confined  himself  to  the  report  of  per- 
sonal clinical  and  experimental  facts. 
From  the  clinical  standpoint,  he  was,  in 
collaboration  with  M.  Dumarest,  one  of 
the  first  to  call  attention  to  the  thermic 
reaction  and  the  general  phenomena  that 
follow  the  instillation  of  tuberculin  into 
the  eye.  In  some  cases  he  has  seen  the 
conjunctival  reaction  accompanied  at  the 
time  by  more  or  less  marked  dilatation 
of  the  pupil;  much  more  rarely  myosis 
was  observed  under  the  same  circum- 
stances. In  his  earliest  researches  he 
also  observed,  without  at  the  time  offer- 
ing any  explanation,  a  phenomenon 
which  he  regarded  as  a  kind  of  local 
anaphylaxis,  namely,  that  a  patient  in 
whom  the  ophthalmo-reaction  was  nega- 
tive at  the  first  instillation  may  react  to 
a  second,  or  even  a  third  test. 

With  regard  to  the  interaction  of 
tuberculin  treatment  and  the  ocular  test, 
it  appears  that  a  previous  ocular  reac- 
tion is  frequently  revived  by  the  sub- 
cutaneous injection  of  medicinal  doses  of 


OPHTHALMOREACTION   TO   TUBERCULIN. 


27 


tuberculin;  but  this  does  not  constitute 
a  contraindication  to  the  employment  of 
the  two  procedures  in  the  same  subject. 
It  also  appears  that  a  previous  impreg- 
nation of  a  patient  with  tuberculin  for 
therapeutic  purposes  has  a  very  variable 
effect  on  a  subsequent  ocular  test. 

The  ocular  reaction  is  not  free  from 
danger.  It  is  occasionally  accompanied 
by  ocular  complications,  such  as  pro- 
longed conjunctivitis  and  ulcerations  of 
the  cornea.  The  previous  instillation  of 
1  to  3,000  adrenalin  is  capable  of  coun- 
teracting certain  excessively  violent  or 
prolonged  reactions. 

In  the  second  part  of  his  communica- 
tion the  author  gives  the  result  of  his  ex- 
perimental researches  on  the  pathogenic 
mechanism  of  the  ocular  reaction  to 
tuberculin :  Non-tuberculous  rabbits  im- 
pregnated with  various  microbic  poisons 
(tuberculin,  typhoid,  staphylococcus  and 
diphtheritic  toxins)  gave  positive  ocular 
reactions.  The  rabbit  was  in  fact  more 
actively  sensitized  by  the  typhoid  toxin 
than  by  tuberculin,  or  at  least  to  an  equal 
degree.  In  the  same  manner,  horses  used 
for  the  production  of  antidiphtheritic 
and  antitetanic  serum  reacted  positively 
under  certain  conditions. 

These  experimental  facts,  which  show 
that  a  positive  ocular  reaction  to  tuber- 
culin may  be  obtained  in  non-tuberculous 
subjects,  accord  with  the  clinical  cases  of 
positive  reactions  in  the  non-tuberculous 
suffering  from  typhoid,  staphylococcic, 
syphilitic,  or  some  other  infection.  On 
the  strength  of  these  two  series  of  ob- 
servations, the  writer  believes  that  the 
ocular  reaction  to  tuberculin,  which  rep- 
resents a  local  vasomotor  reaction,  may 
occur  whenever  the  Tasomotor  centers  of 
an  individual  are  in  a  condition  to  react 
by  vaso-dilatation  by  reason  of  their  be- 
ing impregnated  with  a  microbic  toxin. 
Hence  the  ocular  reaction  to  tuberculin 


occurs  in  individuals  who  are  in  a  state 
of  intoxication,  i.  e.,  whose  organism  is 
impregnated  and  sensitized  by  a  toxin  of 
any  kind.  The  ocular  reaction  is  there- 
fore not  absolutely  specific  from  a  theo- 
retical sense,  but  has  merely  a  relative 
value. 

In  the  third  portion  of  his  paper  the 
author  takes  up  a  comparative  study  of 
the  ocular  reaction  and  the  bacterial 
serum-agglutination  test.  These  two  re- 
actions are  often  found  in  the  same 
individual ;  while  on  the  other  hand,  one 
may  be  present  when  the  other  is  absent; 
or,  finally,  one  may  be  more  intense  than 
the  other. 

The  study  of  the  symptoms  and  of  the 
clinical  course  in  these  cases  of  contra- 
dictory reactions  has  led  the  author  to 
attribute  a  different  value  to  the  ophthal- 
mo-reaction  from  that  which  belongs  to 
the  serum-reaction.  The  ophthalmo-re- 
action  indicates  that  the  organism  is 
intoxicated  with  tuberculin;  the  serum- 
reaction,  on  the  other  hand,  like  aggluti- 
nation reactions,  is  generally  recognized 
as  showing  a  defensive  reaction  of  the 
economy,  while  the  intensity  of  the  reac- 
tion measures  the  degree  of  immunity  of 
the  individual  to  the  tubercle  bacillus. 

It  appears,  therefore,  that  in  practice, 
at  a  certain  point  in  the  evolution  of  a 
tuberculous  disease,  a  positive  ophthal- 
mo-reaction  with  a  negative  serum-reac- 
tion indicates  a  doubtful  prognosis; 
while  the  contrary  would  indicate  a 
favorable  outcome.  When  the  two  phe- 
nomena are  practically  equal  in  intensity, 
it  shows  that  the  organism  is  in  a  state 
of  indifferent  equilibrium  and  that  the 
disease  may  either  end  in  recovery  or 
the  patient  succumb  to  unfavorable  in- 
fluences. 

Such  is  the  significance  which  the 
writer  attributes  to  the  ocular  reaction, 


28 


PANCREATITIS. 


RHEUMATISM  AND  TUBERCULOSIS. 


but  no  positive  conclusion  can  be  drawn 
in  such  a  complicated  question. 

To  sum  up,  the  ocular  reaction  is  a 
convenient  and  easily  available  diagnostic 
procedure;  it  sometimes  fails  in  patients 
who  are  certainly  tuberculous;  and  on 
the  other  hand,  may  occur  in  subjects 
not  suffering  from  a  bacterial  infection. 
Its  diagnostic  value,  although  quite  con- 
siderable in  practice,  is  nevertheless  not 
absolute.  The  test  is  not  always  harm- 
less. It  has  not  proved  itself  superior  to 
the  bacillary  serum-agglutination,  which 
has  the  advantage  over  the  ocular  test  of 
being  absolutely  harmless,  more  constant, 
and  more  delicate.  Finally,  the  oph- 
thalmo-reaction  is  an  indication  rather 
of  the  degree  of  intoxication  of  the  or- 
ganism, while  the  serum-reaction  reveals 
the  forces  available  for  defense  against 
the  infection.  F.  Arloing  (Transactions 
Congress  of  Tuberculosis,  September  29, 
1908). 

PANCREATITIS,  ETIOLOGY  AND  PATHO- 
GENESIS or. 

Gall-stones  are  etiologically  associated 
with  pancreatitis  in  from  nearly  one-half 
to  over  three-fourths  of  tlie  cases  (43 
per  cent,  of  Egdahl  to  83  per  cent,  of 
Mayo).  Anatomical  peculiarities  and 
variations  of  the  terminal  pancreatic 
ducts  are  the  determining  factors  in  the 
occurrence  of  pancreatitis  in  some  cases 
of  gall-stones  and  not  in  others.  Lodg- 
ment of  a  stone  in  the  ampulla  of  Vater, 
temporarily  or  permanently  causing  re- 
trojection  of  bile  into  the  pancreatic  duct 
(Opie),  causes  acute  hemorrhagic  pan- 
creatitis. The  chronic  indurative  or  in- 
terstitial type  is  caused  by  stones  lodged, 
resident,  or  escaping  through  the  com- 
mon duct. 

Bacterial  invasion  is  secondary  to 
some  unph3'siologic  or  mechanical  inter- 
nal injury.    Infection  of  the  pancreas  by 


the  lymphatics  in  cases  of  cholecystitis 
is  probably  a  more  frequent  avenue  than 
by  continuity.  Gastro-duodenitis  ap- 
pears to  be  responsible  for  about  one- 
third  of  the  cases.  "Catarrhal  jaundice" 
is  probably  caused  by  inflammatory 
swelling  of  the  head  of  the  pancreas 
compressing  the  common  duct  of  the 
liver,  in  many  instances.  Mumps  causes 
about  10  per  cent,  of  the  cases  of  pan- 
creatitis, and  some  other  infections  may 
likewise  cause  it  by  metastasis.  Fat 
necrosis,  with  acute  hsemorrhagic  pan- 
creatitis, is  caused  by  some  injury  to  the 
gland  cells,  and  access  of  bile  or  entero- 
kinase,  which  activates  the  haemolytic 
property  of  pancreatic  juice.  W.  D. 
Haggard  (Surgery,  Gyngecology  and  Ob- 
stetrics, December,  1908). 

PLEURAL  ADHESIONS  IN  SUDDEN  DEATH, 
ASPHYXIA  AND  SEVERE  INJURIES. 
Pleural  adhesions  occur  in  80  per  cent, 
of  cases.  They  are  most  frequently  of 
tuberculous  origin.  Every  individual 
with  pleural  adhesions  is  liable  to  sudden 
death.  Every  patient  with  adhesions 
falling  in  water  is  a  doomed  man  ( Lacas- 
sagne).  Adhesions  may  aid  rapid  death 
in  anaesthesia  or  after  severe  surgical  in- 
juries. Their  importance  is  therefore 
very  great  in  general  medicine  and  in 
legal  medicine.  They  are  the  more  inju- 
rious as  they  are  more  extensive.  La- 
cassagne  and  Martin  (Transactions  Con- 
gress of  Tuberculosis,  October  2,  1908). 

RHEUMATISM,    TUBERCULOUS    AND    IN- 
FLAMMATORY TUBERCULOSIS. 

Our  researches  during  the  past  ten 
years  have  established  the  existence  of  ^ 
articular  and  non-articular  tuberculous 
rheumatism.  This  last  comer  among  the 
infectious  rheumatisms  should  be  placed 
in  the  front  rank,  as  it  is  the  most  fre- 
quent, and  its  frequency  is  explained  by 


SCARLET  FEVER,  TREATMENT  OF. 


29 


the  frequency  of  tuberculosis.  The  vari- 
ous forms  of  tuberculous  rheumatisms 
range  from  the  acute  forms  (acute  and 
subacute  articular  rheumatism)  through 
all  the  intermediary  grades  to  the  chronic 
forms  (nodular,  deforming,  ankylosing 
articular  rheumatism). 

As  a  rule,  the  articular  lesions  do  not 
exhibit  the  characteristics  of  classic  tu- 
berculosis, such  as  tubercules,  caseous 
infiltration,  etc.  (macroscopic  features), 
or  tuberculous  follicles,  giant-cells,  etc. 
(microscopic  features)  that  constitute 
the  characteristic  picture  to  which  the 
term  "specific  tuberculosis"  may  prop- 
erly be  applied.  The  lesions,  on  the  con- 
trary, are  made  up  solely  of  inflamma- 
tory tissue;  hence  the  name  "inflamma- 
tory tuberculosis,"  which  we  have  given 
to  this  variety  of  tuberculosis. 

There  are  accordingly  two  great  varie- 
ties of  tuberculosis :  Specific  tuberculo- 
sis, which  has  been  admirably  studied 
and  is  well  known;  and  inflammatory 
tuberculosis,  with  an  insignificant  ana- 
tomic reaction,  purely  inflammatory,  as 
in  all  infections  and  intoxications. 
This  latter  form  of  tuberculosis  has 
been  studied  more  particularly  during 
the  past  five  years  by  the  writer.  It  em- 
braces the  attenuated  forms  of  tuber- 
culosis which  until  that  time  had  not 
been  properly  recognized.  Its  range  is 
no  less  extensive  than  that  of  virulent 
specific  tuberculosis.  It  attacks  all  the 
tissues,  all  the  systems,  all  the  organs, 
as  well  as  the  joints,  where  its  existence 
was  first  revealed  to  us  under  the  form 
of  tuberculous  rheumatism.  Quite  often 
it  takes  the  place  of  the  arthritic,  fibrous 
or  neuro-arthritic  diathesis,  etc.,  terms 
which  are  becoming  more  and  more 
vague  and  less  acceptable,  because  they 
merely  refer  to  syndromes  brought  about 
by  the  tuberculous  virus  under  a  great 
variety   of    circumstances.      A.    Poncet 


(Transactions  Congress  of  Tuberculosis, 
October  2,  1908). 

SCARLET   FEVER,  TREATMENT   OF. 

The  severity  of  the  sore  throat  in 
every  case  of  scarlet  fever  in  the  writer's 
experience  invariably  was  proportional 
to  the  severity  of  the  disease  and  the 
gravity  of  the  prognosis,  especially  in  re- 
gard to  the  complications.  By  keeping 
the  process  in  the  throat  under  control 
it  is  possible  to  attenuate  the  infection 
and  ward  off  complications.  Direct 
local  applications  with  a  brush  are  liable 
to  be  too  superficial  to  do  any  good,  or, 
if  applied  vigorously,  may  abrade  the 
surface  and  open  new  portals  for  infec- 
tion. Gargling  is  also  too  superficial  in 
its  effects,  and  it  is  difficult  to  get  chil- 
dren to  rinse  out  their  mouths  effectu- 
ally with  an  antiseptic  mouth-wash. 
The  author  has  derived  much  benefit 
from  direct  insufflation,  through  a 
straight  tube,  of  a  mixture  of  equal 
parts  of  sodium  sozoiodolate  and  sul- 
phur. It  is  necessary  to  repeat  this  in- 
sufflation every  hour,  day  and  night,  to 
have  it  do  any  good,  and  the  writer  in- 
sists on  this  when  he  sees  that  the 
throat  process  is  assuming  a  progressive 
character.  He  continues  this  local  ap- 
plication until  the  ulcerations  are  cir- 
cumscribed and  the  ml^cous  production 
has  ceased.  As  the  throat  process  be- 
comes attenuated  under  the  influence  of 
this  local  treatment,  the  general  symp- 
toms subside,  and  he  has  never  had 
otitis  develop  or  phlegmon  in  the  maxil- 
lary glands  under  it.  In  a  few  in- 
stances otitis  developed  a  week  later,  but 
this,  he  states,  must  have  been  from  in- 
fection by  way  of  the  blood,  and  the 
otitis  was  always  mild  and  rapidly  sub- 
sided after  paracentesis. 

The  kidney  complications  must  be 
warded  off  by  strict  dietetic  measures, 


JO 


TUBERCLE  BACILLUS.       TUBERCULOUS   EFFUSIONS. 


avoidance  of  all  nitrogenous  foods  and 
alcohol,  and  reliance  on  milk  as  the 
main  article  of  diet.  During  a  very 
tempestuous  onset  of  the  infection,  when 
there  is  danger  of  heart  failure,  large 
doses  of  alcohol  may  be  given  to  tide  the 
patient  past  this  crisis,  but  after  this,  al- 
cohol should  be  forbidden  in  any  form. 
The  author  keeps  his  patients  in  bed  for 
four  weeks.  His  careful  examination  of 
long  series  of  scarlet  fever  patients  has 
failed  to  reveal  the  diphtheria  bacillus 
in  the  throat  in  any  instance.  Eubens 
(Berliner  klinische  Wochenschrift,  Octo- 
ber 19,  1908;  Journal  of  the  American 
Medical  Association,  November  21, 
1908). 

TUBERCLE  BACILLUS,  HOMOGENEOUS 
CULTURES  OF  THE. 
In  1898,  Arloing  made  the  discovery 
of  the  homogeneous  cultures  of  Koch's 
bacillus.  Their  study  has  been  continued 
by  S.  Arloing  and  P.  Courmont,  who  are 
now  in  possession  of  seven  different  kinds 
of  homogeneous  cultures  of  Koch's  bacil- 
lus, obtained  from  different  sources:  5 
human  organisms,  1  bovine,  and  2  avian. 
Courmont  was  able  to  render  homo- 
geneous the  first  organism  isolated  by 
Koch,  which  has  been  cultivated  in  the 
laboratory  for  the  past  27  years.  This 
was  therefore  not  an  achievement  in  new 
lines  of  research,  but  essentially  an  adap- 
tation of  Koch's  bacillus  to  life  in  homo- 
geneous cultures,  i.  e.,  in  liquid  cultures 
of  uniform  turbidity  and  in  which  the 
organisms  are  evenly  scattered.  These 
observers  studied  the  variations  in  mor- 
phology— resistance  to  acid,  and  virulence 
— of  the  bacillus  modified  as  above.  The 
homogeneous  cultures  retain  certain 
characteristics  pointing  to  their  identity 
as  tubercle  bacilli,  including  the  power 
of  tubercle-  formation.  Certain  of  these 
cultures  are  subject  to  agglutination  and 


are  useful  in  serum-diagnosis  (method  of 
Arloing  and  Courmont).  The  discovery 
made  by  these  investigators  is  thus  of 
some  practical  importance  (serum-diag- 
nosis and  prognosis),  as  well  as  of  great 
interest  from  the  view  point  of  general 
bacteriology.  S.  Arloing  and  P.  Cour- 
mont, Oct.  1,  1908;  (Transactions  Con- 
gress of  Tuberculosis,  Oct.  1,  1908). 

TUBERCULOUS  EFFUSIONS  AND  THEIR 
DIAGNOSTIC  AND  PROGNOSTIC  SIG- 
NIFICANCE. 

The  writer  studied  the  fluid  of  tuber- 
culous effusions,  pleural  in  particular. 

1.  Amount. — In  a  tuberculous  effu- 
sion, large  amount  is  a  good  sign  in 
prognosis. 

2.  Coagulability. — High  fibrin-content 
and  clotting  are  favorable,  and  vice 
versa. 

3.  Toxicity.  Anaphylaxis. — Tuber- 
culous effusions  show  high  toxicity  when 
intravenously  injected  in  rabbits,  Cour- 
mont, in  1900,  discovered  the  anaphyl- 
actic property  of  tuberculous  effusions 
when  inoculated  in  guinea-pigs.  Whereas 
a  large  single  dose  is  not  toxic,  repeated 
very  small  doses  cause  death.  It  is 
essential  to  know  whether  the  human 
patient  has  not  been  anaphylacticized 
through  reabsorption  of  his  own  effusion 
(See  Archives  de  Pharmacodynamic, 
1900). 

4.  Bactericidal  Power. — The  observer 
has  shown  that  pleural  fluid  is  bacte- 
ricidal in  vitro  for  homogeneous  cultures 
of  Koch's  bacillus  (C.  R.  de  la  Soc.  de 
Biol.,  1898)  ;  the  process  is  thus  a 
defensive  one. 

5.  Agglutinating  Power. — Tuberculous 
pleural  effusions  agglutinate  the  bacilli 
of  Koch.  (See  special  communication  by 
the  same  author  to  the  Congress  on 
Serum-diagnosis,  on  the  diagnostic  and 


TUBERCULOUS  IMMUNITY.      TYPHOID  FEVER,  ASCITES  IN. 


31 


prognostic    significance,    based    on    120 
personal  observations). 

6.  The  pleura  plays  an  active  role,  it 
produces  antibodies,  and  is  not  a  mere 
passive  filter.  P.  Courmont.  (Trans- 
actions Congress  of  Tuberculosis,  Oct.  1, 
1908). 

TUBERCULOUS  IMMUNITY  AND  NEGA- 
TIVE REINOCULATIONS. 

The  reinoculation  of  tuberculosis  at 
another  point  on  the  body  of  an  animal 
which  is  already  tuberculous  may  give  a 
positive  or  a  negative  result.  Opinions 
on  this  point  are  divided.  The  authors 
have  tested  this  question  on  the  guinea 
pig,  using  very  virulent  cultures  of 
bovine  bacilli  with  their  transcutaneous 
method  of  inoculation  (Societe  de  Bio- 
logic et  Journal  de  Physiologie  et  de 
Pathologic  generale,  1907).  Favorable 
conditions  are  found  in  the  slowness  of 
the  process,  the  insignificance  or  absence 
of  local  lesions,  and  the  magnitude  of 
the  caseous  glands.  If  a  guinea  pig 
which  has  been  tuberculous  for  from 
thirteen  to  twenty  days  is  inoculated 
under  the  skin,  the  glandular  reaction  is 
feebler  than  in  control  animals;  but 
these  results  of  subcutaneous  inoculation 
are  not  conclusive. 

The  results  are  very  clearly  defined 
when  two  successive  transcutaneous  in- 
oculations are  made  at  intervals  of  at 
least  two  weeks.  (This  is  accomplished 
by  simply  rubbing  the  culture  on  the 
skin).  The  reinoculation  is  negative. 
No  local  lesion  wTiatever  is  produced; 
the  glands  do  not  become  tuberculous; 
they  scarcely  hypertrophy  and  are  never 
caseous.  No  general  effect  is  produced 
either  in  the  spleen  or  elsewhere.  On 
the  other  hand,  if  the  animals  are 
allowed  to  live,  the  first  inoculation  runs 


its  normal  course;  it  is  accompanied  by 
general  lesions  and  ultimately  kills  the 
animal.  This  proves  that  a  lesion  in 
process  of  evolution  prevents  the  evolu- 
tion of  a  second  inoculation. 

The  author's  experiments  suggest  the 
following  question :  Is  a  tuberculous 
human  being  during  the  period  of  evo- 
lution immune  to  reinfection?  Jules 
Courmont  and  A.  Lesieur  (Transactions 
Congress  of  Tuberculosis,  October  1, 
1908). 

TYPHOID  FEVER,  ASCITES  IN. 

Peritoneal  effusion  in  typhoid  fever, 
apart  from  peritonitis,  is  of  rare  occur- 
rence. The  writer  has  observed  six 
cases  in  the  past  three  years,  in  all  of 
which  the  effusion  occurred  during  the 
course  of  the  illness,  persisted  from  ten 
days  to  two  weeks,  and  disappeared  in 
all  but  one  of  the  cases  with  convales- 
cence. In  only  one  of  the  cases  was 
there  haamorrhage  or  s3anptoms  of  peri- 
tonitis. In  four  of  the  cases  the  effusion 
was  due  to  pathological  conditions  re- 
sulting from  typhoid  infection,  though 
the  immediate  cause  was  uncertain. 
The  relaxed  condition  of  the  abdominal 
walls  favored  stasis  and  serous  transuda- 
tion. The  enlarged  mesenteric  glands 
may  also  have  caused  sufficient  irritation 
of  the  peritoneum  to  produce  effusion. 
The  element  of  toxaemia  must  also  be 
taken  into  account,  a  toxic  substance 
possibly  so  affecting  the  hepatic  cells  as 
to  obstruct  the  portal  circulation,  or  so 
changing  the  peritoneal  epithelium  as  to 
permit  a  more  rapid  escape  of  serous  ex- 
udate, causing  such  obstruction  to  the 
peritoneal  lymphatic  vessels  that  the  ex- 
udate may  not  be  readily  removed.  A. 
McPhedran  (American  Journal  of  the 
Medical  Sciences,  November,  1908). 


32  BOOK  REVIEWS. 

5ool(  Reviews 


The  Subgert  of  the  Ear.  By  Samuel  J.  Kopetzky,  M.D.  Attending  Otologist,  New  York 
City  Children's  Hospitals  and  Schools;  Attending  Otologist  to  the  New  York  Red  Cross 
Hospital;  Assistant  Surgeon  and  Instructor  in  Operative  Surgery  of  the  Ear,  Man- 
hattan Eye,  Ear,  and  Throat  Hospital;  Pathologist  and  Surgeon,  New  York  Throat, 
Nose  and  Lung  Hospital;  Fellow  of  the  American  Laryngological,  Rhinological  and 
Otological  Society;  Fellow  of  the  New  York  Academy  of  Medicine,  American  iledical 
Association,  Otological  Society  of  Germany,  etc.  Illustrated  with  63  Half-tone  and 
Line  Drawings,  8  Charts  and  4  Colored  Plates.  New  York:  Rebman  Company,  1123 
Broadway. 

The  present  tendencj^  toward  specialism  and  the  recent  advances  made  in  otological 
surgery  influenced  the  author  to  feel  the  necessity  for  a  work  dealing  exclusively  with  the 
surgery  of  the  ear. 

The  volume  presented  for  review  is  written  in  the  form  of  a  series  of  monographs.  An 
attempt  has  been  made  by  the  writer  to  correlate  the  extensive  literature  on  the  subject, 
and  with  the  benefit  of  personal  experience  and  observation,  to  produce  a  book  adapted  to 
the  needs  of  the  medical  student,  the  practitioner  and  the  specialist.  Each  chapter  is 
preceded  by  an  abstract  of  the  substance  contained  therein  and  is  followed  by  the  citation 
of  the  references  used.  Special  stress  has  been  laid  on  the  indication  for  operation,  the 
points  of  technique,  and  the  after  treatment  of  the  wound,  including  the  consideration  of 
the  patient's  general  condition.  The  cuts  are  usually  good,  but  many  rovigli  draviings  are 
also  used  to  further  illustrate  certain  points  in  the  text.  The  quality  of  paper  used  is 
hardly  up  to  the  standard  one  usually  sees,  and  the  binding  of  tlie  book  is  rather  in- 
secure.— R.  B.  S. 

A  Manual  of  the  Pbactice  of  Medicine.     By  A.  A.  Stevens,  A.!\I.,  M.D.,  Professor  of  Thera- 
peutics  and   Clinical  Medicine   in  the   Woman's  Medical   College   of  Pennsylvania.     New 
Eighth  Edition,  Thoroughly  Revised.     12mo  of  558  Pages,  Illustrated.     Philadelphia  and 
London:    W\  B.  Saunders  Company,  1907.     Flexible  Leather,  $2.50  net. 
Of  the  works  which  give  a  brief  outline  of  each  disease,  Dr.  Stevens's  is  undoubtedly  one 
of  the  best.     Each  disorder  is  reviewed  with  great  clearness  and  accuracy,  the  object  being  to 
present  the  saUent  facts  which  the  mind  retains  when  larger  works  are  read.     For  the  present 
edition    (the  eighth)    many  new  articles  have  been  prepared,  while  those  bearing  upon  the 
nervous  system  have  been  rewritten.     We  miss,  however,  a  condition  frequently  met  with  in 
practice:     cystitis   and   other   disorders   of   the   bladder.     The   diseases   of   the   skin   and   its 
appendages  are  treated  quite  fully  for  so  small  a  work — a  fact  which  makes  it  all  the  more 
useful  to  the  student  and  practitioner. 

Atlas  and  Text-Book  of  the  Human  Anatomy,  Volume  III.     Vascular  System,  Lymphatic 

System,   Nervous   System   and    Sense   Organs.     By    Dr.    Johannes    Sobotta,    Professor   of 

Anatomy    in    the    University    of    Wiirzburg.     Edited    with    Additions,    by    J.    Playfair 

McMurrich,  A.M.,  Ph.D.,  Professor  of  Anatomy  in  the  University  of  Toronto;    Formerly 

Professor  of  Anatomy  in  the  University  of  Michigan.     With  297  Illustrations,  Mostly  in 

Colors.     Philadelphia  and  London:    W.  B.  Saunders  Company,  1907.     Cloth,  $6.00. 

The  third  and  last  volume  of  Sobotta  and  McMurrich's  atlas  and  text-book  of  anatomy  is 

in  no  way  inferior  to  its  predecessors  in  scientific  precision  and  artistic  execution.     It  includes 

the  remainder  of  the  vascular  system    (begun  in  the  preceding  volume),  the  entire  nervous 

system,  and  the  organs  of  special  sense.     Of  material  advantage  to  the  student  as  well  as  to 

the   surgeon,   is   the   presentation   of   the   nerves   and  blood-vessels   as   they   are   seen   in   the 

cadaver,  i.  e.,  together.     Tlie  relations   of   these   structures   is   thus  readily  apprehended — an 

advantage  which  is  totally  lost  when,  as  is  usually  the  case,  the  vessels  and  nerves  are  depicted 

separately.     The    plates    illustrating    the    nervous    system    are    particularly    beautiful    and 

instructive.     On  the  whole,  the  author,  editor  of  the  American  edition,  and  the  publishers, 

are  to  be  highly  complimented  for  the  admirable  way  in  which  they  have  performed  their 

respective  tasks. 


ONTHLY   Cyclopaedia 

AND 

Medical  Bulletin 


(Published  thb  Last  of  Each  Month) 


Medical  Bulletin  Section 


Vol.  II.  PHILADELPHIA,  JANUARY,  1909.  No.  1. 


TYPHOID  FEVER— SYPHILIS. 

By  JOHN  V.  SHOEMAKER,  M.D.,  LL.D., 

Professor  of  Materia  Medica,  Therapeutics,  Clinical  Medicine,  and  Diseases  of  the  Skin, 

in  the  Medico-Chirurgical  College  and  Hospital  of  Philadelphia. 

TYPHOID  FEVER. 

Gentlemen  : — I  have  the  pleasure  this  morning  to  show  you  a  patient  who 
presents  a  typical  history  and  symptoms  of  an  acute  infectious  disease. 

The  patient  is  a  male,  age  41  years,  nativity  Poland. 

Family  History: — His  parents  are  both  dead.  The  father  died  of  pneu- 
monia at  the  age  of  51  j^ears  and  the  mother  at  the  age  of  60;  cause  of  death 
was  cancer  of  the  stomach.  He  has  two  brothers  and  three  sisters  living  and 
welL    One  brother  died  at  the  age  of  twelve  from  scarlet  fever. 

He  has  no  definite  knowledge  of  his  grandparents,  uncles  or  aunts,  since 
he  came  to  America  when  a  small  boy. 

Previous  Personal  History: — When  he  was  a  child  he  had  measles,  small- 
pox and  scarlet  fever.  He  had  pneumonia  at  the  age  of  sixteen,  from  which 
time  he  has  always  enjoyed  good  health  until  two  weeks  ago. 

His  habits  are  good;  he  uses  neither  alcoholic  beverages  nor  tobacco.  He 
drank  Schuylkill  water  from  the  spigot. 

Social  History: — He  is  married  and  is  the  father  of  five  healthy  children: 
three  sons  and  two  daughters.  The  wife  is  living  and  in  good  health.  He 
denies  having  had  any  venereal  diseases. 

Present  Ulness: — Two  weeks  ago  he  first  began  to  feel  tired  and  languid. 
His  appetite  became  poor  and  his  bowels  constipated.  He  also  had  headache 
and  a  slight  cough.  Five  days  ago  he  first  called  in  his  family  physician  who 
had  him  transferred  to  the  hospital. 

5  (33) 


34  TYPHOID  FEVER— SYPHILIS. 

On  admission  to  the  hospital  his  temperature  was  103%°  F.,  pulse  88, 
respiration  32  per  minute.  A  physical  examination  showed  that  the  skin  was 
dry  and  hot  to  the  touch  and  that  over  the  abdomen  and  back  were  many  small 
rose  spots,  ^\■hich  disappeared  on  pressure.  The  lymphatic  glands  are  not 
enlarged.  The  odor  of  his  breath  is  offensive;  the  tongue  is  dry  and  parched 
and  the  teeth  are  covered  with  sordes. 

The  organs  of  the  chest  are  apparently  normal.  The  spleen  is  markedly 
enlarged  and  he  complains  of  tenderness  in  the  right  iliac  fossa.  We  also 
obtained  a  positive  Widal  and  Diazo  reaction. 

Diagnosis: — This  is  undoubtedly  a  case  of  typhoid  fever.  The  history  of 
malaise,  anorexia,  constipation  and  headache,  together  with  the  physical  signs 
of  elevation  of  temperature,  no  accelerated  pulse,  normal  respiration,  rose  spots, 
enlarged  spleen,  iliac  tenderness  and  a  positive  Widal  and  Diazo  reaction  are 
all  pathognomonic  of  typhoid  fever.  The  symptoms  in  this  patient  are  so 
typical  that  it  could  not  possibly  be  mistaken  for  any  other  disease.  However, 
in  obscure  cases  care  must  be  exercised  and  a  differential  diagnosis  made  be- 
tween it  and  typhus  fever,  typho-malarial  fever,  septicjemia,  acute  tuberculosis 
and  relapsing  fever. 

Tor  your  convenience  we  have  placed  on  the  blackboard  the  differential 
diagnosis  of  the  diseases  mentioned. 

Differential  Diagnosis. 

Typhoid  Fever.  Typhus  Fever. 

1.  Disease  is  endemic.  1.  Disease  is  epidemic. 

2.  Onset  slow.  2.  Onset  sudden. 

3.  Eruption  of  roseate  spots  appears  from  3.  Appearance  of  maculse  which  are  trans- 

7th  to  10th  day.  formed  into  petechia  on  the  4th  day. 

4.  Eruption    disappears    on    pressure.  4.  Does  not  disappear  on  pressure. 

5.  Temperature     characteristic     for     each       5.  Temperature   high    from    the    first    and 

week  of  disease.  remains  so  until  the  crisis. 

6.  Course  longer.  6.  Course  shorter. 

7.  No  crisis.  7.  Abrupt  termiliation  by  crisis. 

8.  Diarrhoea.  8.  Constipation. 

9.  Gives  Widal  reaction.  9.  Does  not  give  Widal  reaction. 

Typhoid  Fever.  Typho- Malarial  Fever. 

1.  Onset  slow  with  chilly  sensation.  1.  Onset  sudden  with  a  marked  chill, 

2.  Temperature  rises  slowly  and  gradually.       2.  Temperature     rises     suddenly     and     is 

periodical  in  character. 

3.  Characteristic  eruption.  3.  No  characteristic  eruption. 

4.  Diarrhoea  characteristic.  4.  Diarrhoea  not  characteristic. 

5.  Presence  of  typhoid  organisms.  5.  Not  present. 

G.  Gives  Widal  reaction.  6.  Absence  of  Widal  reaction. 

Typhoid  Fever.  Septicemia. 

1.  Temperature  characteristic.  1.  Temperature   very    high    and    irregular 

from  first. 

2.  Characteristic  eruption.  2.  No  eruption. 

3.  History  of  exposure  to  typhoid  poison.       3.  History  of  injury  or  infectious  disease. 

4.  Presence  of  Widal  reaction.  4.  Absence  of  Widal  reaction. 


TYPHOID  FEVER— SYPHILIS.  35 

Typhoid  Fever.  Acute  Tulerculosis. 

1.  Disease  is  endemic.  1.  Disease  is  hereditary  or  secondary. 

2.  No  leucocytosis.  2.  Leucocytosis. 

3.  Peculiar  temperature  curve.  3.  No  peculiar  temperature  curve. 

4.  Presence      of      lenticular      spots  and       4.  Absent. 

abdominal  symptoms, 

5.  Presence  of  typhoid  bacilli.  5.  Presence  of  tubercle  bacilli. 

6.  Gives  Widal  reaction.  6.  Does  not  give  Widal  reaction. 

7.  Countenance  flushed.  7.  Countenance  not  flushed. 

8.  Choroid  normal.  8.  Tubercular  ulceration  of  the  choroid. 

Typhoid  Fever.  Relapsing  Fever. 

1.  Onset  slow.  1.  Abrupt  onset,  rigor,  high  temperature. 

2.  Duration  longer.  2.  Duration  brief. 

3.  No  crisis.  3.  Termination  by  crisis. 

4.  Characteristic  eruption.  4.  No  characteristic  eruption. 

5.  Gives  sero-reaction.  5.  Does  not  give  sero-reaction. 

6.  No  relapse  at  end  of  week.  6.  Occurrence  of  relapse  at  end  of  week. 

7.  Presence  of  typhoid  bacilli.  7.  Finding  of  spirilli. 

Pathology: — The  specific  lesions  of  typhoid  fever  occur  in  the  lymphatic 
structures,  notably  in  the  solitary  follicles,  Peyer's  patches,  mesenteric  glands 
and  the  spleen.  The  lesions  thus  produced  are  due  (1)  either  to  a  direct  effect 
of  the  typhoid  bacilli  upon  these  lymphatic  structures  or  (3)  to  the  continued 
fever  and  infection.  The  former  are  called  primary  lesions  while  the  latter 
are  called  secondary  lesions. 

The  most  striking  changes  occur  in  the  solitary  follicles  and  Peyer's 
patches,  particularly  in  the  ileum  near  the  valve  and  to  a  lesser  extent  in  the 
lower  part  of  the  jejunum.  These  l\Tnph  follicles  become  engorged,  due  to  a 
marked  dilatation  of  the  capillary  blood-vessels.  Later  the  glands  take  on  a 
whitish  or  anaemic  appearance  due  to  a  compression  of  the  engorged  blood- 
vessels as  a  consequence  of  cell  infiltration.  The  mucosa  and  muscularies 
adjacent  to  the  glandular  structures  may  become  similarly  infiltrated  with 
these  large,  round  epithelioid  cells  and  which  may  undergo  granular  or  fatty 
degeneration  followed  by  absorption.  This  infiltration  terminates  from  the 
eighth  to  the  tenth  day  either  in  resolution  or  necrosis.  However,  when  resolu- 
tion occurs,  small  haemorrhages  take  place  in  the  intestinal  glands,  thus  form- 
ing dark  pigmented  spots  which  give  rise  to  a  condition  known  as  the  "shaven 
beard"  appearance.     This  stage  is  known  as  the  stage  of  medullary  infiltration. 

The  stage  of  necrosis  or  sloughing  begins  between  the  eighth  and  tenth 
days  and  terminates  on  or  about  the  twenty-first  day.  This  sloughing  is  due 
partly  to  the  clogging  up  of  the  blood-vessels  by  the  cell  infiltration  and  partly 
as  a  result  of  the  direct  action  of  the  typhoid  bacillus.  After  the  necrotic 
portions  have  been  cast  off  an  ulcer  is  left.  The  ulcerated  surface  has  an 
irregular  outline  with  necrotic  edges.  The  border  is  usually  raised.  The 
floor  of  the  ulcer  is  usually  the  submucosa  or  the  muscular  coat.  It  may 
extend  until  it  reaches,  or  even  perforates,  the  serous  coat.  Then  the  dis- 
charges of  the  necrotic  material  may  cause  peritonitis,  which  is  usually  fatal, 
and  haemorrhages  may  be  caused  by  the  erosion  of  the  blood-vessels,  due  to  the 


36  TYPHOID  FEVER— SYPHILIS. 

extensive  necrosis.  In  the  lower  third  of  the  ileiun  the  small,  deep  ulcers  are 
more  prone  to  perforation  than  the  larger  ones.  Diffuse  peritonitis  may  be 
caused  without  perforation,  due  to  a  collection  of  typhoid  toxin  in  the  peri- 
toneimi,  from  a  rupture  of  suppurating  mesenteric  glands.  The  ulcers  result- 
ing from  the  destruction  of  the  solitary  follicles  are  rounded,  while  those 
involving  Peyer's  patches  are  elongated,  the  long  axis  being  parallel  with  the 
axis  of  the  intestine.  At  the  lower  end  of  the  ileum  the  ulcers  often  coalesce 
until  they  almost  encircle  the  bowel.  Ulceration  may  extend  to  the  appendix, 
where  perforation  may  take  place.  After  the  ulcer  is  formed,  healing  takes 
place.  This  process  advances  onward  from  the  border  of  the  ulcer  dislodging 
the  necrotic  crust.  When  death  occurs  during  a  relapse,  fresh  ulcers  are  found 
by  the  side  of  the  partially  healed  ulcers. 

The  changes  in  the  mesenteric  glands  occur  simultaneously  with  those  in 
the  intestines.  Similar  changes  take  place  contributing  to  their  enlargement, 
those  situated  opposite  the  lower  third  of  the  ileum  being  first  and  prominently 
involved.  These  glands  show  great  variation  in  size,  and  later  they  become 
larger,  harder  and  of  whitish  appearance.  Eesolution  occurs  quite  commonly, 
and  if  this  does  not  take  place,  the  central  part  of  the  gland  begins  to  undergo 
necrosis.  In  most  typhoid  cases  the  spleen  becomes  enlarged,  due  to  active 
hypersemia,  the  organ  generally  reaching  twice  to  three  times  its  normal  size. 
In  rare  cases  there  has  been  rupture  of  this  organ.  Suppuration  may  be 
brought  about  as  a  result  of  infarction.  Very  rarely  perisplenitis  or  abscess 
may  occur. 

Among  the  organs  more  rarely  affected  with  lesions  is  the  liver.  It 
becomes  hypera^mic,  and  later  softer  and  paler  than  is  natural.  The  cells 
show  granular  and  fatty  degeneration.  Pylephlebitis  has  followed  abscess  of 
the  liver  and  the  mesenteric  glands.  Typhoid  bacilli  are  often  found  in  the 
gall-ljladder  in  fatal  cases,  and  in  some  perforation  has  been  met  with. 

The  kidneys  show  parenchymatous  degeneration  and  granular  degenera- 
tion of  the  renal  cells.  More  rarely  the  lesions  are  those  of  acute  hsemorrhagic 
nephritis,  and  the  kidney  substance  may  present  small  lymphomatous  foci. 

Among  the  changes  often  found  in  the  lungs  are  hypostatic  congestion, 
pneumonia,  embolic  infarction  and  gangrene.  Pleurisy  is  rarely  met  with. 
Among  the  rarer  of  the  changes  are  oedema  of  the  glottis,  ulceration  of  .the 
larynx,  and  necrosis  of  the  laryngeal  cartilages.  Catarrhal,  or  even  croupous 
pharyngitis,  may  occur. 

The  circulatory  system  may  be  the  seat  of  moribund  changes.  Endo- 
carditis and  myocarditis  may  be  present.  The  muscle  fibers  suffer  parenchy- 
matous and  hyaline  degeneration.  There  may  be  thrombosis  of  the  right  side 
of  the  heart  and  veins,  especially  the  femoral.  Very  rarely  petechial  or  large 
haemorrhages,  and  abscess  may  be  found  in  the  intermuscular  tissues. 

The  blood  in  typhoid  fever  presents  few  alterations.  Leucocytosis  is 
absent,  and  there  is  often  a  leucopenia,  the  mononuclear  leucocytes  predomi- 
nating. The  red  corpusles  are  increased  during  the  febrile  period,  but 
decreased  during  the  convalescent  period. 


TYPHOID  FEVER— SYPHILIS.  37 

The  nervous  system  presents  no  gross  lesions.  Meningeal  hgemorrhages 
have  occurred  in  a  few  instances.  Slight  oedema  of  the  cerebal  cortex  has  also 
been  noted.     Meningitis  is  a  rare  event. 

Etiology. — The  definite  cause  of  typhoid  fever  is  the  specific  bacillus  of 
Eberth,  which  was  discovered  by  him  in  1880. 

It  is  a  short,  thick  bacillus,  whose  length  is  three  micromillimeters  and 
breadth  one  micromillimeter,  and  has  rounded  ends.  It  is  a  motile  organism 
due  to  the  presence  of  cilia  on  both  sides,  and  it  stains  readily  with  the  aniline 
dyes.  Contains  vacuoles  which  were  thought  to  be  spores  during  the  early  days 
of  observation;  which,  however,  is  not  the  case.  The  bacillus  typhosus  has 
been  confused  with  the  bacterium  coli  commune  on  account  of  their  almost 
identical  morphology  and  characteristic  growths  upon  the  different  culture 
media.  However,  the  differential  characteristics  of  the  two  bacilli  have  been 
pointed  out  by  the  recent  investigations  of  bacteriologists.  On  a  potato  which 
has  been  slightly  acidified  this  bacillus  of  Eberth  forms  a  transparent  growth. 
Fatal  results  have  occurred,  due  to  the  inoculation  of  cultures  of  these  bacilli 
into  animals.  It  has  been  demonstrated  that  they  possess  great  vitality  and 
multiply  very  rapidly  in  the  drinking  water,  milk  and  soil.  Their  thermal 
death  point,  according  to  Sternberg,  is  156°  F.  (69°  C),  and  they  have  been 
kept  alive  by  him  for  one  year  in  hermetically  sealed  bouillon  cultures.  Cold 
does  not  kill  them,  as  they  have  been  repeatedly  thawed  and  frozen.  The 
bacilli  are  very  active  in  distilled  water,  and  retain  their  vitality  for  three 
months;  but  they  are  destroyed  in  ordinary  water,  due  to  the  presence  of 
saprophytes. 

In  the  human  body  the  bacilli  have  been  in  the  blood,  bile,  intestinal  tract, 
spleen,  liver,  Ijonph  glands  and  the  rose-colored  spots.  They  have  also  been 
found  in  the  stools  of  about  50  per  cent,  of  the  cases,  the  urine,  sputa,  foci  of 
suppuration,  and  the  pleural,  endocardial,  meningeal  exudations. 

The  methods  of  conveying  the  poison  into  the  human  body  are  through 
the  dejecta  of  patients  suffering  with  typhoid  fever;  this  may  take  place 
through  the  careless  attention  to  the  discharges  from  the  typhoid  fever  patients, 
and  from  food  contaminated  by  the  contagion  from  the  common  house  fly. 
The  infrequent  contagion  of  those  attending  to  tj^ohoid  fever  patients,  such  as 
the  physician  and  nurse,  is  explained  by  the  fact  that  they  are  infected  through 
the  stools  and  the  careless  disposition  of  the  discharges,  whereby  they  are 
allowed  to  dry,  thus  liberating  the  bacilli  and  so  contaminate  the  air.  These 
bacilli  then  settle  upon  the  tonsils,  pharynx,  etc.,  and  in  this  manner  enter  the 
different  channels  of  the  body.  Many  cases  of  typhoid  fever  have  been  caused 
by  oysters  whose  beds  have  become  infected  with  water  polluted  by  sewage. 

The  typhoid  bacilli  get  into  the  body  by  deglutition  and  inhalation.  Most 
of  them,  when  they  get  into  the  stomach,  arc  destroyed  by  the  acid  secretions 
of  the  glands.  Some,  however,  pass  into  the  intestines  where  they  find  favor- 
able conditions  and  media  in  the  alkaline  secretions,  and  so  begin  to  multiply. 
They  then  penetrate  the  intestinal  wall  and  attack  the  solitary  follicles, 
Peyer's  patches,  and  reach  the  circulation,  spleen,  liver  and  other  organs  a  little 
later.     Other  bacilli  reach  the  blood-stream  through  the  respiratory  tract. 


38  TYPHOID  FEVER— SYPHILIS. 

Typhoid  fever  is  a  disease  wliich  occurs  in  adolescents,  also  in  robust 
individuals  between  the  ages  of  fifteen  and  thirty  years.  It  is  less  common  in 
children,  but  cases  have  been  reported  in  very  young  babes.  The  disease  is 
most  common  at  the  end  of  summer  and  beginning  of  autumn.  Although  the 
disease  may  occur  during  other  months  of  the  year,  nevertheless  spring  yields 
the  fewest  cases.     It  is  more  apt  to  be  prevalent  after  a  hot  and  dry  summer. 

Pettenkoffer  and  Buhl  have  contended  that  more  cases  succeed  seasons 
when  the  standing  water  in  the  soil  reaches  a  high  level  than  when  the  springs 
are  low  and  the  upper  layers  of  the  soil  comparatively  dry.  This  has  been 
explained  as  due  to  the  fact  that  the  germs  remain  in  situ  when  the  ground- 
water is  high,  but  when  the  ground-water  is  low  the  constant  circulation 
between  the  air  in  the  loose  soil  and  that  above  it  conveys  the  germ  upwards, 
and  they  then  pervade  the  air  accordingly.  Cases  of  t}'phoid  fever  have  been 
observed  following  intestinal  catarrh.  Nervous  diseases,  such  as  mental  excite- 
ment and  overwork,  are  predisposing  causes. 

Treatment. — No  special  routine  treatment  can  be  set  forth  in  the  success- 
ful treatment  of  this  disease.  Each  patient  needs  individual  attention  and  to  be 
treated  according  to  the  merits  of  the  symptoms  as  they  arise.  In  some  cases 
of  high  temperature  the  tepid  sponge  bath  will  reduce  the  temperature  as  much 
as  the  ice-water  sponge;  while  in  others  it  has  no  value,  and  the  ice-water 
sponge  must  be  employed  to  obtain  results.  In  patients  where  the  temperature 
does  not  exceed  103°  F.,  an  alcohol  rub  will,  in  some  cases,  reduce  the  tem- 
perature two  degrees,  and  again  in  others,  the  ice-water  sponge  must  be 
employed  to  produce  an  impression. 

In  asthenic  patients  it  is  never  well  to  employ  very  cold  sponges.  When- 
ever the  temperature  exceeds  102%°  F.  a  "temperature"  bath  should  be  given. 
An  ice-bag  applied  to  the  head  is  very  valuable  to  relieve  the  headache,  and 
also  assists  in  keeping  the  temperature  down. 

The  diet  is  of  great  importance.  Foods  that  leave  very  little  or  no  residue, 
and  that  are  easily  digested  in  the  stomach,  or  that  are  predigested,  should  be 
employed.  An  absolute  liquid  diet  of  peptonized  milk,  broths,  lemon  and 
orange  albumin  and  expressed  beef-juice  produces  better  results  in  my  patients 
than  the  now  semi-solid  diet  employed  by  some  physicians. 

Medicinally  we  are  giving  this  patient  for  its  antiseptic  and  antipyretic 
action,  a  capsule  containing: 

I^   Strychninse  sulphatia    gr.  1/^q. 

Quininse  bisulphatis    gr.  iss. 

Phenylis  salieylatis   gr.  iij. 

M.     Fiat  capsula  No.  i.     Sig. :     One  such  capsule  every  three  hours. 

Also  after  each  feeding  he  gets  ten  minims  of  dilute  hydrochloric  acid. 
For  his  constipation  he  gets  an  enaema  daily  containing  six  ounces  of  soap  suds 
and  three  ounces  of  glycerin. 

A  fact  not  to  be  neglected  under  hygiene  is  the  careful  disinfection  of  all 
the  dejecta.  To  avoid  middle-ear  infection,  the  mouth  and  nose  must  be 
cleansed  thoroughly  and  frequently  with  mild  antiseptic  solutions. 


TYPHOID  FEVER— SYPHILIS.  39 

SYPHILIS. 

The  next  patient  is  an  interesting  case,  a  young  woman,  age  twenty- 
eight  years.     Nativity,  United  States. 

Family  History. — Her  parents  are  both  dead.  The  father  died  at  the  age 
of  seventy-eight  years,  cause  apoplexy;  and  her  mother  died  of  nephritis  at 
the  age  of  sixty-four  years.  She  has  two  brothers  and  one  sister,  all  of  which 
are  in  good  health. 

Previous  Personal  History. — As  a  child  she  had  measles,  mumps  and 
diphtheria.  At  the  age  of  sixteen  she  had  typhoid  fever,  which  was  not  fol- 
lowed by  any  complications,  and  her  recovery  was  good. 

Social  History. — She  is  single,  and  is  a  domestic  by  occupation.  She 
admits  of  having  a  venereal  sore  situated  on  the  left  labia  majora.  Upon 
examination  of  this  lesion  we  find  it  to  be  a  shallow  ulcer  about  the  size  of  a 
pea,  and  from  it  exudes  a  scanty,  serous  fluid.  It  is  dark-red  in  color,  indu- 
rated, and  there  is  enlargement  of  the  neighboring  lymphatic  glands. 

We  also  observe  an  eruption  upon  the  trunk  and  limbs  which  consists  of 
a  number  of  large  flat  papules,  which  vary  in  size  from  a  small  shot  to  a  bean. 
The  majority  of  these  eruptions  are  scaly,  elevated  above  the  surrounding  sur- 
face, firm,  smooth  to  the  touch  and  possess  a  characteristic  copper  color.  Some 
of  these  eruptions  have  undergone  desquamation,  and  have  been  transformed 
into  moist  and  squamous  papules.  These  flat  papules  are  found  in  the  axilla, 
under  the  mammas  and  the  perineum. 

Symptoms. — She  appears  to  be  very  despondent,  and  is  very  irritable. 
Her  appetite  is  impaired,  bowels  are  constipated,  urine  is  scanty  and  high  col- 
ored, and  the  patient  experiences  a  general  sensation  of  malaise.  She  also 
complains  of  insomnia,  headache  and  pain  around  the  joints  and  in  the  bones. 

Diagnosis. — From  the  characteristic  lesions  present,  namely,  the  chancre, 
the  large,  fiat,  papular  syphilide,  and  from  the  s3Tnptoms  which  I  have  men- 
tioned before,  we  are  able  to  diagnose  this  case  as  oiie  of  secondary  syphilis  of 
the  large  flat  papular  variety. 

Differential  Diagnosis. — The  only  affections  resembling  the  large  papular 
syphilide  are  lichen  planus,  acne  and  psoriasis.  The  points  of  difference  are 
briefly  and  clearly  shown  on  the  blackboard. 

Papular  Syphilide.  Lichen  Planus 

1.  Lesions  are  round  and  oval  in  outline       1.  Papules    are    angular    in    outline    and 

and  not  depressed  in  the  center.  depressed  in  the  center. 

2.  Lesions  are  diffused  over  several  regions       2.  Papules   never   appear   on   the   face   or 

of  the  surface.  neck  and  are  limited  to  the  forehead, 

arms  and  legs. 

3.  Lesions    are    not    covered    with    waxy       3.  Covered    by    large,    waxy,    translucent 

scales.  scales. 

Papular  Syphilide.  Acne. 

1.  Lesions  are  diffused  over  several  regions       1.  Papules    are   acuminated    in    form   and 

of  the  body.  confined  to  certain  regions  of  tlie  body. 

2.  Papules  have  a  copper  color.  2.  Papules  are  bright  red  in  color. 

3.  Papules   run    a    protracted    course   and       3.  Papules    are    more    brief    in    duration, 

frequently  recur.  frequently  becoming  pustular  and  dis- 

appearing by  absorption. 


40  TYPHOID  FEVER— SYPHILIS. 

Papular  Syphilide.  Psoriasis. 

1.  History  of  syphilis.  1.  History  perhaps  of  previous  outbreaks. 

2.  Scales  are   scanty  and  possess  a  dirty-       2.  Scales    are    abundant,    lamellated    and 

grayish  color.  silvery. 

3.  Itching  usually  absent.  3.  Itching   present. 

Pathology. — The  sypliilitic  process  is  cliaraeterized  by  distinctly  circum- 
scribed and  homogeneous  cell  infiltration.  The  induration  of  the  initial  lesion 
is  produced  by  infiltration  of  the  papilla  of  the  corium  and  the  subcutaneous 
connective  tissue  with  small,  round,  nucleated  cells,  composed  of  finely  granular 
protoplasm.  They  all  penetrate  into  the  walls  of  the  cutaneous  vessels  and 
lessen  their  calibre.  This  increased  pressure  upon  the  arterioles  causes  an 
interference  with  the  nutrition,  and  finally  results  in  ulceration.  Adjacent 
adenitis  develops,  and  soon  becomes  general.  The  mucous  patch  has  its  seat 
on  the  mucous  membrane  or  soft,  moist  skin.  It  consists  of  an  inflammatory 
infiltration  of  the  papilla  of  the  corium  and  epidermis  with  small  cells.  The 
macular  syphilide  is  characterized  by  round  cell  infiltration  in  the  papilla  of 
the  corium  and  around  and  within  the  walls  of  the  papillary  vessels.  The 
papular  lesions  are  due  to  circumscribed,  dense,  round  cell  infiltration  in  the 
papillary  and  sub-papillary  layers  of  the  corium,  and  in  the  upper  portion  of 
the  subcutaneous  connective  tissue.  In  the  pustular  lesions  there  is  more  or 
less  exudation  or  migration  of  the  leucocytes  preceded  by  round  cell  infiltration 
of  the  corium  and  its  vessels.  The  tubercles  or  gumma  consist  of  small  round 
cells,  in  which  coagulation  necrosis  takes  place  in  the  centre,  due  to  local 
anaemia,  and  there  is  a  conversion  of  the  peripheral  into  fibrous  tissue.  The 
gumma  originates  around  small  blood-vessels,  which  become  surrounded  by  a 
mass  of  round  cells  intermingled  with  fibrillated  tissue,  forming  a  coarse  retic- 
ulum. The  various  lesions  of  the  muscular,  fibrous,  osseous,  and  nervous  sys- 
tems, and  of  the  internal  organs,  are  also  due  to  cellular  proliferation  and 
infiltration. 

Etiology. — Syphilis  is  due  to  the  entrance  into  the  system  of  a  specific 
parasite — Spirochasta  pallida,  discovered  by  Shaudinn  and  Hoffman.  Syphilis 
can  1)0  communicated  by  direct  or  indirect  contact,  or  by  hereditary  transmis- 
sion. The  most  ordinary  method  is  by  sexual  intercourse  with  the  one  diseased. 
The  system  may  be  infected  by  the  entrance  of  the  parasite  through  an  abrasion, 
fissure  or  laceration,  etc.  This  disease  may  also  be  acquired  by  indiscriminate 
kissing,  or  by  using  the  towels,  knives,  spoons,  forks  and  other  articles  which 
have  previously  been  used  by  the  diseased  individual.  The  wet-nurse  may 
infect  the  mouths  of  sucking  babes,  or  the  infant  may  infect  the  nipple  of  the 
nurse.  Many  cases  of  acquired  syphilis  are  caused  by  sexual  intercourse.  Phy- 
sicians are  not  infrequently  infected  in  midwifery  practice,  the  initial  lesion 
making  its  appearance  on  the  fingers.  Vaccination  has  also  been  a  moans  of 
infection.  Cases  have  been  reported  in  which  infants  have  been  infected, 
caused  by  the  mother  washing  the  eye-lids  of  the  infant  with  spittle,  and  it  has 
also  been  transmitted  by  bites.  Syphilis  may  also  be  transmitted  to  the 
offspring  through  the  father  and  mother.  However,  a  syphilitic  father  or 
mother  may  beget  healthy  offspring,  the  infant  having  acquired  some  immunity 
which  protects  it  from  its  mother. 


MEDICAL  MISSIONS.  41 

Treatment. — In  suspicious  cases  it  is  well  to  make  a  microscopic  examina- 
tion of  the  lesion,  and  if  the  spirocha^ta  pallida  is  present  in  the  serum  of  the 
lesion,  it  is  folly  to  wait  until  the  secondary  lesions  appear.  During  the  pri- 
mary stage  more  good  can  be  derived  by  specific  treatment  in  one  week  than 
can  be  derived  in  one  month  during  the  secondary  stages. 

The  treatment  of  these  patients,  of  course,  is  constitutional,  and  the 
remedy  par  excellence  is  mercury.  In  the  secondary  stage  hydrargyri  cum 
cretse  is  the  preparation  to  be  employed,  especially  in  patients  who  have  a 
derangement  of  the  digestive  organs,  as  in  this  case.  We  will  give  a  prescrip- 
tion containing: 

^  Hydrargyri  cum   ereta    gr.  iij. 

Pepsini, 

Phenylis  salicylatis,  of  each    gr.  ij. 

M.     Fiat  capsula  No.  i.     Sig. :     One  such  capsule  three  times  a  day. 

Tonics  such  as  iron,  arsenic,  quinine  and  the  vegetable  alteratives  are  all 
valuable  remedies,  and  should  be  substituted  for  a  few  weeks  when  the  mer- 
curial treatment  cannot  be  continued  owing  to  its  full  physiological  action. 

Locally,  for  the  rough  and  scaly  condition  of  her  face,  the  following  oint- 
ment will  meet  the  special  requirements : 

IJ  HydrargjTi  ammoniati    gr.  xx. 

Camphorse, 

Phenolis,  of  each   gr.  x. 

Acidi  salicylici   gr.  xx. 

Unguenti  aquse  rosse    §j. 

M.     Fiat  unguentum.     Sig.:     Apply  locally  to  the  face  twice  daily. 

The  diet  of  all  these  patients  should  consist  of  plenty,  wholesome,  well- 
cooked  and  nutritious  foods,  to  increase  the  quantity  and  quality  of  the  blood. 
Hygienic  measures  must  not  be  neglected.  The  patient  should  frequently  take 
hot  baths  to  assist  elimination. 

Prognosis. — As  to  life  the  prognosis  is  good,  provided  the  patient  takes 
treatment  for  a  sufficient  length  of  time  during  the  secondary  stage  of  the  dis- 
ease. But  when  the  disease  is  allowed  to  go  on  without  treatment  until  the 
tertiary  stage  is  reached,  the  patient  will,  sooner  or  later,  suffer  from  grave 
symptoms.  The  nervous  system  may  become  involved,  and  syphilitic  lesions 
occur  in  the  brain,  rendering  the  case  hopeless. 


Original  Articles 

MEDICAL  MISSIONS. 

By  R.  C.  THOMAS,  M.D., 

ILOILO,   PHILIPPINE   ISLANDS. 


Since  misconceptions  concerning  medical  missions  are  broadcast  in  the 
medical  profession  to-day,  a  few  words  of  explanation  may  be  of  interest  con- 
cerning their  origin,  their  status  in  the  matter  of  methods  and  equipment,  and 
the  opportunity  they  offer  the  practitioner. 


42  MEDICAL  MISSIONS. 

Origin. — The  pioneer  medical  missionary  from  America  was  Dr.  John 
Scudder,  of  Xew  York  City,  who  went  to  India  in  1819.  Two  years  later  Dr. 
Jonathan  Price  sailed  to  Burma.  Both  these  men  did  creditable  work,  though 
Dr.  Price  lived  but  seven  years  after  reaching  his  field.  In  1834  Dr.  Peter 
Parker,  who  is  familiarly  known  as  the  man  who  "opened  China  at  the  point 
of  the  lancet,"  landed  in  Canton.  Through  his  agency  the  Medical  Missionary 
Society  of  China  was  organized  in  1838.  From  this  time  onward  the  cause  of 
medical  missions  continued  to  progress,  growing  by  leaps  and  bounds  during 
the  last  few  years,  until  now  there  are  over  750  medical  missionaries  repre- 
senting the  missionary  societies  of  the  world. 

Methods  and  Equipment. — Medical  missionary  methods  arc,  so  far  as  con- 
ditions allow,  fully  up-to-date.  Naturally  lack  of  funds,  native  ignorance  and 
superstition  are  hindrances  to  the  highest  degree  of  asepsis  and  surgical  technic, 
but  in  spite  of  these  drawbacks  the  general  status  of  the  work  is  exceedingly 
creditable.  Modern  medical  missionaries  are  generally  graduates  of  both 
medical  school  and  hos2jital,  who  go  to  the  foreign  field  because  they  feel  called 
to  the  work,  and  not  because  they  fear  they  could  not  secure  a  practice  at  home. 
Moreover,  as  a  rule  these  men  are  progressive  in  their  aims  and  secure  hos- 
pitals early  in  their  missionary  career.  Some  of  these  hospitals  are  in  no  way 
inferior  to  those  in  our  own  land,  and  the  character  of  the  work  done  is  entirely 
modern.  Trained  nurses  from  American  hospitals  carry  on  the  routine  schedule 
of  duties  in  the  wards  with  the  same  painstaking  attention  to  detail  as  at  home. 
In  such  institutions  as  these,  major  operating  may  be  carried  on  upon  a  large 
scale,  as  for  example,  in  the  mission  hospital  in  Tokyo,  where  3,000  abdominal 
sections  were  performed  in  less  than  seven  years. 

The  Opportunity  Offered. — To  the  young  practitioner,  depending  for  his 
livelihood  upon  the  "psychic  disturbances"  of  a  few  rich  families  in  the  wealthy 
district  which  he  has  chosen  as  the  proper  place  to  allow  his  "shingle"  to  become 
weather-beaten,  medical  work  in  a  foreign  land  should  oiler  an  alluring  oppor- 
tunity. In  the  first  place,  patients  are  plenty.  One  of  the  most  attractive 
features  of  foreign  work  is  the  enormous  amount  of  so-called  "material." 
Thousands  upon  thousands  of  the  sick  flock  to  the  doctor.  In  1902,  for 
example,  it  is  declared  upon  good  authority  that  6,500,000  patients  were  treated 
in  Asia,  Africa  and  Oceanica. 

The  great  variety  of  diseases  to  be  found  in  this  horde  of  Orientals  con- 
stitutes another  appeal  to  the  scientific  practitioner.  Trypanosomes,  Leish- 
man  Donovan's  bodies  and  other  elusive  denizens  of  the  tropics  court  his  atten- 
tion. If  the  past  augurs  anything  for  the  future,  frequent  discoveries  may  be 
expected  in  pathology,  bacteriology  and  other  branches  of  medical  research. 
Dr.  W.  W.  Keen,  of  Philadelphia,  states  that  quinine  was  given  to  the  world  by 
the  Jesuit  missionaries  of  South  America,  "while  the  Calabar  bean,  the  kola 
nut  and  strophanthus  we  owe  to  Dr.  Nassau,  an  African  missionary.  Much  of 
our  knowledge  of  cataract,  lithotomy,  elephantiasis,  leprosy  and  many  other 
tropical  diseases  comes  from  medical  missionaries."  These  and  other  impor- 
tant additions  to  medical  science  have  been  made  in  the  past,  and  who  can  tell 
in  this  age  of  opsonic  treatment  what  may  be  in  store  for  the  future. 


MEDICAL  MISSIONS.  43 

Finally,  the  need  for  medical  work  is  incomparably  greater  abroad  than  it 
is  at  home,  whereas  the  provision  for  that  need  is  incomparably  less.     This 
fact,  in  itself,  should  promise  a  most  welcome  opportunity  to  the  conscientious 
medical  man,  who  is  in  the  profession  more  for  the  good  he  can  render  to  the 
world  than  for  the  dollars  and  cents  he  can  squeeze  out  of  it.     One  needs  but 
to  glance  at  the  statistics  to  discover  how  insignificant  is  the  provision  for  this 
need  abroad  in  comparison  with  that  made  in  our  own  land.     The  proportion 
of  physicians  in  mission  fields   to  those   at  home   is   but   1   to   4,000.     In 
the  United  States  there  is  one  physician  to  every  636  persons,  whereas  in 
foreign  mission  fields  there  are  countless  thousands  with  no  medical  aid  what- 
ever.    Moreover,  as  already  stated,  this  dearth  of  medical  aid  is  the  more 
pathetic  when  one  realizes  the  prevailiag  ignorance  of  medicine.     As  a  sample 
of  the  conditions  that  obtain,  we  learn  that  in  China  the  native  doctor  ascer- 
tains from  the  right  pulse  the  maladies  of  liver,  heart  and  kidneys,  while  the 
left  pulse  is  the  monitor  for  the  other  organs.     The  pulse  is  the  important 
medical  asset  of  the  Chinese  practitioner,  and  at  this  point  the  methods  of  his 
foreign  confrere  are  appreciated,  though  sometimes  he  labors  under  difficulties, 
as  when  the  Chinese  lady,  being  too  modest  to  face  a  strange  man,  tied  a  string 
around  her  wrist  and  dangled  the  string  out  of  the  window,  as  a  less  vulgar 
method  of  bringing  him  into  contact  with  her  radial  artery.     In  this  same 
land  "wind"  in  the  bodily  organs  is  supposed  to  be  the  cause  of  disease.     To 
relieve  this  pneumatic  pressure  needles  from  three  to  six  inches  in  length  are 
thrust  into  the  skin,  as  many  as  sixty  or  more  having  been  thus  administered 
to  the  scalp  of  a  single  patient.     In  fact,  once  such  a  needle  was  thrust  through 
the  thorax  with  fatal  result.     The  treatment  of  the  eye  is  often  barbarous,  as 
when  groimd  glass  is  used  as  a  medicament,  and  as  in  one  recorded  instance, 
when  the  eye-ball  was  pierced  to  'let  in  more  light."     Again,  to  quote  from  a 
writer  on  India,  we  are  told  that  "in  anatomy  there  is  an  elaborate  system  of 
guesses,  and  the  people  are  taught  there  are  900  bones  in  the  body;   that  there 
is  no  difference  in  structure  or  function  of  nerves,  veins,  arteries  and  ligaments, 
and  that  the  pulse  is  an  organ  independent  of  the  heart."     Again,  in  the 
Friendly  Islands  of  the  Pacific,  it  is  the  custom  to  bury  alive  those  in  delirium, 
and  of  one  such  unfortunate  we  are  told  that  he  twice  "burst  open  his  grave," 
and  then  was  tied  to  a  tree  and  allowed  to  starve.     Moreover,  in  the  matter 
of  public  health  the  conditions  that  prevail  are  as  bad.     Dr.  Keen  declares  that 
in  Burma  he  saw  "hundreds  of  pilgrims  drinking  the  green  scum-covered  water 
of  many  a  temple  tank,"  as  well  as  "Imndreds  of  others  drinking  the  foul  waters 
of  the  Ganges  at  Benares,  while  other  hundreds  at  their  elbows  were  washing 
themselves  and  their  clothing  in  the  river,  with  decaying  bodies  of  animals 
floating  on  the  tide,  and  a  large  sewer  delivering  its  filth  into  the  same  stream 
less  than  three  hundred  feet  away."     To  one  who  has  lived  in  the  tropics  and 
witnessed  the  ravages  of  cholera,  such  a  recital  is  doubly  impressive,  as  it  is 
known  for  a  certainty  that  the  spirillum  that  begins  its  mischief  at  such 
polluted  sources  as  this  will  continue  to  create  havoc  later  among  millions  in 
distant  towns,  simply  and  solely  because  these  poor  people  are  too  ignorant  to 
boil  their  drinking  water.     The  welcome  change  from  a  somewhat  similar  state 


44      SYMPTOMATOLOGY  AND  DIAGNOSIS  OF  THE  ENLARGED  PROSTATE. 

of  affairs  in  the  Philippines  to  modern  methods  of  sanitation,  the  writer  can 
say  from  experience,  has  been  a  delightful  contrast  to  this  dark  picture 
described  by  Dr.  Keen,  as  well  as  a  happy  portent  for  the  future  in  all  these 
lands  that  are  being  brought  under  the  sway  of  modern  medicine. 

The  time  has  passed  when  young  medical  men  should  need  to  be  "induced" 
to  undertake  medical  mission  work.  Medical  missions  have  ceased  to  be  an 
experiment.  The  names  of  David  Livingstone,  Peter  Parker  and  Jolm  Ken- 
neth MacKenzie  are  not  to  be  discounted  when  testing  values  in  medical  achieve- 
ment. The  tremendous  impetus  of  the  movement,  which  as  early  as  1903 
boasted  379  hospitals  and  783  dispensaries,  is  in  itself  an  unanswerable  argu- 
ment to  those  who  would  speak  disparagingly  of  it.  The  undertaking  must 
be  recognized  as  well  worth  while  by  fair-minded  medical  men,  and  the  call  to 
such  a  service  as  this  of  the  foreign  field  to  treat  uncared-for  millions,  to  foster 
correct  sanitation  amid  untutored  races  and  to  endeavor  to  enrich  the  world  of 
science  by  research  in  isolated  regions,  cannot  fail  to  appeal  to  a  man  of  genuine 
scientific  and  humanitarian  caliber.  For  the  Christian  physician,  to  these  other 
motives  must  be  added  the  most  profound  of  all — the  opportunity  of  uplifting 
the  degraded  to  the  highest  plane  of  living — a  pure  Christianity. 


THE  SYMPTOMATOLOGY  AND  DIAGNOSIS  OF  THE  ENLARGED  PROSTATE.' 

By  H.  M.  CHRISTIAN,  M.D., 
Clinical    Professor    of    Genito-Urinary    Diseases,    Medico-Chirurgical    College;     Genito- 
urinary Surgeon,  PhiladeliAia  General  Hospital;     Professor  Geuito-Urinary 
Diseases,  Philadelphia  Polyclinic. 

Clinically  speaking,  I  believe  that  the  cases  of  enlargement  of  the  prostate 
that  are  forced  to  consult  the  physician  will  be  found  in  one  of  the  following 
classes : — 

1.  Prostate  moderately  enlarged;  some  increased  urinary  frequency, 
nocturnal  and  diurnal:   little  or  no  residual  urine;   urine  sterile. 

2.  Prostate  decidedly  enlarged;  marked  increased  urinary  frequency; 
two  to  four  ounces  of  residual  urine;  urine  sterile. 

3.  Same  condition  as  just  described,  with  a  more  or  less  infected  bladder. 

4.  Enlargement  with  chronic  retention  either  complete  or  with  overflow. 

5.  Marked  enlargement  with  large  amount  of  residual  urine;  atony  of 
bladder  and  chronic  cystitis,  causing  frequent  and  painful  urination  both 
night  and  day. 

1.  Increased  urinary  frequency,  chiefly  nocturnal  in  character,  is  the 
earliest  and  most  frequently  encountered  symptom  of  the  affection.  There 
can  be  no  doubt  that  many  cases  of  hypertrophied  prostate  never  develop  beyond 
this  point.  Just  what  percentage  of  old  men  are  living  useful  and  comfortable 
lives,  save  for  the  fact  that  they  are  compelled  to  rise  two  or  three  times  at 
night  to  urinate,  it  is  almost  impossible  to  estimate. 


1  Read  before  North  Branch  Philadelphia  County  Medical  Society. 


SYMPTOMATOLOGY  AND  DIAGNOSIS  OF  THE  ENLARGED  PROSTATE.       45 

In  many  patients  enlargement  of  the  prostate  never  causes  any  but  these 
slight  symptoms  of  increased  urinary  frequency.  Deaver  states  that  about 
seven  per  cent,  of  prostatiques  are  forced  to  seek  the  aid  of  a  physician. 

Many,  I  believe,  live  their  lives  through  without  the  knowledge  of  the 
existence  of  a  prostate  gland,  the  nocturnal  urinations  being  performed  in  an 
automatic  manner  and  hardly,  in  most  cases,  disturbing  their  sleep.  In  the 
early  stages  of  hypertrophied  prostate,  where  there  is  little  or  no  residual  urine, 
the  increased  urinary  frequency  is  in  all  probability  due  to  the  intense  hyper- 
emia and  hyperesthesia  of  the  posterior  urethra,  and  the  mucous  membrane  of 
the  trigone  of  the  bladder  due,  in  large  part,  to  mechanical  obstruction. 

It  has  always  been  supposed  that  these  factors  are  more  in  evidence  when 
the  patient  is  in  the  recumbent  position,  owing  to  the  force  of  gravity,  hence, 
the  well-recog-nized  significance  of  nocturnal  urinary  frequency  as  a  symptom 
of  prostatic  enlargement.  I  am  not  so  sure  that  this  is  a  convincing  explana- 
tion of  a  well  known  clinical  phenomenon. 

2,  Difficulty  in  starting  the  stream  is  a  common  symptom,  many  patients 
stating  that  the  only  satisfactory  act  of  urination  that  they  have  is  that  obtained 
in  the  morning  at  the  usual  stool.  It  is  easy  to  understand  why  this  should  be 
so.  In  the  normal  act  of  urination,  at  such  time  as  the  bladder  becomes  full, 
the  posterior  urethra  dilates  and  for  the  time  being  becomes  part  of  the  bladder 
itself.  This  condition  of  affairs  cannot  of  course  obtain  where  the  posterior 
urethra  is  bound  down  hand  and  foot  by  a  prostatic  overgrowth.  The  character 
of  the  stream  is  very  much  altered.  There  is  inability  to  project  the  stream 
from  the  body,  i.  e.,  there  is  loss  of  the  so-called  parabolic  curve.  Along  with 
this  is  persistent  dribbling  after  urination,  a  most  annoying  symptom,  I  find,  to 
men  of  a  temperamental  mind,  as  the  persistent  and  increasing  staining  of 
their  trouser  flies  is  only  another  forcible  evidence  of  the  passing  of  time. 

This  dribbling,  of  course,  is  a  mechanical  proposition  and  is  due  to  the 
inability  of  the  bladder,  owing  to  the  resistence  at  its  neck,  to  empty  itself 
promptly.  As  pointed  out  by  Hansen  Moulin,  the  voluntary  muscles  dealing 
with  the  act  of  urination  are  not  at  fault,  but  the  bladder,  as  a  matter  of  fact, 
is  unable  to  pass  the  urine  along  into  their  hands. 

3.  Complete  or  partial  retention  of  urine.  Incontinence  of  urine  with 
retention. 

Where  retention  of  urine  depends  upon  the  presence  of  an  enlarged 
prostate  it  will  occur  in  one  of  two  forms,  viz:  (1)  acute  complete  retention; 
(2)  chronic  incomplete  retention. 

In  the  first  variety  the  retention  occurs  suddenly,  and  is  complete — no 
urine  being  voided.  The  patient  is  seized  with  the  attack  in  the  midst  of 
apparently  perfect  health,  after  exposure  to  cold  or  damp;  or  perhaps  after 
excessive  drinking  of  gin  or  whisky. 

Constipation  is  not  an  unusual  occurrence,  and  is  an  important  factor  in 
these  cases. 

Examination  of  tlic  rectum  will  show  in  all  instances  marked  enlargement 
of  the  prostate,  but  the  gland  will  feel  soft,  as  if  very  considerably  congested. 
In  fact,  acute  complete  retention  occurs  most  frequently  in  those  cases  where 


46      SYMPTOI^IATOLOGY  AND  DIAGNOSIS  OF  THE  ENLARGED  PROSTATE. 

the  hypertrophy  is  of  the  glandular  or  soft  variety,  such  a  prostate  being 
especially  prone  to  congestion,  as  a  result  of  exposure  to  cold,  intemperance  or 
constipation. 

In  the  second  form,  that  of  chronic  incomplete  retention,  the  retention 
does  not  occur  suddenly,  nor  is  it  complete,  the  patient  being  able  to  pass  some 
little  urine,  but  in  small  quantities  at  frequent  intervals. 

The  causes  operating  to  bring  about  chronic  retention  are  (1)  gradually 
increasing  obstruction  to  flow  of  urine  produced  by  growth  of  the  gland,  and 
(2)  corresponding  loss  of  power  in  the  detrusor  muscles  of  the  bladder,  with 
consequent  inability  to  empty  the  bladder,  the  result  being  the  gradual  accumu- 
lation in  the  bladder  of  residual  urine.  As  this  residuum  increases  in  amount 
the  atony  of  the  muscular  coat  of  the  bladder  becomes  more  and  more  marked 
until  finally  all  power  to  expel  the  urine  being  lost,  the  bladder  overflows  and 
there  results  a  constant  dribbling  of  urine,  the  condition  known  as  the  incon- 
tinence of  retention. 

Eegarding  chronic  infection  of  the  bladder  there  is  little  to  be  said  save 
that  it  is  the  sword  of  Damocles  hanging  over  the  head  of  every  man  with 
enlargement  of  the  prostate  gland. 

There  is,  of  course,  here  the  large  and  potent  element  of  immunity. 
Many  cases,  of  course,  go  through  their  lives  without  any  infection,  and  I  might 
remark  right  here  that  it  is  not  the  size  of  the  hypertrophy  that  determines  a 
prostatic's  health  and  happiness  as  much  as  the  question  as  to  whether  his 
bladder  is  or  is  not  infected.  The  man  with  a  fairly  high  degree  of  hyper- 
trophied  prostate  is  capable  of  leading  a  fairly  comfortable  and  useful  life, 
so  long  as  his  bladder  remains  free  from  infection. 

Diagnosis. — It  would  not  seem  as  if  the  diagnosis  of  enlargement  of  the 
prostate  should  prove  to  be  a  very  difficult  matter.  When  a  man  over  sixty 
complains  of  nocturnal  and  diurnal  frequency  of  urination,  with  difficulty  in 
starting  the  stream  and  with  considerable  dribbling  and  loss  of  force  in  pro- 
jecting the  stream,  one  is  almost  of  necessity,  led  to  the  conclusion  that  he  is 
dealing  with  a  case  of  hypertrophical  prostate.  When  such  is  suspected, 
physical  examination  will  determine  the  true  character  of  the  case. 

There  is,  in  the  first  place,  the  examination  by  the  rectum.  This  will,  in 
a  majority  of  cases,  not  only  show  approximately  the  amount  of  the  enlarge- 
ment, but  also  its  character,  whether  it  is  small  and  hard  or  large  and  soft. 
In  this  connection,  it  must  be  borne  in  mind  that  many  cases  exhibiting  most 
active  S}Tnptoms  of  urinary  obstruction  fail  to  show  any  or  but  little  enlarge- 
ment upon  rectal  examination.  In  these  cases  we  are  probably  dealing  with 
an  intra-vesical  projection  of  the  so-called  middle  lobe.  Here  the  length  of 
the  urethra  along  with  the  determination  of  the  residual  urine,  if  any,  becomes 
an  important  factor.  The  examination  of  the  rectum  with  the  left  fore- 
finger while  a  stone  searcher  is  held  in  an  inverted  position  against  the  prostate 
with  the  right  hand,  gives  a  most  excellent  method  of  determining  both  the 
urethral  length  and  also  the  thickness  and  general  character  of  the  hypertrophy. 

While  it  is  a  well  lmo\\'n  fact  that  stone  in  the  bladder  is  often  found 
associated  with  enlargement  of  the  prostate  the  physical  signs  and  symptoms 


AIDS  IN  THE  BASSINI  OPERATION  FOR  HERNIA. 


47 


presented  by  the  two  diseases  are  so  dissimilar  that  I  can  hardly  consider  the 
possibility  of  their  being  confounded. 

In  calculus  there  is  pain  connected  with  the  urinary  act;  in  addition  to 
this  there  is  hematuria,  there  is  no  failure  in  the  force  of  the  stream  and  the 
frequency  of  urination  is  greatest  during  the  day  time  and  is  increased  by 
motion. 

The  diagnosis  between  benign  enlargement  of  the  prostate  and  malignant 
disease  of  that  organ  is  often  a  most  difficult  if  not  impossible  question  to 
decide  prior  to  operative  procedure. 

Possibly  the  impression  received  by  digital  examination  through  the 
rectimi  should  be  of  some  aid.  As  a  general  rule  I  think  that  it  can  be  stated 
that  in  malignant  disease  the  prostate  is  somewhat  irregular  in  contour  and  of 
stony  hardness — a  condition  rarely  met  with  in  the  non-malignant  enlargement. 
Hematuria  is  a  most  common  sjanptom  and  what  I  have  noted  in  the  two  or 
three  cases  I  have  encountered  is  an  obstinate  sciatica,  extending  along  the 
whole  length  of  the  nerve. 


AIDS  TO  SUCCESSFUL  RESULTS  IN  THE  BASSINI  OPERATION  FOR 
THE  RADICAL  CURE  OF  HERNIA. 

By  ERNEST  LAPLACE,  M.D., 

PHILADELPHIA. 

While  the  anatomical  basis  of  the  Bassini  operation  for  the  radical  cure 
of  hernia  makes  this  operation  an  ideal  one,  it  has  often  happened  that 
unforeseen  suppuration  of  the  subcutaneous  cellular  space  and  deeper  struc- 
tures has  brought  on  complications,  whereby  the  ultimate  success  of  the 
operation  has  been  jeopardized. 

I  have  watched  series  of  cases  in  various  clinics,  and  it  is  fair  to  say  that 
in  spite  of  most  careful  aseptic  precautions  and  blameless  catgut  and  kangaroo 
tendon  sutures,  a  certain  proportion  of  cases  showed  suppuration  daring  the 
healing  process.  I  will  grant  that  an  imperfect  sterilization  of  catgut  sutures 
may  be  the  cause  in  many  cases,  but  eliminating  this  possibility  and  tissue 
malnutrition,  there  remains  the  majority  of  cases  of  suppuration  still  to  be 
accounted  for.  I  have  concluded  that  these  unfortunate  results  might  be  due 
to  oozing  of  blood  taking  place  in  the  deeper  structures  about  the  internal 
oblique  and  transversalis  muscle  or  under  the  skin,  after  the  operation.  The 
operation,  and  still  at  times  an  accumulation  of  blood  can  be  detected  in  the 
tissues  a  day  or  two  after  the  operation.  Seeking  an  explanation  for  this 
secondary  oozing,  which  no  doubt  led  to  contamination  and  subsequent 
suppuration,  I  concluded  that  the  movements  of  the  patient's  leg  in  bed, 
notably  flexion  and  extension  of  the  thigh,  fhiglit  account  for  it.  The  Johns 
Hopkins  Hospital  surgeons  practiced  the  application  of  a  plaster  of  Paris  spica 


48  MODERN  AND  GRECIAN  ATHLETICS. 

bandage  about  the  pelvis  and  thigh  to  immobilize  the  limb  on  the  operated 
side.  This  offered  the  serious  inconvenience  of  being  difficult  of  application 
and  not  allowing  an  inspection  of  the  wound  for  necessary  dressings. 

In  my  last  one  hundred  cases  of  Bassini  operation  for  hernia  I  have 
obviated  the  possibility  of  oozing  and  kept  the  parts  at  rest  effectually  by  the 
following  procedures : 

First:  At  the  time  of  the  operation  the  utmost  care  is  exercised  to  stop 
all  oozing  by  compression  and  by  suture  ligatures  with  very  fine  silk  or  catgut. 

Second :  When  the  wound  is  completely  closed^  an  inverted  cone  com- 
press is  applied  directly  on  the  line  of  incision.  That  is,  a  gauze  roll  is  made 
an  inch  in  diameter  and  as  long  as  the  incision,  and  applied  directly  on  the 
incision.  Covering  this  is  a  pad  two  inches  wide  and  as  long  as  the  underlying 
pad.  This  is  secured  in  two  places  by  one-inch  adliesive  plaster.  Over  this 
is  applied  the  regular  wide  section  dressing  of  gauze  and  absorbent  cotton,  and 
fastened  in  position  by  broad  adhesive  straps,  snugly  applied.  It  follows  that 
the  pressure  produced  by  these  straps  is  multiplied  on  the  line  of  incision,  be- 
cause of  the  inverted  cone  dressing  directly  applied  to  the  incision.  This  extra 
pressure  tends  to  further  arrest  any  capillary  oozing  and  to  cause  all  secretions 
immediately  to  pass  into  the  dressing,  obliterating  at  the  same  time  all  dead 
spaces. 

The  next  point  is  immediately  to  immobilize  the  limb  on  the  operated 
side.  This  is  done  by  the  use  of  the  Liston  splint,  which  extends  from  the 
axilla  to  the  foot.  The  splint  is  well  padded  and  is  fastened  by  bandaging  it 
for  two  or  three  inches  about  the  chest  of  the  patient,  again  about  the  thigh 
and  also  about  the  leg.  This  prevents  the  patient  from  bending  the  leg  and 
causing  any  oozing.  The  splint  is  well  tolerated  by  the  patient  and  is  left  in 
place  as  long  as  the  patient  is  kept  in  bed — about  twenty-one  days.  The 
patients  all  get  well  under  one  dressing  and  in  the  last  one  hundred  cases  we 
have  not  had  a  single  breaking  down  of  the  wound  by  suppuration  or  any 
other  cause.  These  results  are  entirely  attributed  to  the  extra  local  com- 
pression removing  dead  spaces,  effectually  stopping  capillary  ha^'morrhage,  and 
also  to  the  immobilization  of  the  limb  on  the  operated  side  by  the  use  of  the 
Ijiston  splints.  We  therefore  recommend  the  use  of  these  aids  to  the  dressings 
and  after  treatment,  to  improve  the  final  results  to  be  hoped  for  in  the  Bassini 
radical  cure  of  hernia. 


Editorials 


MODERN  AND  GRECIAN  ATHLETICS. 

It  was  a  distinguishing  feature  among  the  ancient  Greeks  to  consider 
corporeal  exercise  as  a  no  less  important  factor  of  education  than  mental 
progress  itself,  j^o  nation  ever  had  a  higher  ideal  of  athletics  than  the  ancient 
Greeks;    no  where  did  honorable  and  beneficial  athletics  hold  a  higher  place. 


MODERN  AND  GRECIAN  ATHLETICS.  49 

They  indulged  in  their  exercises  in  open  air  gymnasiums,  which  were  scattered 
throughout  the  country,  and  which  were  supported  partly  by  public  and  partly 
by  private  means.  It  was  here  that  the  people  spent  a  part  of  the  day  in 
athletic  exercises.  The  various  exercises,  such  as  running,  jumping,  tlirowing 
the  discus  or  javelin,  swimming,  etc.,  were  a  part  of  their  every-day  life.  Their 
primary  object  was  to  develop  the  body  together  with  the  mind.  The  har- 
monious development  of  the  body,  and,  indeed,  of  every  single  limb,  was 
thought  to  be  of  the  utmost  importance  for  the  attainment  of  self-conscious 
determination  in  the  practical  demands  of  life. 

At  the  present  time,  however,  athletics  neglect  the  principle  of  proportion 
and  harmony  that  distinguishes  all  that  is  best  art  and  development.  We  do 
not  possess  the  principle  of  acting  through  means  of  the  body  on  the  mind,  as 
was  realized  in  the  physical  training  of  the  ancient  Greeks.  Their  aim  was, 
'^A  beautiful  soul  in  a  beautiful  body."  With  ourselves,  in  spite  of  our  addi- 
tion to  athletics,  the  body  takes  a  secondary  place,  and  after  a  certain  age  at 
least,  there  are  very  few  men  who  make  systematic  exercise  an  important  factor 
of  their  every-day  life.  The  Greeks  aimed  at  balance  in  harmony.  They 
believed  in  beauty  in  flesh.  This  is  very  well  illustrated  by  their  beautiful 
sculptures,  both  in  manly  strength  and  j^outhful  grace,  which  gave  to  the  artist 
and  sculptor  inspiration  and  encouragement  in  the  choice  of  athletic  subjects. 
However,  the  athletic  sports  of  to-day  are  not  pursued  for  pleasure  or  recrea- 
tion, therefore  they  are  not  remedial  helps  and  aids  in  physical  development 
and  improvement.  There  are  some  individuals,  however,  who  take  exercise  for 
the  beneficial  effects  which  can  be  derived  from  it.  They  engage  in  the  various 
exercises  with  zeal  and  enthusiasm,  and  their  common  thought  is  that  the  more 
exercise  they  take,  the  more  favorable  it  will  be  to  their  health.  We  can  thus 
see  that,  instead  of  deriving  benefit,  they  are  harmed  and  their  health 
jeopardized,  due  to  great  strain  and  exertion  under  which  they  place  themselves. 

The  idea  of  the  modern  athlete  is  to  concentrate  the  entire  energy  of  his 
body  upon  the  development  of  special  powers  in  order  that  he  may  overcome 
his  opponent.  It  is,  therefore,  easily  seen  why  the  modern  athletes  lack 
symmetry  of  development  as  was  attained  by  the  ancient  Grecian  athletes. 
They  also  train  beyond  their  ability,  and  finally  develop  their  muscular  system 
to  such  perfection  that  it  is  detrimental  to  the  heart,  lungs  and  digestive  organs. 

The  older  sports,  in  which  the  old  athletes  competed,  were  friendly  and 
honorable  rivalry,  but  now  it  has  given  way  to  professional  displays.  Love 
of  excitement  has  taken  the  place  of  love  for  sport.  Competition  has  increased 
to  such  an  extent  that  modern  athletes  have  discovered  that  special  excellence 
in  certain  events  could  be  accomplished  by  special  training.  The  boxer  and 
wrestler  train  in  order  to  secure  more  weight,  while  the  jumper  and  nmner 
train  in  order  to  acquire  more  activity  and  fleetness.  Therefore,  the  beauty  of 
development  is  lost,  and  results  in  ill-proportioned  and  one-sided  athletes. 

The  great  evil  lies  in  the  fact  of  overtraining  in  that  particular  branch  of 

athletics.     We  observe  that  the  muscles  of  the  modem  athletes  are  excessively 

developed  at  the  expense  of  his  vital  organs  so  as  to  make  him  fit  for  his  special 

branch  of  athletics.     These  excessively  developed  muscles  being  larger  and 

6 


50  THE  PINELLAS  PENINSULA,  FLORIDA. 

having  more  work  to  perform  tlian  other  parts  of  their  anatomy  which  have 
not  reached  such  a  stage  of  development,  will  naturally  require  and  consume 
more  nourishment,  and  consequently  they  will  use  up  a  considerable  amount 
of  the  nutritive  fluids  of  the  body  that  should  serve  the  needs  of  other  and 
more  important  organs.  In  order  to  retain  the  size  and  development  of  these 
muscles  he  must  undergo  a  special  training  table  and  constantly  keep  himself 
in  trim.  This,  therefore,  necessitates  considerable  attention  and  time.  Since 
this  muscular  development  does  not  prove  the  basis  of  the  life  occupation  of 
the  college  athlete,  and  since  these  well-developed  muscles  are  only  temporary, 
we  therefore  see  why  his  career  is  ended  suddenly  after  he  is  settled  in  life. 
Most  college  athletes,  instead  of  continuing  their  active  athletic  work  after 
they  have  graduated,  inevitably  drift  into  more  or  less  confined  and  sedentary 
occupations  of  city  life.  It  is  at  this  time  that  these  well-developed  muscles 
begin  to  play  havoc.  It  is  an  established  fact  that  large  and  well-developed 
muscles  or  other  organs  will  not  return  normally  to  their  primary  undeveloped 
condition.  Since  this  is  so,  these  muscles  will  undergo  atrophy  and  degenera- 
tion, especially  fatty  degeneration,  due  to  the  lack  of  strenuous  exercise  required 
to  keep  them  in  their  mature  condition.  The  training  necessary  to  preserve 
such  muscular  development  and  to  retain  it  at  its  health  point  is  practically 
impossible,  even  if  it  were  desirable,  in  the  ordinary  gi-inding  duties  of  the  life 
of  a  physician  or  other  sedentary  profession.  We  also  observe  that  heart 
affections  are  not  infrequent  among  athletes.  A  great  majority  present  s}Tnp- 
toms  of  heart  dilatation  and  valvular  defects,  as  is  shown  by  the  characteristic 
heart  murmurs. 

The  physical  training  of  the  bodily  organs  is  not  conducted  with  a  view  to 
the  promotion  of  bodily  health  and  vigor,  but  to  professionalism  and  a  spirit 
of  competition,  and  emulation  has  taken  the  place  of  friendly  rivalry.  If  exer- 
cise was  taken  for  the  mere  promotion  of  health,  there  would  be  less  disease  and 
more  symmetry  of  development.  The  reason  that  the  ancient  Greeks  were  so 
healthy  was  due  to  the  fact  that  they  engaged  in  appropriate  exercise,  made 
intelligent  use  of  air,  food,  sleep  and  resorted  less  to  drugs. 


THE  PINELLAS  PENINSULA,  FLORIDA. 

The  subjects  of  climate  and  health  resorts  are  among  the  most  important 
questions  confronting  us  to-day.  The  natural  desire  of  man  for  longevity 
and  for  the  promotion  or  restoration  of  health  causes  many  people  to  annually 
seek  a  change  of  scene  and  climate,  for  rest,  recreation,  and,  above  all,  for  its 
curative  effects. 

From  the  heat  and  discomfort  of  summer,  relief  is  sought  in  the  mountains 
or  by  the  seashore.  The  coasts  and  woods  of  Maine,  the  breezy  uplands  of 
Vermont  and  New  York  State,  the  hillsides  of  Pennsylvania  or  Virginia,  or 
the  wild  and  beautiful  peaks  of  "The  Land  of  the  Sky" — all  have  their  attrac- 
tions sung  by  enthusiastic  lovers,  but,  for  the  winter  change,  even  the  most 


THE  PINELLAS  PENINSULA,  FLORIDA.  51 

enthusiastic  will  admit,  that  other  scenes  with  more  gentle  climate  must  be 
sought,  if  benefit  to  the  less  robust  of  physique  is  to  follow. 

Such  a  locality  has  been  found  in  Hillsborough  County,  on  the  western 
coast  of  Florida.  Here  are  the  "fortunate  isles,''  or,  to  be  more  geographically 
correct,  here  is  the  beautiful  Pinellas  Peninsula,  a  strip  of  land  forty  miles 
long  and  averaging  about  ten  miles  wide,  with  Tampa  Bay  on  the  east  and  on 
the  west  the  Gulf  of  Mexico,  from  whose  occasional  boisterous  moods  it  lies 
protected  by  the  "Keys,"  an  almost  unbroken  chain  of  lovely  palm-covered 
islands  stretching  along  the  western  side  of  this  peninsula. 

Owing  to  the  great  length  of  the  coast  line  in  proportion  to  the  area,  the 
Pinellas  possesses  a  climate  of  remarkable  uniformity,  whose  curative  effect  is 
highly  recommended.  The  winter  weather  is  charmingly  warm,  the  breezes 
invigorating,  and  yet  so  mild  that  health-giving,  open  air  life  becomes  alluring 
to  the  invalid  as  well  as  enjoyable  to  the  recreation-seeking  tourist.  No  more 
attractive  home  or  winter  resort  could  be  found  in  a  locality  where  such  general 
healthful  climatic  conditions  prevail  the  3'^ear  round. 

In  addition  to  a  salubrious  and  equa|^le  climate,  the  Pinellas  is  able  to 
boast  of  attractive  scenery.  Pine  groves,  cultivated  gardens  and  orange  groves 
framed  in  by  the  blue  waters  of  Bay  or  Gulf,  form  a  most  pleasing  picture, 
while  some  of  the  other  senses  cannot  but  be  gratified  by  the  abundant  and 
delicious  fruits,  such  as  oranges,  grape-fruit,  pineapples,  peaches,  grapes,  figs, 
melons,  strawberries,  and  many  other  tropical  and  sub-tropical  fruit?,  as  well 
as  vegetables. 

Another  factor  making  this  peninsula  so  well  suited  for  a  health  resort 
is,  that  on  it,  at  the  southern  end,  is  the  beautiful  and  rapidly  growing  city  of 
St.  Petersburg — a  wide-awake,  hospitable  and  model  place,  possessing  all  the 
advantages  of  a  much  larger  town  in  its  educational  institutions,  business 
enterprises  and  modem  conveniences.  Still  another  fact  of  importance,  espe- 
cially to  the  invalid,  is  the  accessibility  of  the  Pinellas  Peninsula.  The 
Atlantic  Coast  Line  has  a  terminus  in  St.  Petersburg,  and  there  is  a  swift  boat 
connection  between  that  town  and  Tampa,  twenty  miles  away;  the  fast  and 
finely  equipped  steamer  "Favorite"  making  two  trips  daily,  thus  making  avail- 
able also  the  Seaboard  Air  Line.  But  wliile  St.  Petersburg  can  be  reached  in 
convenience  and  comfort  by  both  these  lines,  the  writer  often  advises  his  patients 
and  friends  to  use  the  magnificent  routes  of  the  Southern  Eailway,  by  which  it 
is  possible  to  go  by  way  of  Eichmond,  the  Carolinas  and  southern  Georgia,  a 
most  attractive  way  South,  there  being  many  interesting  points  at  which  the 
journey  can  be  broken,  a  consideration  sometimes  of  much  importance  to  an 
invalid  or  delicate  person,  not  only  allowing  a  more  gradual  change  to  take 
place,  but  pemiitting  perchance  much  needed  rest.  Both  Richmond  and 
Savannah  are  pleasant  stopping  places.  Again,  it  is  possible  when  using  the 
Southern's  Eoads  to  return  North  by  a  different  route  from  that  taken  on  the 
journey  down.  Atlanta  may  be  visited  and  opportunity  is  accorded  to  see 
Chattanooga  with  its  magnificent  scenery,  to  visit  historical  Lookout  Mountain, 
to  go  through  the  far  famed  valley  of  East  Tennessee  and  through  the  glorious 
mountain  region  of  northern  Carolina,  where  the  charms  of  the  "Sapphire 


52  THE  PINELLAS  PENINSULA,  FLORIDA. 

Country"  and  "Land  of  the  Sky"  may  well  invite  the  traveller  to  linger  before 
proceeding  toward  Lynchburg,  the  gate  way  of  the  James,  and  the  beautiful 
Shenandoah  Valley.  Such  a  leisurely  and  interesting  trip  home  will  do  much 
to  augment  the  benefit  gained  by  the  winter's  stay  in  a  region  such  as  the 
Pinellas. 

As  has  already  been  said,  the  climate  is  so  pleasant  a  large  portion  of  the 
time  may  be  spent  in  the  open  air  and  sunshine  engaged  in  the  most  healthful 
exercises,  such  as  boating,  bathing  and  fishing,  or  in  amusements  such  as  driv- 
ing, gunning,  etc.  The  clearness  of  the  atmosphere,  free  from  dust,  dirt, 
germs,  smoke,  etc.,  has  a  most  beneficial  effect  on  any  lung  or  throat  trouble, 
while  the  perpetual  summer,  with  its  abundance  of  sunshine  and  bracing  tonic 
air  of  the  sea,  is  also  very  favorable  in  the  treatment  of  such  difficulties,  as  well 
as  in  rheumatism  and  nervous  diseases. 

For  such  diseases  as  are  especially  amenable  to  climatic  treatment,  the 
writer  heartily  recommends  the  Pinellas,  having  been  acquainted  with  this 
locality  for  a  number  of  years,  and  having,  by  personal  investigation,  satisfied 
himself  that  it  is  designed  by  nature  as  a  sanatorium.  He  also  speaks  from 
personal  experience  with  reference  to  its  beneficial  effects,  having  sent  there 
since  1890  several  hundred  patients  with  uniformly  splendid  results.  Among 
those  sent  have  been  some  of  our  most  prominent  people,  and  cases  which  have 
baffled  the  best  skill  under  more  severe  climatic  conditions. 

He  has  advised  a  considerable  number  of  patients  whose  conditions  were 
especially  baffling  to  go  to  the  St.  Petersburg  region,  in  order  that  they  may 
spend  the  pleasant  winter  there.  In  those  patients  who,  following  advice,  went 
there  during  the  earlier  stages  of  the  disease,  the  climate  alone  frequently  effected 
complete  recovery.  These  beneficial  effects  the  writer  attributes  as  due  to  the 
balmy  air  laden  with  ozone  and  the  balsamic  emanations  from  the  surround- 
ing pine  forests.  It  is  surprising  to  note  how  rapidly  weakly  children  recup- 
erate, as  well  as  patients  suffering  witli  chronic  rheumatism,  gout,  blood 
diseases,  chronic  bronchitis,  asthma,  and  nervous  diseases.  This  advance 
toward  well-being  is  easily  explained  by  tlie  improvement  in  digestion,  which 
in  turn  increases  the  appetite  and  restores  the  lost  energy  and  strength.  The 
strain  upon  the  kidneys  is  reduced,  and  the  entire  organism  feels  the  difference. 

Good  health  is  naturally  restored  and  maintained  by  the  bracing  salt  air, 
the  pleasant  sunshine  all  day  long,  and  the  indescribable  restorative  effects  of 
the  delicious  spring-like  atmosphere. 

Other  phj'sicians  have  already  taken  advantage  of  the  great  benefits  to  be 
derived  by  their  patients  from  this  climate.  The  last  written  opinion  of  Dr. 
Levis  on  this  climate  is  here  quoted :  "The  situation  is  far  enough  South  to  be 
secure  from  the  chilling  influences,  and  not  so  far  as  to  be  inflicted  with  insect 
annoyances;  for  outdoor  life,  at  all  seasons  and  throughout  all  hours  of  the 
day  and  night,  this  vicinity  is  unequaled.  The  climate  is  peculiarly  suited  for 
cases  of  chronic  bronchitis,  catarrhal,  rheumatic  and  renal  affections.  My 
convictions  have  been  from  personal  experience  after  climatic  observations  of 
California,  the  French  and  Italian  Eiviera,  the  North  African  Coast,  the 
Egyptian  Deserts,  the  Valley  of  the  ISTile,  and  the  borders  of  the  Eed  Sea.     It 


BROMIDE  IN  EPILEPSY. 


BROMURAL  IN  SEASICKNESS. 


53 


is  remarkable  for  the  limited  range  of  the  thermometric  and  barometric 
changes,  and  for  the  comparative  dryness  of  the  atmosphere,  it  being  free  from 
the  vicissitudes  and  severe  mists  and  chilling  frost  of  the  California  Coast." 

All  testimony  sustains  the  verdict  of  the  special  committee  of  the  Ameri- 
can Medical  Association  in  the  early  80's,  that  this  is  the  most  healthful  of  all 
known  regions. 


Jlatcria  Jlcdica  and  Therapeutics 


BROMIDE  AND  DEPRIVATION  OF  SALT 
IN  EPILEPSY. 
Drs.  Jules  Courmont  and  Cremien 
tried  the  combined  treatment  of  bromide 
and  deprivation  of  salt  in  a  young  epi- 
leptic whose  crisis  occurred  every  ten 
daj^s  at  least.  Four  grams  of  bromide 
per  diem,  with  a  complete  absence  of  salt 
from  the  diet,  caused  an  absolute  cessa- 
tion of  the  crisis  for  the  thirty-five  days 
during  which  the  treatment  lasted.  The 
cessation  of  the  attacks  was,  however,  ac- 
companied by  a  grave  nervous  condition, 
characterized  by  delirium  and  suicidal 
impulse,  which  passed  away  with  the 
addition  of  salt  to  the  diet.  The  mental 
phenomena  were  complex  and  corre- 
sponded neither  to  epileptic  delirium  nor 
to  bromide  intoxication.  The  patient,  on 
becoming  calm,  had  perfect  recollection 
of  all  that  had  happened  in  the  delirious 
stage.  The  phar}Tigeal  reflex  was  not 
abolished,  the  temperature  was  above 
rather  than  below  the  normal,  and  there 
was  no  bromide  rash.  It  would  seem 
necessary  to  include  the  three  factors — 
the  epilepsy,  the  bromide,  and  the  de- 
privation of  salt — in  the  causation  of 
mental  disturbance.  (British  Medical 
Journal,  November  21,  1908.) 


BROMURAL  AS  A  HYPNOTIC  FOR 
CHILDREN. 

Professor  Ziehen  highly  recommends 
bromural,    particularly    in    the    severer 


forms  of  neurasthenic  sleeplessness.  His 
greatest  praise  of  the  preparation  is, 
however,  devoted  to  its  use  as  a  hypnotic 
for  children.  Bromural  is  a  drug  which, 
in  spite  of  the  trifling  percentage  of  bro- 
mine it  contains,  exhibits  powerful 
bromine  effects.  Owing  to  its  freedom 
from  by-effects,  it  is  to  be  warmly  recom- 
mended for  children  in  the  dose  of  a 
quarter,  a  third  or  half  a  tablet,  from 
1/4  to  3^  grains.  (Deutsche  med. 
Woch.,  1908,  Ko.  14.) 


BROMURAL  IN  THE  TREATMENT  OF 

SEASICKNESS. 
Dr.  Eugene  Perrenon  reports  that  this 
drug  was  employed  with  the  best  results 
in  the  treatment  of  seasiclniess.  The  ex- 
cellent hypnotic  properties  were  very 
evident,  and  the  effect  on  the  develop- 
ment of  seasickness  was  very  gratifying, 
especially  in  nervous,  overworked  in- 
dividuals, particularly  if  the  remedy  was 
given  prophylactically  at  the  beginning 
of  the  trip.  In  those  predisposed  to  sea- 
sickness, from  0.3  to  0.6  grams  (5  to  10 
grains),  according  to  constitution,  were 
given  before  the  first  large  meal.  This 
dose  was  repeated  the  first  evening  before 
retiring,  and  the  same  treatment  con- 
tinued on  the  second,  and,  if  necessary, 
on  the  third  day.  The  use  of  the  drug 
was  not  followed  by  any  bad  effect,  such 
as  nausea,  loss  of  appetite,  etc.  If  the 
treatment  was  begun  later,  after  symp- 


54 


CALCIUM  SALTS  IN  CONVULSIONS. 


CORSETS  FOR  PTOSES. 


toms  of  seasickness  had  already  ap- 
peared, larger  doses  were  necessary,  and 
the  administration  had  to  be  continued 
over  a  longer  period,  (New  York  Med- 
ical Monatsch.,  February,  1908.) 


CAICIUM  SALTS  IN  THE  TREATMENT  OF 
CONVULSIONS. 

Dr.  Silvestri  states  that  the  treatment 
of  the  various  convulsive  types  of  disease 
is  based  on  the  hypothesis  that  these  con- 
ditions are  due,  in  part,  to  a  diminution 
of  calcium  salts  in  the  blood.  The  au- 
thor records  three  cases  where  benefit 
accrued:  (1)  A  case  of  hystero-epi- 
lepsy;  (2)  tetany  occurring  in  successive 
pregnancies;  (3)  convulsions  in  a 
rickety  child.  The  salt  may  be  given  as 
a  hypophosphite,  cliloride  or  lactate. 
Various  experiments  on  animals,  clinical 
facts,  and  studies  in  metabolism,  in  ad- 
dition to  the  results  of  therapy,  agree  in 
declaring  there  is  some  association  be- 
tween various  idiopathic  convulsions 
common  to  infancy  and  maternity,  and 
some  disturbance  in  the  metabolism  of 
calcium — namely,  a  hypocalcification  of 
the  nervous  system.  Probably  this  defect 
is  due  to  a  latent  insufficiency  or  rela- 
tively diminished  activity  in  the  parathy- 
roid glands.  There  are  a  few  cases  where 
severe  tetany  has  been  definitely  asso- 
ciated with  injury  to  the  parathyroids. 
In  symptomatic  types  of  convulsion,  due 
to  intoxication  or  infection,  a  relative  in- 
sufficiency of  the  parathyroid  should  be 
borne  in  mind  as  a  causal  factor.  (Gazz. 
degli.  Osped.,  October  4,  1908.) 


CORSETS  FOR  PTOSES. 
A.  E.  Gallant,  New  York,  holds  that 
the  great  majority  of  the  symptomatic 
movable  kidneys  can  be  cured  sympto- 
matically  by  wearing  a  corset;  in  fact, 
he  says  that  his  present  opinion  would 
be  that  not  more  than  1  per  cent,  require 


operation.  He  soon  learned,  however, 
that  while  a  corset  laced  tightly  at  the 
waist  line  would  readily  support  a  re- 
placeable kidney  the  more  grave  and  det- 
rimental chronic  gastro-intestinal  ptosis 
and  its  symptoms  were  not  relieved,  but 
made  decidedly  worse  by  the  indispensa- 
ble tightening  of  the  corset  at  the  waist 
line.  He  therefore  describes  the  essen- 
tials of  a  corset  made  to  relieve  all  these 
sjTnptoms  which  must  be  suited  to  the 
individual  case  as  carefully  as  any  other 
orthopaedic  apparatus.  Its  essentials  are 
substantially,  that  it  must  conform  to  the 
fashions  or  women  will  not  wear  it.  At 
the  bottom  the  front  steels  must  overlap 
the  upper  half-inch  of  the  symphysis 
pubis;  must  reach  dowTi  low  and  fit 
snugly  around  the  hips,  stretching  tightly 
across  from  one  anterior  superior  spine 
to  the  other,  to  flatten  and  reduce  the 
hypogastrium  to  a  minimum.  To  pre- 
vent constriction  the  circumference  must 
equal  that  of  the  natural  waist;  at  the 
same  time  there  must  be  a  well-marked 
incurving  of  the  sides  to  support  the  kid- 
ney, to  prevent  slipping  and  to  give  a 
good  figure.  At  the  back  and  sides  the 
upper  portion  must  accurately  fit  the 
thorax,  while  in  front  ample  room  must 
be  given  for  the  replaced  stomach,  and 
below  the  waist  the  corset  must  be  in- 
elastic and  inflexible  to  prevent  recur- 
rence of  the  ptosis  of  the  viscera.  Above 
the  waist  it  should  give  free  play  to  the 
chest  walls  and  muscular  movements  and 
not  embarrass  the  heart  or  respiration. 
He  gives  details  as  to  the  adjustment.  It 
is  not  advisable  to  use  such  a  corset  (a) 
when  the  kidney  is  not  replaceable  above 
the  waist  line;  (b)  when  the  stomach  is 
held  down  below  the  umbilicus  by  peri- 
toneal adhesions;  (c)  in  the  presence  of 
pus  tubes  or  pelvic  or  abdominal  tumor. 
On  the  other  hand,  he  has  seen  a  most 
intractable  case  of  vomiting  of  pregnancy 


DECAPSULATION  OF  KIDNEY. 


EUCALYPTUS  IN  HEMORRHAGE. 


55 


stopped  immediately  by  pelvic  packing  in 
the  knee-cliest  posture  and  the  use  of  a 
corset.  He  sums  up  the  distinguishing 
features  of  his  plan  as  follows:  "1. 
Gravity  replacement  in  the  semi-opis- 
thotonos  posture,  massage,  exercises,  and 
rest  cure.  2.  Support  of  the  replaced 
organs  by  a  special,  made-to-order  corset 
of  fashionable  design  'V^ed'  in  front,  fas- 
tened by  one  lace,  inserted  from  the  waist 
down,  put  on  and  laced  while  in  the  semi- 
opisthotonos  posture,  and  worn  at  all 
times,  except  when  lying  down."  (Jour- 
nal of  the  American  Medical  Association, 
November  7.) 


DECAPSULATION  OF  KIDNEY  FOR 
CHRONIC  NEPHRITIS. 
Dr.  Gatti  gives  the  history  of  this 
operation  and  reports  its  application  in 
the  case  of  a  young  man  with  Bright's 
disease  who  survived  for  twenty-eight 
months  after  the  bilateral  decapsulation. 
The  general  health  showed  marked  im- 
provement for  twenty  months,  so  that  the 
patient's  earning  capacity  was  restored; 
but  then  the  old  symptoms  returned,  the 
intervention  not  having  permanently  ar- 
rested the  disease.  A  new  capsule  formed 
around  the  kidneys,  but  of  compact 
fibrous  tissue  with  few  and  small  blood- 
vessels. (Archiv.  fiir  klinische  Chirur- 
gie,  Berlin,  October  31.) 


ELECTRIC  TREATMENT  OF  ASTHMA. 

Dr.  Giinzel  is  convinced  that  asthmatic 
spasm  is  frequently  traceable  to  some 
peripheral  point.  In  one  case  removal  of 
a  small  projection  in  the  nose  completely 
cured  nocturnal  asthma  in  a  boy  of  five. 
Besides  this  class  of  cases,  in  .50  cases  of 
bronchial  asthma  he  has  applied  the 
high  frequency  current.  This  current 
passed  through  an  aching  nerve  renders 
it  insensible,  and  it  can  be  used  to  induce 
local  anaesthesia,  to  cure  neuralgia,  rheu- 


matoid pains,  etc.  In  an  acute  attack  of 
asthma  the  electricity  rapidly  soothes 
and  the  spasm  subsides.  From  two  to 
four  applications  at  one-hour  intervals 
relieve  and  cure  the  attack  of  asthma 
without  necessity  for  morphine.  (Jour- 
nal of  the  American  Medical  Association, 
December  19,  1908.) 


EUQUININE  IN  THE  TREATMENT  OF 
WHOOPING-COUGH  AND  TYPHOID 
FEVER. 
Dr.  C.  Binz  reports  excellent  results 
obtained  in  these  diseases  with  quinine 
carbonic  ether,  or  euquinine,  in  two 
cases  who  were  under  close  observation 
throughout  their  entire  illness,  and  a 
careful  account  of  the  number  of  attacks 
per  day  was  kept.  In  one  of  the  cases 
there  were  as  many  as  forty  or  fifty 
severe  spasms  per  day,  and  on  the  thir- 
tieth day,  after  treatment  was  begun 
with  the  euquinine,  the  patient  was  en- 
tirely free  from  the  spasms.  The  drug 
is  best  given  in  the  form  of  powders  or 
tablets;  acid  drinks  should  not  be  taken 
immediately  after,  as  euquinine  is  some- 
what soluble  in  these,  and  a  bitter  taste 
will  result.  The  child  receives  twice 
daily  as  many  decigrams  as  it  is  years 
old,  and  for  the  first  year  of  life  as  many 
centigrams  as  it  is  months  old,  with  the 
exception  that  for  older  children  the 
maximum  dose  is  generally  0.75  grams 
(13  grains)  twice  daily.  During  the 
first  year  0.05  grams  (%  grain)  may  be 
given  twice  daily.  This  drug  has  an 
efl'ect  on  the  spasms,  and  exerts  a  specific 
action  on  the  germ  in  pertussis.  (The 
Clinique,  November,  1908.) 


EUCALYPTUS  IN  HAEMORRHAGE. 
Dr.    A.    Todd-White    highly    recom- 
mends the  application  of  the  tincture  of 
eucaly])tus  for  the  arrest  of  any  form  of 
haemorrhage.     He  mentions  three  cases 


66 


FORMOL  FOR  SWEATING  FEET. 


GLYCERIN  EXTRACT  OF  LIVER. 


in  ^^■llic•ll  all  means  to  stop  the  persistent 
hEemorrhage  failed,  but  the  bleeding 
ceased  immediately  upon  the  application 
of  the  tincture  of  eucalyptus.  One  case 
was  that  of  a  bo}',  who  had  a  tooth  ex- 
tracted three  days  before,  and  had  per- 
sistent heemorrhage  from  the  socket. 
Another  case  was  that  in  which  there  was 
profuse  ha3morrhage  from  the  cut  in  the 
patient's  foot,  and  in  the  last  case  the 
hemorrhage  followed  the  application  of 
a  leech  to  the  gum.  He  also  calls  atten- 
tion to  the  use  of  this  preparation  as  a 
dressing  on  lint  after  circumcision  or 
other  minor  operations.  (British  Med- 
ical Journal.) 

FORMOL  IN  THE  TREATMENT  OF  SWEAT- 
ING FEET. 

Dr.  Viela  (Archives  de  Medicine  et  de 
pharmacie  Militaires,  March,  1908)  re- 
lates the  use  of  formol  in  treatment  of 
sweating  feet.  Sweating  hands  are  cured 
by  similar  treatment,  which  has  the  effect 
of  slightly  blunting  tactile  sensibility. 
The  method  of  application  is  as  follows : 
On  the  first  day  in  the  morning,  at  noon, 
and  in  the  evening  the  ordinary  com- 
mercial solution  of  formol,  one-third 
strength,  is  painted  over  the  soles  of  the 
feet.  On  the  second  day  three  applica- 
tions are  again  made,  but  with  a  solution 
of  half  strength.  On  the  third  day 
three  more  applications  are  made  with  a 
solution  of  full  strength.  Thereafter 
every  eight  days  a  solution  of  full 
strength  is  applied.  In  many  subjects 
cure  is  maintained  by  an  application  re- 
peated not  more  frequently  than  once  in 
fifteen  or  twenty  days.  When  the  epider- 
mis is  greatly  macerated  the  beginning 
treatment  may  be  begun  with  1 :  10, 
1 :  20,  or  even  1:30,  according  to  the 
degree  of  sensibility.  If  the  application 
causes    very    violent    burning,    washing 


with  water  and  a  weaker  strength  of  solu- 
tion are  employed. 


GELATIN  AND  SALT  SOLUTION  INFU- 
SIONS IN  TYPHOID  HiEMORRHAGE. 
Dr.  Witthauer  reports  four  typhoid 
cases,  with  severe  hemorrhage  from  the 
bowel,  treated  with  subcutaneous  injec- 
tions of  sterile  gelatin.  Three  out  of 
four  recovered,  and  in  the  fourth  the 
haemorrhage  stopped  three  days  before 
death.  The  preparation  used  was  given, 
50  grams  per  dose,  either  daily  or  every 
other  day  till  the  bleeding  stopped  and 
remained  absent.  In  conjunction  with 
this  the  author  used  salt  solution  infu- 
sions during  the  height  of  the  bleeding. 
He  had  previously  used  gelatin  by  mouth 
and  rectum  without  success,  but  he  be- 
lieves the  subcutaneous  use  of  gelatin  in 
typhoid  to  be  of  much  value,  and  he 
hopes  that  further  observations  on  the 
subject  will  be  instituted.  (Boston  Med- 
ical and  Surgery  Journal,  July  23, 
1908.)  

GLYCERIN  EXTRACT  OF  LIVER  IN  ALCO- 
HOLIC  CIRRHOSIS. 

Dr.  Jacques  Carles  reports  a  case  of 
cirrhosis  of  the  liver  in  a  woman  forty- 
eight  years  of  age.  She  suffered  from 
bilious  vomiting,  had  repeated  attacks  of 
ha3matemesis,  felt  very  ill,  lost  flesh,  and 
finally  became  jaundiced.  At  this  time 
she  was  admitted  to  the  hospital,  and 
there  it  was  observed  that  there  were 
numerous  enlarged  veins  over  the  ab- 
domen, a  large  quantity  of  ascitic  fluid 
was  i^resent,  and  some  oedema  of  the 
feet.  The  patient  had  a  thin  facial 
appearance,  conjunctive  were  highly 
icteric,  and  she  was  subject  to  attacks 
of  nightmare  and  alcoholic  delirium. 
The  lower  border  of  the  liver  could  not 
be  felt,  but  the  spleen  was  somewhat  en- 


HIGH  FREQUENCY  CURRENT. 


HOT  IRRIGATIONS. 


57 


larged.  The  patient  was  then  put  on  a 
milk  and  vegetable  diet,  with  a  little 
white  meat  twice  weekly.  She  was  also 
given  every  day  20  cubic  centimeters  of 
glycerin  extract  of  liver.  This  extract 
was  made  by  macerating  pigs'  liver  in 
glycerin.  Under  this  treatment  her  con- 
dition very  rapidly  improved.  The  en- 
larged veins  on  the  abdomen  disappeared, 
ascites  rapidly  diminished  and  diuresis 
became  well  marked.  After  six  weeks' 
treatment  the  patient  left  the  hospital, 
and  three  months  after  she  had  been  ad- 
mitted her  health  was  very  good.  This 
treatment  is  successful  in  early  cases  of 
cirrhosis,  but  the  results  are  not  favor- 
able in  those  cases  where  the  greater  part 
of  the  liver  has  already  been  seriously 
involved.  (British  Medical  Journal, 
October  3,  1908.) 


HIGH  FREaUENCY  CTJRRENT  IN  THE 
TREATMENT  OF  ENLARGED  PROSTATE. 
Dr.  Hunter,  of  ISTorfolk,  Va.,  brought 
the  Piontgen  ray  to  the  foreground  as  a 
treatment  for  enlarged  prostate,  due  to 
its  atrophying  powers  on  glandular  tis- 
sue. After  the  patient  is  placed  in  the 
Sim's  position  a  vacuum  rectal  tube  is 
lubricated  and  passed  into  the  rectum, 
placed  firmly  against  the  prostate,  and 
held  there  by  the  operator,  who  raises 
and  lowers  the  handle  of  the  tube  holder, 
moving  the  electrode  over  the  entire  sur- 
face of  the  prostate  gland.  The  tube 
holder  is  connected  with  the  resonator 
by  a  single  wire.  The  strength  of  the 
current  is  indicated  by  the  spark  gap. 
The  patient  is  not  conscious  of  the  least 
discomfort.  Of  the  twelve  patients 
treated,  six  were  senile  hypertrophy,  and 
six  were  in  men  under  forty-five  years  of 
age,  and  who  were  suffering  from  nerv- 
ous break-down.  The  humane  feature  of 
the  treatment  is  so  marked,  there  is  no 
ether,  vomiting,  nervous  shock,  tedious 


convalescence,  or  loss  of  valuable  time, 
and  no  death,  (Journal  of  the  Ameri- 
can Medical  Association,  November  28, 
1908.)  

HOT  AIR  IN  THE  TREATMENT  OF  ACUTE 
INFLAMMATIONS. 

Dr.  Jselin  reports  encouraging  results 
in  the  treatment  of  tendon-sheath  phleg- 
mons and  suppurating  inflammation  in 
general.  He  uses  an  ordinary  apparatus 
for  using  superheated  air,  applying  it 
twice  a  day  for  two  or  three  hours  each 
time,  maintaining  a  temperature  of  from 
90°  to  110°  C.  (194°  to  230°  F.)  within 
the  frame  at  half  its  height.  Thus  ar- 
ranged, the  temperature  on  the  skin 
averaged  44°  or  47°  C.  (111°  or  116° 
F.),  and  the  acceleration  and  sweating 
induced  seemed  to  keep  the  temperature 
of  the  skin  within  due  bounds.  The  ap- 
plications of  the  hot  air  are  made  the  day 
after  the  abscess  has  been  incised  and 
evacuated,  and  the  cavity  packed  with 
iodoform  gauze.  He  also  states  that  neg- 
lected injuries  of  the  fingers,  which 
would  otherwise  have  necessitated  ampu- 
tation, healed  under  this  hot  air  treat- 
ment without  requiring  operative  meas- 
ures, and  recovery  was  hastened,  also  fol- 
lowed by  abolition  of  pain.  (Zentralblatt 
fiir  Chirurgie,  Leipzig,  October  24.) 


HOT  IRRIGATIONS  IN  THE  TREATMENT 
OF  VENEREAL  ULCERS. 
Dr.  Zinsser  calls  attention  to  the  treat- 
ment of  venereal  ulcers  by  hot  irriga- 
tions. The  treatment  consists  of  irriga- 
tion three  to  five  times  daily  with  a 
stream  of  potassium  permanganate  solu- 
tion 1 :  4000,  as  hot  as  can  be  borne ; 
temperature  ranging  from  45°  to  50°  C. 
Four  to  five  liters,  running  from  a  height 
of  two  to  three  meters  in  a  stream  about 
two  milliineters  thick,  are  used  at  each 
sitting.    The  results  have  been  astonish- 


58 


EOT  SOLUTIONS  IN  CAKBUNCLES. 


MERCURY  IN  TUBERCULOSIS. 


ingly  good  in  cases  of  gangrenous  ulcers 
with  necrosis  of  the  surrounding  tissues ; 
excessive,  foul  exudate;  Ij-mphangitis ; 
and  high  fever.  After  irrigation  the 
ulcer  is  dried  with  gauze,  sprinkled  with 
iodoform,  and  tamponaded  with  iodo- 
form gauze  saturated  with  spirit  of  cam- 
phor and  water  equal  parts.  Over  this 
hot  linseed  poultices  are  placed  and  fre- 
quently renewed.  In  gangrenous  cases 
the  treatment  should  be  repeated  every 
two  or  three  hours.  In  about  a  day  the 
necrotic  mass  has  separated,  the  bad 
odor  has  disappeared,  the  secretion  is 
much  less,  the  temperature  again  nor- 
mal. A  few  days  later  granulations  can 
be  seen  at  the  edge  of  the  wound,  and 
epithelialization  has  begun. 

Kemarkable  results  have  also  been  ob- 
served in  phagedenic  ulcers,  and  in 
buboes,  in  which  cases  the  invasion  of  the 
tissues  stops  just  as  soon  as  the  above- 
mentioned  treatment  is  begun.  (Miin- 
chener  medizinische  Wochensehrift 
Jahrg.  55,  nr.  18.) 


has  never  had  occasion  to  make  further 
incisions  or  to  ligate  any  of  the  vessels. 
(Deutsche  medizinische  Wochensehrift, 
Berlin,  October  15.) 


HOT  SOLUTIONS  OF  BORIC  AND  SALIC- 
YLIC ACID  IN  THE  TREATMENT  OE 
CARBUNCLES. 
Dr.  Grassman  relates  the  eflficacy  of 
the  applications  of  hot  solutions  of  boric 
and  salicylic  acid  in  the  treatment  of 
carbuncles.  After  making  a  crucial  in- 
cision  he  turns  back  the  flaps  and  cuts 
into  sound  tissue;  then  the  flaps  are 
packed  underneath  with  gauze  dipped  in 
a  hot  solution  of  boric  and  salicylic  acid. 
A  large  moist  dressing  is  applied,  and 
the  application  is  repeated  in  twenty- 
four  hours ;  or,  if  the  fever  has  subsided, 
not  until  the  second  day.  The  surround- 
ing skin  is  protected  with  a  salve  against 
burning  from  the  hot  solution.  This 
treatment  is  very  effectual  in  preventing 
haemorrhage  and  in  promoting  the  expul- 
sion of  the  necrotic-tissue.    The  author 


HYPERiEMIA    IN    THE    TREATMENT    OF 
CHILBLAINS. 

Dr.  C.  Eitter  states  that  not  one  case 
of  chilblains  failed  to  improve  under  the 
application  of  Bier's  method  of  hyper- 
a;mia.  The  only  apparatus  required  for 
inducing  this  artificial  hyperaemia  is 
Bier's  constricting  bandage,  by  the  appli- 
cation of  which  hypersemia  is  produced. 
The  same  thing  can  be  brought  about  by 
the  application  of  hot  air  to  the  part,  in 
the  absence  of  the  constricting  bandage. 
The  application  should  extend  from  six 
to  twelve  hours,  with  a  pause  of  at  least 
two  hours  daily.  (British  Medical  Jour- 
nal, in  Hospital  Assistant,  1908.) 


HYPODERMICS  OF  IRON  IN  ANiEMIA. 
Dr.  Leroy  F.  Peters,  of  Silver  City, 
New  Mexico,  advocates  the  use  of  iron 
by  means  of  hypodermic  injection  in  the 
anremia  of  tuberculosis  as  a  method  of 
treatment  that  gives  rapid  results.  He 
sums  up  the  treatment  by  this  method  of 
forty-two  patients.  An  effect  is  obtained 
rapidly,  and  the  condition  disappears 
after  twenty  consecutive  doses.  He  uses 
citrate  of  iron  combined  with  arsenic  and 
strychnine.  (Medical  Eecord,  October 
10,  1908.)  

MERCURY  IN  TUBERCULOSIS. 

Dr.  B.  L.  Wright,  Colo.,  reports  the 
results  obtained  in  the  treatment  of 
tuberculosis  by  mercury.  Of  the  total 
number  of  patients  under  treatment,  85.5 
per  cent,  have  been  improved,  and  there 
have  been  two  cases  counted  as  cures, 
thus  showing  that  this  drug  has  an  anti- 
tuberculous  as  well  as  an  antisyphilitic 
action.    Of  the  remaining  13.5  per  cent. 


METHYLENE-BLUE  FOR  NIPPLES. 


OXYGEN  IN  PUERPERAL  INFECTION.  59 


two  patients  have  held  their  own,  six 
have  failed,  and  one  has  died.  The  con- 
trast between  the  patients  who  refused 
the  mercury  treatment  and  those  who  re- 
ceived it,  all  under  the  same  conditions 
otherwise,  was  very  marked,  only  33  per 
cent,  of  those  refusing  having  improved, 
and  this  chiefly  in  the  general  condition 
rather  than  in  the  pulmonary  lesions, 
Wright  believes  that  the  mercury  acts  as 
a  tonic  and  as  a  bactericide  in  the  blood. 
His  method  is  to  give  an  injection  of 
%  grain  of  hydrargyrum  succinimdum 
every  other  day  until  thirty  injections 
have  been  given.  Then  the  patient  is 
placed  for  two  weeks  on  iodide  of  potash, 
followed  by  a  week  without  medication. 
Then  the  mercury  is  resumed  with 
slightly  reduced  doses  for  another  thirty 
days,  and  so  on.  The  drug  should  never 
be  pushed  to  the  point  of  salivation,  and 
the  doses  given  above  are  not  absolute, 
but  must  be  determined  by  close  observa- 
tion of  each  individual  patient.  (Jour- 
nal of  the  American  Medical  Association, 

ISTovember  28.)    

METHYLENE-BLUE  FOR  FISSURED 
NIPPLES. 
Dr.  Dresh,  of  Aix-les-Therermes,  has 
employed  a  3-per-cent.  solution  of  meth- 
ylene-blue  as  a  topical  application  for 
the  cure  and  prevention  of  fissured  nip- 
ples, after  cleaning  the  ends  of  the 
nipples  and  the  infant's  mouth  with  a 
lukewarm  2-per-cent.  solution  of  bicar- 
bonate of  soda.  He  then  swabs  the  nip- 
ples with  the  solution  of  methylene-blue. 
Eight  or  ten  days  of  treatment  are  suffi- 
cient, and  it  is  necessary  to  make  the 
application  immediately  after  nursing, 
when  the  nipple  is  at  its  maximum  of 
erectility.  The  methylene-blue  prevents 
the  constant  maceration  of  the  nipple  in 
the  saliva  and  milk  by  the  promotion  of 
keratinization.  (Gaz.  des  Sciences  med. 
de  Bordeaux;   Gaz.  des  Hopitaux.) 


OIL  IN  THE  TREATMENT  OF  STOMACH 
AFFECTIONS. 
Dr.  Eiitimeyer  concludes  from  his  own 
experience  and  study  the  results  of  this 
treatment  in  100  cases  of  stomach  affec- 
tions. In  some  cases  of  hypersecretion 
and  hyperacidity,  with  or  without  neur- 
asthenia, the  secretion  was  reduced  when 
30  grams  butter  or  100  grams  warmed 
oil  was  taken,  fasting  in  the  morning. 
In  another  case  of  threatening  post-op- 
erative spasm  of  the  pylorus,  with  ex- 
treme dilatation  of  the  stomach,  100 
grams  of  oil  poured  into  the  stomach 
each  morning,  with  lavage  of  the  stomach 
twice  a  day,  promptly  cured  the  spasm. 
In  one  case  a  merchant  of  forty-one  pre- 
sented signs  of  chronic  ulcer  and  spasm 
of  the  pylorus,  with  excessive  secretion 
and  intense  pains.  After  being  treated 
by  various  measures  for  two  years,  oper- 
ation was  proposed.  Finally,  as  a  last 
resort,  a  systematic  course  of  oil  was  in- 
stituted. The  patient  rinsed  out  his 
stomach  every  morning,  and  took  100 
grams  of  oil,  and  in  two  weeks  the  pains 
and  spasms  vanished.  He  soon  gained 
weight,  and  was  soon  capable  of  eating 
any  ordinary  kind  of  food.  The  most 
striking  benefit  of  the  oil  treatment  is  in 
its  influence  on  the  subjective  disturb- 
ances. (Correspondez-Blatt.  fiir  schwei- 
zer  Aertze,  Basle,  November  1,  1908.) 


OXYGEN  IN  PUERPERAL  INFECTION. 

Dr.  Eeynier  reports  four  cases  of 
severe  anasrobic  puerperal  infection  in 
which  marked  improvement  followed  the 
use  of  a  current  of  oxygen  allowed  to 
flow  continuously  and  slowly  into  the 
uterus,  through  a  recurrent  catheter.  In 
the  case  of  one  patient  who  was  much 
prostrated,  six  days  after  her  confine- 
ment, the  temperature  being  40°  C. 
(104°  F.),  and  the  lacerated  perineum 
and  cervix  were  covered  with  diphtheroid 


60 


PAEAFFIN  FOR  INCONTINENCE. 


RADIUM  IN  ANGIOMATA. 


false  membranes;  the  uterus  was  rinsed 
out  with  hydrogen  dioxide  morning  and 
evening,  followed  by  an  iodized  injection, 
and  this  by  the  continuous  oxygen  treat- 
ment. Soon  the  temperature  dropped, 
and  the  patient  made  a  rapid  recovery. 
(Bulletin  de  L' Academic  de  Medecine, 
Paris,  October  13,  1908.) 


the  author's  experience  the  latter  is  not 
bacteriologically  a  diphtheritic  laryn- 
gitis. (Giorn.  Internaz.  d.  Sci.  med., 
XXX,  310,  Naples,  1908.) 


PARAFFIN  FOE,  INCONTINENCE  OF 
URINE. 

Drs.  Fabre  and  Trillat  report  a  case 
where  a  woman,  whose  age  was  not 
stated,  who  had  been  subject  for  six 
years  to  incontinence  of  urine,  appar- 
ently of  traumatic  origin.  It  became  so 
complete  as  to  prevent  her  working  for 
a  living.  There  was  a  posterior  colpocele 
without  prolapse  of  the  anterior  vaginal 
wall;  the  uterus  lay  a  little  below  the 
normal  level.  The  urethra  Avas  intact, 
but  its  sphincter  had  lost  its  normal  tone. 
In  order  to  narrow  the  relaxed  urethral 
canal  and  to  afford  a  resisting  medium 
upon  which  the  sphincter  might  act,  the 
author  injected  solid  paraffin  into  the 
urethral  canal  after  Gersuny's  method. 
The  incontinence  disappeared  in  a  few 
da3^s,  and  did  not  return.  (Ann.  de 
Gynec.  et  d'Obstet.,  September,  1908.) 


PILOCARPINE  IN  THE  LARYNGEAL  OB- 
STRUCTION OF  MEASLES. 
Dr.  A.  Montefusco  notes  the  good  re- 
sults obtained  by  the  subcutaneous  in- 
jection of  the  nitrate  of  pilocarpine  in 
doses  of  1  milligram,  repeated  as  neces- 
sary. The  author  has  treated  forty-five 
cases  in  the  past  four  j^ears  with  two 
deaths — which  he  attributes  to  pneu- 
monia. This  method  of  treatment  has 
been  found  an  almost  certain  cure  for 
the  very  severe  obstructive  forms  of 
lar}Tigitis  occurring  at  any  time  dur- 
ing measles.  This  laryngitis  may  be 
stridulous    or    pseudo-membranous;     in 


QUININE  IN  CHOLERA. 

The  China  Medical  Missionary  Jour- 
nal for  Ma}^,  1908,  calls  attention  to  the 
use  of  quinine  in  cholera.  Very  decided 
success  has  been  obtained  by  its  use  by 
Dr.  Ussher  in  the  Philippines.  iSTinety 
per  cent,  of  the  patients  suffering  with 
cholera  recovered.  It  was  also  used  in 
the  treatment  during  the  epidemic  of 
cholera  which  raged  on  the  Yang-tse, 
and  very  good  results  were  secured.  The 
plan  of  treatment  is  as  follows :  Sul- 
phate of  quinine  in  10-grain  doses  every 
hour  until  the  rice-water  stools  had  dis- 
appeared and  bile  was  passed  into  the 
motions.  For  suppression  of  urine,  fric- 
tion of  the  limbs,  hot  fomentations,  dry 
cupping  over  the  loins  and  sweet  spirits 
of  nitre  were  found  useful.  When  evi- 
dence of  failing  circulation  intervened, 
subcutaneous  injection  of  saline  solution 
Droved  beneficial. 


RADIUM  TREATMENT  OF  ANGIOMATA. 
The  Eev.  de  med.,  1908,  Nos.  6  and  7, 
discusses  the  efficacy  of  radium  in  an- 
giomata.  Eadium  spontaneously  gives 
forth  light,  heat  and  electricity.  Besides 
the  emanation,  alpha,  beta,  and  gamma 
rays  are  produced,  and  these  different 
rays  may  be  separated  by  means  of  an 
ilium inum  or  lead  plate.  The  treatment 
of  nasvi  by  means  of  radium  is  painless, 
so  that  it  can  even  be  used  for  children. 
The  radio-active  substance  is  applied 
upon  a  metal  plate  with  a  varnish,  and 
the  surrounding  parts  of  the  skin  pro- 
tected by  means  of  lead.  The  very  best 
results  are  seen  in  very  vascular,  project- 
ing forms  and  in  nsevous  tuberosus,  while 
the  cure  of  nasvus  planus  is  not  always 


SILVER  NITRATE. 


SULPHURIC  ACID  IN  CARBUNCLES. 


61 


satisfactory.  There  will  be  no  visible 
destruction  of  tissue,  and  hence  no  scar- 
ring. The  method  is  preferable  to  elec- 
trolysis for  this  and  because  it  is  pain- 
less. (Merck's  Archives,  November, 
1908.)  

SILVER   NITRATE  IN  INFECTIONS. 

Drs.  A.  Schatzky  and  N.  Grjasnow 
find  that  intravenous  injections  of  a 
1 :  1000-silver-nitrate  solution  form  a 
harmless  and  very  effective  method  of 
treating  general  injection,  if  used  in 
amounts  of  500  cubic  centimeters.  The 
method  is  indicated  in  all  cases  of  infec- 
tion without  localization,  and  also  where 
there  is  localization,  but  with  pronounced 
s3anptoms  of  intoxication.  The  abscess, 
etc.,  should,  of  course,  be  treated  locally 
as  well.  At  first  there  will  be  a  rise  of 
temperature,  sometimes  with  a  chill,  an 
increase  of  pulse  and  respiration  rate, 
then  profuse  respiration  and  fall  in  tem- 
perature. Earely  this  action  is  incom- 
plete or  absent  altogether.  A  pronounced 
reaction  is  usually  followed  by  perma- 
nent low  temperature  and  rapid  improve- 
ment. The  subjective  symptoms  and 
general  condition  are  almost  always 
favorably  affected.  The  intravenous  in- 
jections of  silver  nitrate  induce  hsmol}^- 
tic  processes,  followed  by  ferment  action. 
The  method  must  not  be  regarded  as  a 
panacea,  yet  it  sometimes  leads  to  sur- 
prising cures.  (Klin.-therap.  Woch., 
August  17,  .1908;   Merck's  Archives.) 


SPIROSAL  FOR  RHEUMATISM. 
Dr.  Otto  Lelimann  discusses  spirosal 
as  an  ideal  antirheumatic  for  external 
use.  Spirosal  is  an  oily,  colorless  fluid, 
which  is  miscible  with  alcohol  in  every 
proportion.  The  chief  advantage  claimed 
for  it  is  that  it  does  not  cause  irritation 
of  the  skin.  It  is  best  to  take  equal  parts 
of  the  drug  and  alcohol,  as  the  drug  can 


be  better  rubbed  into  the  skin  this  way, 
and  an  agreeable  sensation  of  warmth 
will  result.  After  about  two  hours 
salicylic  acid  can  be  readily  detected  in 
the  urine.  The  best  results  were  seen  in 
subacute  and  chronic  rheumatic  poly- 
arthritis, and  chronic  muscular  rheuma- 
tism, while  in  the  acute  forms  the  inter- 
nal administration  is  of  more  impor- 
tance. Three  rubbings  are  given  daily, 
and  no  general  or  local  irritation  will 
follow.  (Therap.  d.  Gegenwart.,  Au- 
gust 11,  1908.) 


SULPHURIC  ACID  IN  CARBUNCLES, 

BOILS,  ETC. 
Drs.  J.  and  E.  J.  Reynolds,  of  London, 
Eng.,  report  the  beneficial  effects  of  this 
remedy  in  the  treatment  of  staphylo- 
coccic infection  of  the  skia  and  sub- 
cutaneous tissue.  They  say  that  after 
these  cases  have  been  put  under  treat- 
ment it  will  be  noticed  that  after  the 
first  twelve  or  eighteen  hours  the  affected 
area  becomes  distinctly  circumscribed, 
and  the  lesion  ceases  to  extend,  softening 
of  the  tissues  in  the  affected  area  rapidly 
takes  place  and  pus  is  discharged, 
healthy  granulations  commence  to  form 
at  the  base,  and  the  process  of  repair 
goes  on  uninterruptedly.  It  is  quite  un- 
necessary to  cut  or  to  interfere  with  the 
part  in  any  way,  except,  perhaps,  to 
apply  some  antiseptic  dressing,  such  as 
carbolized  vaselin  (1  in  40)  on  lint. 
The  sulphuric  acid  should  be  adminis- 
tered in  doses  of  20  to  30  minims,  well 
diluted  with  water,  and  should  be  taken 
regularly  every  four  hours.  This  treat- 
ment should  be  continued  for  at  least  a 
fortnight  after  the  lesion  has  disap- 
peared. The  treatment  is  very  simple, 
and  in  all  the  cases  that  they  have  ad- 
ministered this  remedy  it  has  never 
failed.  It  also  does  not  disturb  the 
patient's  digestion  nor  cause  any  incon- 


62 


TREATMENT  OF  ULCER. 


ZINC  IONS  IN  OPHTHALMIA. 


venience  in  any  wa3^     (British  Medical 
Journal,  August  15, 1908.) 


TREATMENT   OF  GASTRIC  ULCER. 

Dr.  Borgbjaerg  states,  in  discussing 
the  treatment  of  gastric  ulcer,  that  since 
the  pain  is  not  due  to  the  sensitiveness 
of  the  gastric  mucosa,  but  is  due  to  the 
spread  of  the  inflammation  into  the 
l3'mphatics  or  of  traction  on  the  parietal 
peritoneum  from  the  contractions  of  the 
stomach,  therefore,  the  first  thing  to  do 
is  to  omit  such  foods  from  the  diet  as 
are  liable  to  promote  peristalsis,  and  to 
give  food  in  very  small  quantities.  Water 
should  be  supplied  by  the  rectum  if  there 
be  much  thirst.  The  author  has  had 
striking  results  with  a  7-  to  10-per-cent. 
suspension  of  olive  oil  and  bismuth.  One 
of  his  cases  was  very  much  emaciated, 
due  to  the  loss  in  weight  for  a  period  of 
six  months.  The  patient  presented 
symptoms  of  hsematemesis,  followed  by 
sudden  pain  in  the  stomach  region,  hy- 
persecretion and  morning  retention. 
Since  he  showed  no  improvement  under 
dieting  and  a  course  of  Carlsbad  water, 
he  took  100  gm.  (3  ounces)  olive  oil 
every  morning,  and  the  pains  subsided, 
while  he  gained  nearly  25  pounds  in 
weight,  and  the  suspicion  of  cancer  was 
dispelled.  The  combination  of  olive  oil 
and  bismuth  generally  proves  more 
effectual  than  either  alone.  (Ugeskrift 
for  Lgeger,  Copenhagen,  August  27,  '08.) 


VERONAL  IN  THE  INSOMNIA  OF  MENTAL 
DISEASES. 

Dr.  Salluste  Eoy,  physician  to  the 
Insane  Asylum  of  Beauport,  Quebec,  re- 
ports that  veronal  has  commended  itself 
in  combating  insomnia  in  the  insane 
asylum. 

In  two  cases  of  acute  maniacal  excite- 
ment in  which  the  other  hypnotics  had 


proved  unreliable  in  their  action,  veronal 
had  produced  a  calm  and  refreshing 
sleep  of  four  to  six  hours'  duration.  The 
same  results  were  obtained  in  the  case 
of  an  insane  patient  who,  during  periods 
of  excitement,  had  shown  himself  refrac- 
tory to  the  action  of  other  hypnotics. 
The  doses  in  these  cases  varied  from  15 
to  25  grains,  the  results  consisting  in  an 
abatement  of  the  symptoms  of  excite- 
ment, showing  that  this  medicament,  be- 
sides its  hypnotic  qualities,  has  a  marked 
sedative  effect  upon  the  cerebrum.  It 
promptly  produces  a  natural  sleep  in 
melancholic  depression,  neurasthenia  and 
hypochondriasis.  (Merck's  Archives, 
October,  1908;  Le  Bull.  med.  de  Que- 
bec.) 


ZINC  IONS  IN  THE  TREATMENT   OF 
OPHTHALMIA   NEONATORUM. 

Dr.  H.  K.  Eamsden  describes  the  re- 
cent treatment  of  a  case,  claiming  that 
many  cases  of  corneal  opacity  can  be  pre- 
vented by  the  method  employed.  The 
conjunctiva  of  the  diseased  eje  was 
everted  and  a  positive  electrode  which 
consisted  of  some  cotton  wool  saturated 
in  a  2-per-cent.  solution  of  zinc  sulphate 
was  applied.  The  nurse  held  the  nega- 
tive electrode  in  the  child's  hand.  The 
battery  employed  was  an  ordinary  bi- 
chromate battery,  which  gave  twenty 
volts,  and  half  a  milliampere  current  was 
passed  for  three  minutes.  Twelve  hours 
after  the  application  the  inflammation 
was  subsiding,  and  another  application 
was  made.  Two  days  later  the  case  was 
cured.  In  the  author's  experience  the 
case  ordinarily  treated  by  silver  nitrate 
or  protargol  applications  (twice  a  day) 
would  have  taken  fourteen  days,  and 
would  have  been  an  anxious  one.  (Brit- 
ish Medical  Journal,  November  7,  1908.) 


BOOK  REVIEWS.  63 

5ool<  Reviews 


Tbansactioxs  of  the  Sixth  Annual  Conference  of  State  and  Territobiax  Health 
Officers  with  the  United  States  Public  Health  and  Marine-Hospital  Service. 
Washington,  D.  C,  April  27,  1908.     Washington  Government  Printing  Office,   1908. 

This  handsome  volume  of  79  pages  presents  the  discussion  which  took  place  at  the  sixth 
annual  conference  of  State  and  Territorial  Health  Officers  with  the  United  States  Public 
Health  and  Marine-Hospital  Service  on  April  27,  1908,  at  10  o'clock.  The  discussion  con- 
siders the  various  precautions  taken  with  regard  to  the  public  health  and  also  the  proposed 
interstate  quarantine  regulations.  Many  suggestions  and  helpful  points  will  be  found  which 
will  be  of  service  to  the  reader. 

A  Hand-Book  of  Suggestive  Therapeutics,  Applied  Hypnotism,  Psychic  Science.  By 
Henry  S.  Munro,  M.D.,  Americus,  Georgia.  Second  Edition.  St.  Louis:  C.  V.  Mosby 
Medical  Book  and  Publishing  Company,  1908. 

The  feature  of  this  book  is  that  it  deals  with  the  practical  application  of  suggestive 
therapeutics,  applied  hypnotism  and  psychic  science.  The  author  states  that  the  human 
mind  is  receptive  to  suggestions  and  cites  cases  where  suggestion  has  so  influenced  cell  life, 
that  a  hat  pin,  without  previous  sterilization,  was  thrust  through  a  large  fold  of  the  cheek 
of  a  person  without  the  slightest  ill-effects  following.  Special  emphasis  is  made  upon  the 
fact  that  the  physician  should  make  the  patient  believe  that  he  will  get  well.  In  order  that 
he  may  strengthen  the  bridge  that  is  to  tide  him  over  to  recovery.  The  author  brings  to 
the  medical  profession  the  facts  and  the  detailed  explanation  of  how  to  apply  suggestion 
efficaciously  both  with  and  without  hypnotism  as  a  therapeutic  adjunct. 

Some  of  the  important  chapters  are  "Hypnotism  and  Suggestion,"  "Suggestion  Applied 
Without  Hypnotism,"  Correct  Diagnosis  a  Safeguard  Against  Blunders,"  "Philosophy  and 
Religion  and  their  Relation  to  Health,"  "Roughing  it  as  a  Means  of  Health,"  "Personality 
as  a  Factor  in  Therapeutics."  This  work  is  one  of  considerable  interest  to  the  medical  pro- 
fession and  will  be  read  with  profit  by  all  those  to  whom  the  subject  and  its  application 
are  comparatively  new.  The  book  is  written  in  a  style  which  is  simple  and  attractive  and 
which  makes  the  assimilation  of  the  facts  both  easy  and  effective. 

Taber's  Pocket  Encyclopedic  Medical  Dictionary.  Edited  by  Clarence  W.  Taber,  Author 
of  "Taber's  Medical  Dictionary  for  Xurses,"  "The  Secret  of  Sex,"  Co-Author  of  "Eales' 
and  Taber's  Anatomical  and  Physiological  Chart."  Associate  Editor,  Nicholas  Senn, 
M.D.,  Ph.D.,  LL.D.,  CM.,  Professor  of  Surgery  University  of  Chicago;  Professor  and 
Head  of  the  Surgical  Department  Rush  Medical  College;  Surgeon-in-Chief  St.  Joseph's 
Hospital,  etc.     Chicago,  U.  S.  A.:     C.  W.  Taber,  Publisher. 

This  little  book  is  intended,  as  is  stated  in  the  preface,  "to  fill  a  demand  not  supplied 
by  any  other  pocket  medical  dictionary."  Besides  grouping  the  subject  of  special  interest 
in  separate  vocabularies  for  the  purpose  of  facilitating  access  to  them,  the  author  has  also 
inserted  a  cross  index  system  by  which  a  word  may  be  found  whether  it  is  kno^vn  by  the 
consultant  or  not.  The  information  is  simple  and  explicit  as  could  be  given  in  the  space 
occupied.  It  will  render  valuable  service  to  the  consultant  and  its  flexible  covers  will  pre- 
serve it  during  its  frequent  use  as  a  guide.  Tlie  work  as  a  whole  is  very  commendable. 
It  covers  the  necessary  ground  and  no  more,  being  free  from  vague  and  obsolete  terms  or 
words  with  no  medical  significance. 

Gonobbh(ea  in  Women.  By  Palmer  Findley,  M.D.,  Professor  of  Gynecology  in  the  College 
of  Medicine  of  the  University  of  Nebraska,  Omaha;  Gynecologist  to  the  Clarkson 
Memorial  Hospital  and  Wise  Memorial  Hospital;  Fellow  of  the  American  GjTiecological 
Society.     St.  Louis,  Mo.:   C.  V.  ]\Iosby  Medical  Book  and  Publishing  Company,  1908. 


64  BOOK  REVIEWS. 

This  book  is  devoted  exclusively  to  the  consideration  of  gonorrhoea  in  women  and  em- 
bodies the  views  of  the  best  workers  in  this  field.  Tlie  first  section  gives  an  excellent  account 
of  the  "Historical  Sketch,"  then  comes  "Etiology,"  "Pathogenesis,"  "Pathology,"  "Course  of 
Gonorrha'al  Infection,"  "Diagnosis,"  "Frequency  of  Gonorrha?a  in  Women,"  "Sociologj-," 
"Treatment,"  "Systemic  Gonorrhceal  Infections,"   and  "Literature." 

In  the  chapter  devoted  to  the  treatment,  the  author  considers  in  detail  those  remedies 
which  have  proven  of  value,  and  individual  preferences  are  brought  into  prominence.  The 
subject  matter  is  printed  in  large  type  and  on  good  paper;  important  points  are  emphasized 
by  bold-faced  type.  On  the  whole,  the  book  admirably  fills  the  place  for  which  it  was  in- 
tended. 

TniETY-FiFTn  Annum.  Report  of  the  Secretary  of  the  State  Board  of  Health  of  the 
State  of  Michigan  foe  the  Fiscai.  Year  ending  June  30,  1907.  By  Authority. 
Lansing,  Michigan:   Wynkoop,  Hallenbeck,  Crawford  Company,   State  Printers,   1908. 

This  volume  gives  a  report  of  all  the  diseases  within  the  jurisdiction  of  the  State  of 
Michigan  and  describes  the  dangers  to  health  which  threaten  the  life  of  the  people  in  the 
State.  Also  the  various  means  for  the  elimination  of  these  diseases  are  pointed  out.  The 
numerous  tables  scattered  throughout  this  report  give  valuable  information  concerning  the 
health  of  the  State. 

Arteriosclerosis:  Etiology,  Pathology,  Diagnosis,  Prognosis,  PR0PHYLi\:s:is,  and  Treat- 
ment. By  Louis  M.  Warfield,  A.B.,  M.D.,  Instructor  in  Medicine,  Washington  Uni- 
versity Medical  Department;  Physician  to  the  Prostestant  Hospital;  Adjunct  Attending 
Physician  to  the  Martha  Parsons  Hospital  for  Children,  St.  Louis,  Mo.,  etc.  With 
an  introduction  by  W.  S.  Thayer,  ]\I.D.,  Professor  of  Clinical  Medicine,  Johns  Hopkins 
University.  Eight  Original  Illustrations.  St.  Louis:  C.  V.  Mosby  Medical  Book  and 
Publishing  Company,  1908. 

Dr.  Warfield  has  brought  this  Avork  up  to  such  a  standard  as  to  keep  it  abreast  of  the 
most  recent  advances  made  in  arteriosclerosis.  He  lays  stress  upon  the  earliest  possible 
diagnosis  and  points  out  how  this  diagnosis  is  to  be  arrived  at.  The  treatment  of  this  dis- 
ease is  unusually  full  and  practical  and  is  the  result  of  the  author's  many  years  of  ex- 
perience in  the  treatment  of  this  disease.  A  feature  of  especial  value  is  the  chapter  devoted 
to  "Prophylaxis"  and  to  "Practical  Suggestions."  Nothing  has  been  omitted  which  would 
add  to  the  completion  of  the  subject.  Indeed,  it  is  the  most  valuable  work  on  arterio- 
sclerosis yet  published  and  is  therefore  unhesitatingly  recommended  to  the  profession. 

Saunders'  Books.  A  Descriptive  Catalogue  of  IMedical  and  Surgical  Works.  Illustrated 
Revised,  December,  1908.  W.  B.  Saunders  Company,  925  Walnut  Street,  Philadelphia; 
London,  9  Henrietta  Street,  Covent  Garden;  Australian  Agency,  430  Bourke  Street, 
Melbourne. 

This  catalogue  is  devoted  exclusively  to  the  description  of  the  various  medical  and 
surgical  works  which  have  very  recently  come  before  the  medical  profession.  It  gives  the 
peruser  a  brief  and  concise  description  of  the  various  books  on  the  different  subjects  and  also 
shows  some  of  the  illustrations  to  be  found  in  these  books. 

In  order  to  facilitate  the  access  to  the  description  of  a  certain  book  treating  a  certain 
subject,  there  is  a  classified  index  at  the  end  of  the  catalogue  which  indicates  all  the  most 
recent  volumes  written  on  a  definite  subject. 

This  catalogue  will  undoubtedly  prove  very  helpful  to  the  physician,  by  keeping  him 
posted  on  the  latest  works,  and  in  this  manner  enable  him  to  increase  his  knowledge  on  any 
subject.  This  catalogue  can  be  secured  by  addressing  W.  B.  Saunders  Company,  925  Walnut 
Street,  Philadelphia,  Pa. 


Monthly   Cyclopaedia 

AND 

Medical  Bulletin 


(Published  the  Last  of  Each  Month) 


Monthly  Cyclopaedia  Section 


Vol.  II.  PHILADELPHIA,  FEBRUARY,  1909.  No.  2. 


Original  Articles 


Department  in  charge  of  J.  MADISON  TAYLOR,  A.M.,  M.D. 


THE  TREATMENT  OF  TYPHOID  FEVER  WITH  SOLUTION  OF  CALCIUM 

CREOSOTE. 

Analysis  of  118  Cases — Practical  Remarks  on  the  Disease.' 

By  LOUIS  KOLIPINSKI,  M.D., 

WASHINGTON,   D.   C. 

Non  eadem  ratio  est,  sentire  et  demere  niorbos, 
Sensus  ineat  cunctis,  tollitur  arte  malum. 

Ovid,  ex  Ponto,  iii,  9. 

In  the  days  when  it  was  thought  that  wood-creosote,  given  in  the  largest 
possible  doses,  could  cure  pulmonary  tuberculosis,  the  preparation  was  conceived 
to  which  the  name  of  "Solution  of  Calcium  Creosote"  has  been  given.  The 
acridity  of  the  raw  material  was  overcome  and  creosote  thus  combined  can 
be  taken  in  doses  of  any  amount  without  producing  poisonous  results.  It  has, 
moreover,  a  stimulating  and  mildly  exliilarating  action  which  is  often  agree- 
able to  the  sick.  It  was  found  to  have  the  medicinal  properties  ascribed  to 
its  original  form  and  intrinsic  powers  of  its  own,  so  that  all  the  effects  of 
creosote  could  be  obtained  from  it.  Its  capabilities  and  limitations  could  be 
accurately  defined  and  its  usefulness  in  various  diseases  determined.  Herein, 
however,  its  action  in  typhoid  fever  is  separately  reviewed.  The  description 
of  its  properties  in  other  diseases  is  referred  to  some  future  time. 


1  The  treatises  on  typhoid  fever  by  Curschmann,  in  Nothnagel's  "Encyclopedia  of 
Practical  Medicine,"  edited  by  Wm.  Oslr-r,  and  of  McCrae  in  "Modern  Medicine,"  edited 
by  the  same,  were  used  as  guides  to  the  text  of  this  essay. 

«  (65) 


66  TREATJMENT  OF  TYPHOID  FEVER  WITH  CALCIUM  CREOSOTE. 

Preparation  of  solution  of  calcium  creosote. — After  the  method  of  the 
British  Pharmacopoeia,  take  a  sufficiency  of  lime,  freshly  prepared,  and  convert 
it  into  calcium  hydrate  by  the  addition  of  water,  two  parts  to  one.  Cover  the 
vessel  and  allow  its  contents  to  cool.  Pass  the  product  through  an  iron  wire 
sieve  by  gentle  agitation.  Place  the  sifted  calcium  hydrate  in  an  appropriate 
percolator  of  glass,  of  porcelain  or  of  earthenware.  One  made  off  hand  with 
a  large  flower  pot  is  convenient.  Add  creosote  with  constant  stirring.  It  is 
best  to  use  an  excess  of  slacked  lime  for  continuous  production  and  the  original 
quantities  should  be  three  pounds  of  calcium  hydrate  to  one  of  creosote.  The 
gross  molecular  proportions  in  which  these  bodies  combine  being  64  to  124. 
The  smooth,  white  substance  of  the  lime  becomes  gray  and  granular,  and  heat 
is  evolved.  When  the  reaction  is  completed  add  water  in  sufficient  quantity  to 
produce  a  thin  magma.  Allow  it  to  stand  a  day  and  then  proceed  to  obtain 
the  solution  by  percolation.  The  specific  gravity  of  the  liquid  for  use  should 
be  1.010  to  1.012.  Where  the  first  collection  is  below  this,  return  and  reper- 
colate.  A  pound  of  creosote  yields  about  twenty  pints  of  the  preparation. 
When  this  has  been  collected  more  creosote  should  be  added  to  the  lime  and 
the  process  may  be  continued  for  months.  Solution  of  calcium  creosote  has  a 
yellow  color  turning  red  on  keeping.  It  should  be  preserved  in  well-corked 
bottles.  The  contact  of  air  produces  in  it  a  heavy  turbidity  and  the  deposition 
of  calcium  carbonate. 

It  has  a  strong  alkaline  reaction.  Half  a  fluid  ounce  represents  ten  to 
twelve  minims  of  creosote.  Its  taste  is  sharp  and  later  peppery;  its  odor 
faintly  of  creosote  or  smoked  meat.  It  has  no  irritating  or  caustic  action  and 
can  be  swallowed,  undiluted. 

In  the  treatment  of  typhoid  fever  with  calcium  creosote  certain  principles 
must  be  known  and  followed  for  a  rational  and  successful  result.  The  select 
case  is  where  the  diagnosis  is  made  early  and  correctly,  and  the  daily  details 
of  treatment  are  carried  out  either  with  sufficient  experience  or  sufficient  under- 
standing. The  many  occurrences  and  accidents  possible  must  be  known  before, 
and  anticipated  or  actively  opposed.  Everything  done  must  be  with  the 
knowledge  acquired  from  former  cases.  In  a  fresh  one  the  prime  principle  is 
to  smother  or  abort  the  disease;  where  this  attempt  fails  from  complication, 
recrudescence  or  relapse,  the  treatment  continues  as  before.  When  an  early 
cure  is  not  obtained  a  safe  recovery  in  the  shortest  time  is  sought. 

The  calcium  creosote  must  be  given  in  the  maximum  practical  doses. 
These  are  for  a  child  of  six  or  seven  years,  one  teaspoonful  every  two  hours. 
For  an  adult,  two  to  four  teaspoonfuls  in  the  same  length  of  time.  The 
solution  is  given  day  and  night  for  the  greater  part  of  the  first  week  until  fall- 
ing temperature,  normal  pulse,  normal  faculties  allow  the  discontinuance  of 
the  night  doses.  The  time  then  for  natural  rest  and  sleep.  It  is  advanta- 
geous to  offer  the  liquid  well  diluted,  in  half  a  tumblerful  of  water.  It  is  never 
refused  by  the  patient  and  most  of  them  declare  that  it  refreshes  and  revives 
them,  clears  and  composes  the  mind. 

Nausea  and  occasionally  vomiting  are  apt  to  occur  either  from  the 
creosote  crowded  on,  or  from  milk;   it  is  not  always  possible  to  determine  at 


TREATMENT  OF  TYPHOID  FEVER  WITH  CALCIUM  CREOSOTE.     67 

once  which  is  the  exciting  cause.  Then  the  raw  milk  may  be  replaced  by  a 
boiled  diluted  milk,  or  the  calcium  creosote  may  be  omitted  for  a  few  hours  or 
the  dose  of  it  reduced.  Such  symptoms  and  also  diarrhoea  are  transient.  At 
the  end  of  seven  to  ten  days  the  medicine  is  continued  in  three-hour  intervals. 
When  the  temperature  becomes  normal  or  sub-normal,  four  doses  a  day  are  given 
until  the  patient  returns  to  an  ordinary  varied  diet. 

This  is  the  sole  treatment  and  it  must  be  accompanied  by  certain  unvary- 
ing essentials  of  nursing,  namely,  the  patient's  rest  and  frame  of  mind,  the 
functions  of  his  body  and  the  administering  of  daily  estimated  food. 

The  typhoid  fever  subject  should  not  be  allowed  to  leave  his  bed  until  in 
convalescence  he  is  far  enough  recovered  to  partake  of  solid  food.  He  should 
not  be  raised  up  or  propped  up  with  pillows  or  a  head  rest.  The  greater  part 
of  the  time  should  be  passed  in  the  supine  posture.  Each  day,  however,  he 
may  vary  the  position,  resting  on  either  side  for  some  hours,  but  not  turning 
his  body  or  changing  his  position  at  short  intervals.  It  follows  that  the  bed 
pan  must  always  be  used  to  receive  the  dejecta.  The  majority  submit  to  this 
necessity  and  those  who  at  first  oppose  its  use  can  invariably  be  induced  to 
yield  by  the  irrefutable  argument  that  they  are  well  able  to  do  what  anybody 
else  may  have  to  learn  to  do. 

The  patient's  mind  must  be  kept  free  from  care  and  all  thoughts  of  matters 
of  daily  life.  Unnecessary  conversation,  reading  and  the  admission  of  visitors 
must  be  interdicted.  The  patient  must  be  made  to  feel  the  moral  tone  and 
decision  of  the  treatment  and  the  nursing.  To  inform  him  of  the  name  of 
his  disease  is  always  harmful  and  by  this  knowledge  his  condition  can  never  be 
improved.  Much  is  the  physician's  labor  lightened  if  he  alone  conducts  the 
council  of  war.  Death,  through  fear  of  the  disease  is  possible  in  typhoid  and 
has  occurred  although  it  may  not  appear  in  the  many  descriptive  monographs. 

The  proper  food  is  milk.  A  patient  cannot  be  cured  without  it.  Drink- 
ing water  should  be  given  freely  and  by  some  is  taken  in  large  quantities  and 
with  much  benefit.  To  continue  it  long  and  liberally  is  not  necessary,  as  the 
sick  often  decline  to  continue  such  libations.  It  is  better,  therefore,  to 
determine  the  amount  of  milk  the  patient  requires  to  sustain  himself,  and  to 
persevere  therewith  until  recovery.  The  quantity  needed  by  an  adult  is  from 
six  to  eight  pints  per  diem.  The  proper  amount  is  determined  by  the  state 
of  the  pulse. 

When  the  pulse  is  slow  and  full  the  quantity  given  is  sufficient;  when  the 
pulse  is  rapid,  dicrotic  and  weak,  it  must  be  increased.  Milk  given  regularly 
through  the  night  for  the  first  7  to  14  days  of  treatment  is  markedly  beneficial. 
In  some  subjects,  notably  Hebrews,  raw  milk  acts  as  a  brisk  purgative,  causing 
oppression  and  flatulence.  Occasionally  such  an  accident  may  occur  in  any 
case,  in  those  who  before  were  taking  it  well.  With  this  diarrhoea  may  also 
occur  vomiting  and  intestinal  pain,  more  or  less  severe. 

These  are  instances  of  milk  containing  deleterious  impurities,  whose 
nature  we  cannot  always  determine,  except  by  such  effect.  This  is  more  often 
an  accident  of  the  Winter  months.  Impurities  may  have  collected  in  the  milk 
supplied,  having  been  longer  kept  or  stored.     When  the  milk,  tliercfore,  dis- 


68     TREATMENT  OF  TYPHOID  FEVER  WITH  CALCIUM  CREOSOTE. 

agrees  with  the  patient  it  is  suspended  or  discontinued.  In  its  place  is  given 
one  or  the  other  of  these  milk  preparations : — 

Prepare  rice  water  by  boiling  a  teaspoonful  of  rice  flour  in  two  or  three 
pints  of  water  for  about  fifteen  minutes ;  add  an  equal  quantity  of  well-boiled 
milk;  or  add  one  teaspoonful  of  barley  meal  to  one  pint  of  water,  boil  five 
minutes  and  mix  with  the  same  quantity  of  boiled  milk.  Either  of  these 
foods  invariably  agrees  and  is  well  digested.  Beyond  these  foods  no  otlier  is 
necessary  or  of  benefit. 

The  diet  of  convalescence  should  be  varied  yet  harmless.  It  is  not 
difficult  to  satisfy  the  desire  of  himger  without  injury.  When  the  afebrile 
state  has  persisted  four  days  the  following  can  be  written  out  for  the  patient's 
approval : — 

1st  day.  Milk,  oyster  broth,  schmierkaese  or  curds. 

2d  day.  The  same,  also  chicken,  beef  or  mutton  broth,  clear. 

3d  day.  As  the  second;  add  rice  or  barley  to  the  meat  broth  and  strain. 

4th  day.  The  same  as  the  third;   do  not  strain  out  the  meat  broths. 

5tli  day.  The  same  as  the  fourth;   a  cup  of  cocoa. 

6th  day.  As  the  fifth;   a  couple  of  poached  or  scrambled  eggs. 

7th  day.  The  daily  fare  of  a  person  in  health,  but  food  at  three-  or  four- 
hour  intervals. 

The  functional  discharge  of  the  bowels  must  be  regulated.  The  early 
diarrhoea  rights  itself  as  the  treatment  progresses.  There  is  usually  a  marked 
tendency  to  constipation.  The  intestines  must  be  subjected  to  daily  evacua- 
tions. Constipation  is  not  a  good  state  and  results  in  intestinal  pain,  rise  of 
fever,  meteorism,  faecal  impaction,  haemorrhoids  and  retention  of  urine. 

To  move  the  bowels  purgatives  are  not  safe.  Their  efi^ect  is  often  beyond 
our  control.  They  tend  to  derange  the  stomach.  Daily  enemata  of  water, 
soap  suds,  salt  solution  or  sweet  oil,  are  best.  The  bowels  should  be  moved 
copiously  once  a  day,  which  may  be  accomplished  with  one  or  two  injections. 
The  inconveniences  to  the  patient,  just  mentioned  are  usually  avoided  herein 
and  the  antiseptic  action  of  the  calcium  creosote  is  favored. 

The  preceding  is  a  description  of  the  general  treatment,  and  what  follows 
the  results  which  are  usually  obtained.  Solution  of  calcium  creosote  subdues 
the  fever  by  lysis  either  within  ten  days  or  in  two  or  three  weeks.  The  week 
of  rising  temperature,  the  two  weeks  of  steady  elevation,  the  week  of  decline — 
the  typical  fever  cure  of  Wunderlich  is  not  found.  The  highest  fever  is  most 
common  at  the  onset.  However  high  the  temperature  rises  it  does  not  appear 
to  harm  the  economy  or  imperil  the  favorable  outcome.  Toxaemia,  considered 
apart  from  the  febrile  elevation  is  not  apparent  in  that  the  subject  but  rarely 
passes  into  a  delirium,  coma  or  prostration  with  tremor.  There  is  nothing 
like  a  mental  disturbance  in  which  it  is  not  possible  to  converse  with  the  sick; 
where  he  forgets  his  surroundings,  or  attempts  to  struggle  or  escape.  The 
typhoid  state  in  typhoid  fever  no  longer  seems  an  appropriate  term. 

The  pulse  remains  below  100  beats  a  minute,  not  alone  in  the  first  week 
in  which  it  is  to  be  found  so  in  cases  however  treated,  but  it  does  not  increase 
in  number  of  beats  in  the  second,  third  or  fourth  week.     A  pulse  that  in  the 


TREATMENT  OF  TYPHOID  FEVER  WITH  CALCIUM  CREOSOTE. 


69 


beginning  of  treatment  may  be  120,  in  a  few  days  may  come  down  to  ninety 
beats.  There  are  no  symptoms  of  heart  weakness,  none  of  typhoid  myocarditis. 
The  lips  and  teeth  remain  more  or  less  natural,  the  tongue  with  an  even  white 
coating  is  moist,  it  does  not  become  dry,  does  not  enlarge  or  shrink. 

The  intestinal  mucosa  and  contents  are  disinfected  if  one  may  judge  from 
the  character  of  the  stools ;  the  putrid  odor,  the  pea-soup  color  and  consistence  do 
not  appear  or  are  speedily  corrected.  The  stool  grows  odorless,  firmer,  is  white 
or  yellow  in  color,  later  it  is  scybalous.  The  urine  is  of  low  specific  gravity, 
pale,  clear  unless  turbid  with  typhoid  bacilli.  It  does  not  contain  albumin. 
This  diuretic  urine  is  found,  however,  with  other  treatments  where  much 
liquid  is  administered. 

Typhoid  fever  may  be  viewed  clinically  from  the  standpoint  of  a  treatment 
like  this  as  presenting  two  forms  of  the  disease.  The  pure  or  aseptic  fever  in 
which  the  s}Tiiptoms  of  toxaemia  do  not  appear  or  any  of  its  graver  and 
dangerous  phases.  This  form  pursues  a  mild  and  easy  course  with  recovery  in 
one  to  three  weeks.  The  septic  or  toxsemic  form  which  lasts  four  weeks  or 
more,  in  which  the  typhoid  state  develops,  in  which  dangerous  complications 
arise  and  which  always  imperilling  life,  gives  a  certain  number  to  death. 

In  theory  and  if  these  statistics  are  any  proof,  in  fact,  a  remedy  with  the 
properties  of  calcium  creosote  has  as  its  special  purpose  and  action,  the 
abrogation  or  prevention  of  the  septic  secondary  infection  and  restores  the 
patient  to  health  by  preventing  him  from  harboring  secret  enemies  or  by 
destroying  those  foes  which  he  himself  may  engender.  The  accompanying 
fever  charts  are  illustrative  of  cases  typical  of  this  treatment : — 


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TREATMENT  OF  TYPHOID  FEVER  WITH  CALCIUM  CREOSOTE. 


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1st.  Male  child   3          years:  10  days  duration 

2d.  A  youth  of    15          years:  10  days  duration 

3d.  Married   female    26          years:  15  days  duration 

4th.  Married  female   34         years :  17  days  duration 

5th.  A  male   43          years :  20  days  duration 

6th.  A  male    56          years :  16  days  duration 

In  the  sixth  chart  tlie  final  excursion  of  fever  was  due  to  the  patient's 
igitation  on  the  sudden  desertion  of  his  nurse. 

7th.  Female  child   21^2  years:  8  days  duration 


TREATMENT  OF  TYPHOID  FEVER  WITH  CALCIUM  CREOSOTE.     73 

Very  sudden  onset;  the  highest  fever  temperature,  107°  F.,  general 
tremor  but  no  convulsion  or  delirium.  Urine  abundant  with  ty})hoid  bacilli, 
Ehrlich's  diazo-reaction.  Twenty  drops  of  calcium  creosote  every  two  hours, 
night  and  day. 

Comparative  Analysis  of  Cases  and  of  Symptoms  Observed. 

The  number  of  consecutive  cases  treated  by  this  method  was  118.  Of 
these  43  were  children;  26  adolescent;  48  adults.  There  were  58  males,  60 
females. 

Extremities  of  age. — The  youngest  patients  were  two  years  old,  two  cases; 
the  oldest  patient  a  man  of  sixty-five. 

Comparing  the  frequency  of  typhoid  infection  by  months  the  following 
appears : — 


1903.— 

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4 

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3 

5 

4 

6 

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—  27 

1904.— 

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1905.— 

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1906.— 

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1907.— 

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—  25 

10  5  9  7  4  2        12        21        15        23  8  2  118 

Jan.       Feb.     Mch.     Apl.    May     June      July     Aug.     Sept.     Oct.       Nov.      Dec. 

Second  attack. — There  was  no  genuine  case  of  a  second  attack  encountered. 
In  one  instance  the  patient  declared  that  he  had  had  the  fever  four  years  before, 
which  was  not  confirmed  by  the  testimony  of  his  medical  attendant. 

Multiple  cases  in  one  family. — Two  instances  in  this  collection.  The 
dates  of  the  onset  of  the  disease  were : — 

First  family.— Girl  10  years,  Oct.  12,  1906 

Girl  7  years,  Oct.  12,  1906 

Mother  Oct.  17,  1906 

Second  family.— Father  Aug.  30,  1904 

Son  8  years,  Sept.  23,  1904 

Daughter 13  years,  Sept.  23,  1904 

Son  6  years,  Sept.  25,  1904 

Son  3  years,  Dec.  10,  1904 

Contact  infection  of  attendants  was  not  observed.  As  almost  every 
patient  had  a  separate  nurse,  the  exposure  to  infection  was  enormously  multi- 
plied by  the  number  of  persons,  if  susceptible. 

Incubation  period  was  not  determinable.  In  many  the  invasion  was 
sudden.  So  sudden  that  the  narrative  of  how  the  patient  grew  sick  and  what 
brought  it  on  was  to  be  completely  discarded  and  ignored.  One,  for  example, 
described  how  he  contracted  a  cold  and  muscular  rheumatism  by  riding  a 
bicycle  in  his  shirt  sleeves,  whilst  his  body  was  perspiring  from  the  work  he 
had  left. 


74     TREATMENT  OF  TYPHOID  FEVER  WITH  CALCIUM  CREOSOTE. 

The  fever. — The  schematic  division  of  fever  of  Wunderlich  was  not  found 
in  a  single  case.  In  most  there  is  a  tendency  for  the  highest  temperature  to 
decline  in  the  first  week's  end  whether  it  continues  to  do  so  or  rises  again. 

Height  of  fever. — The  height  of  elevation  of  the  temperature  considered 
alone,  is  of  no  moment.  A  pure  uncomplicated  febrile  rise  does  not  endanger 
the  chances  of  recovery.  In  the  118  cases  there  were  43  with  a  temperature 
of  104°  F.  and  over;   11  with  105°  F.  and  more. 

Average  duration  of  the  fever. — The  average  duration  of  the  cases  collected 
was  for  the  child,  14.75  days;  for  the  adolescent,  15.3  days;  for  the  adult,  16.25 
days.  Excluding  all  abortive  cases  and  all  cured  within  ten  days  by  calcium 
creosote,  the  average  duration  for  the  remaining  was  in  the  child,  18.4  days; 
in  the  adolescent,  18  days;   in  the  adult,  20.4  days. 

Termination  of  fever. — The  recession  by  lysis  is  the  rule;  by  crisis  was 
found  16  times. 

Inverted  type  of  fever. — Partial  or  complete  examples  two  times. 

Intermittent  form. — 13  cases:  3  adult  females;  3  adult  males;  5  females, 
7  to  18  years  of  age;  2  males  of  10  to  14  years. 

Relapses  occurred  in  seven  patients.  They  were,  contrary  to  the  well- 
established  opinion,  as  long  or  longer  than  the  primary  fever. 

A  girl  of  15  years,  12-day  fever;   relapse  12  days. 

A  girl  of  17  years,  7-day  fever;    relapse  11  days. 

Single  woman  of  27  years,  21-day  fever,  relapse  24  days. 

A  married  woman  of  26  years,  11-day  fever;    relapse  22  days. 

A  widow  of  37  years,  12-day  fever;   relapse  13  days. 

A  lad  of  14  years,  16-day  fever;   relapse  14  days. 

Chills  of  pronounced  degree  were  present  in  four  instances.  In  one  at  the 
inception,  in  three  towards  defervescence.  They  were  of  the  periodic  quotidian 
variety  and  all  yielded  to  quinine.  In  the  fourth  case,  a  prolonged  relapse  was 
followed  after  a  week  by  a  malarial  intermittent  fever,  proven  by  immediate 
cure  with  quinine. 

Lesions  of  the  shin. — A  diffused  roseola  simulating  German  measles, 
present  in  one  case.     The  rose  spot  evolution  was  not  watched  for  or  recorded. 

Furunculosis. — One  case;  none  of  herpes,  erythema,  urticaria  or  ulcers. 

There  was  one  bed-sore.  A  most  extensive  sacral  decubitus  following 
profuse  intestinal  hsemorrhage.  Bed-sores  also  appeared  on  the  heels,  the  calves 
of  the  legs  and  the  extremities  of  the  great  toes.  The  sacrogluteal  ulcer  was 
not  quite  healed  a  year  after  recovery. 

Sweating  is  more  often  found  with  the  calcium  creosote  treatment  than 
without.  This  both  in  the  first  week  and  salutory  night-sweats  with  the 
decline  of  fever.  Sudamina  (miliaria  crystallina)  and  lichen  tropicus  (prickly 
heat)   are  rather  frequent  accompaniments. 

Falling  of  the  hair  is  rare,  never  extensive.  After-treatment  by  cutting 
the  hair  short  or  by  shaving  the  scalp  is  not  recommended.  The  defluvium  is 
so  scant  that  it  does  not  attract  the  convalescent's  attention. 

{To  he  concluded  in  our  March  issue.) 


OCULAR  TRATIMATISM,  A  CAUSE  OF  THE  NEUROSES.  75 


OCULAR  TRAUMATISM,  A  CAUSE  OF  THE  NEUROSES.' 

By  HOWARD  F.  HANSELL,  M.D., 
Professor  of  Ophthalmology  in  Jefferson  Medical  College, 

PHILADELPniA. 

By  what  peculiar  mentality  or  flight  of  imagination  an  insignificant 
injury  to  the  eye  may  be  the  forerunner  of  serious  disturbance  of  the  nervous 
system  has  thus  far  baffled  the  skill  of  the  neurologist  and  ophthalmologist  to 
determine.  Equally  unintelligible  is  the  remarkable  and  well-known  fact  that 
serious  ocular  injury,  by  which  vision  is  permanently  compromised  or  lost,  is 
seldom  ascribed  as  the  cause  of  functional  disorders  of  the  nervous  system.  In 
arriving  at  a  conclusion  which  shall  as  nearly  as  possible  explain  this  curious 
freak  in  the  science  of  etiology,  conditions  outside  of  the  accident  or  its  con- 
sequences must  be  considered,  such  as  the  circumstances  of  the  injury,  the 
en\'ironment  of  the  injured  and  the  responsibility  for  the  injury.  These  are 
important  determining  factors  in  the  development  of  a  neurosis.  Should  the 
injury  be  purely  accidental,  a  so-called  dispensation  of  Providence,  slight  or 
grave,  interest  is  centered  in  the  eye  only.  Should,  however,  the  accident  be 
attributed  to  inefficiency  of  a  servant  of  a  corporation  or  imperfections  in  the 
machinery  of  a  corporation  and  without  contributory  negligence  on  the  part  of 
the  victim,  the  interest  becomes  diffused  and  invades  the  ranks  of  the  medical 
and  legal  professions,  and  the  judiciary,  in  its  far-reaching  consequences.  In 
other  words,  what  effect  has  a  possible  or  probable  claim  for  damages  in  the 
exaggeration  of  the  extent  of  the  injury  to  the  eye  and  in  the  production  of 
reflex  disorders? 

My  purpose  in  choosing  this  subject  and  presenting  it  for  your  con- 
sideration is  two-fold:  First,  to  remind  you  that  ocular  traumatisms  like 
traumatisms  to  other  parts  of  the  body  may  be  the  cause  of  hysteria,  and 
second,  to  discuss  the  value  of  medical  expert  testimony  in  trials  for  damages 
resulting  from  ocular  injuries  and  their  effects  on  the  nervous  system. 

Amaurosis,  partial  or  complete,  results  from  direct  injuries  to  the  eye. 
Enumeration  of  the  variety  of  injuries  and  their  result  upon  the  eye  would 
mean  naming  all  possible  accidents  and  all  possible  ocular  conditions — a  waste 
of  time.  Amaurosis  may  also  be  caused  by  indirect  injuries,  for  example  to  the 
skull  and  to  the  orbit,  and  may  be  monocular  or  binocular.  One  or  two 
examples,  selected  from  the  many  reported  in  the  literature,  may  be  cited.^ 
A  man  of  45  was  thrown  by  the  breaking  of  a  machine,  violently  to  the  floor, 
striking  his  head  on  the  hard  surface.  He  bled  from  the  nose  and  mouth  and 
was  unconscious  for  ten  hours.  Upon  awakening  the  left  eye  was  perfectly 
blind  and  the  right  side  of  the  body  was  paralyzed.  The  diagnosis  was  fracture 
of  the  base  of  the  skull  and  of  the  spinal  column.  The  pupil  was  dilated, 
reacting  only  consensually,  the  optic  nerve  became  atrophic  and  the  blindness 


1  Read  before  the  College  of  Physicians,  Pittsburg,  Pa.,  April,  1908. 

2  Leber  and  Deutschman:     Arch.  f.  Ophthal.,  Bd.  XXVII,  S.  281. 


76  OCULAR  TRAUMATISM,  A  CAUSE  OF  THE  NEUROSES. 

permanent.  The  right  eye  remained  healthy,  Capron^  speaks  of  a  man  who 
received  a  blow  with  a  beer  glass  in  the  neighborhood  of  the  left  eye.  Vision 
in  the  left  eye  which  had  been  perfect  up  to  that  time  sank  to  light  perception. 
Excepting  the  external  wound  nothing  abnormal  could  be  discovered  beyond 
a  whitening  of  the  inner  two-thirds  of  the  disk.  As  an  example  of  binocular 
partial  amaurosis,  following  injury  to  the  bones  of  the  skull,  I  may  refer  to 
the  following  case  from  my  own  practice.  A  coachman  was  thrown  by 
collision  with  an  electric  car  from  his  box  on  a  carriage,  struck  his  head  against 
the  street  pavement  and  was  picked  up  unconscious.  After  recovery  from  the 
immediate  effect  of  the  accident,  he  complained  of  partial  loss  of  vision.  For 
the  next  two  or  three  years  vision  slowly  declined  until  at  the  time  of  my 
examination  it  equalled  %oo5  excentrically.  He  had  a  large  negative  complete 
central  scotoma,  and  atrophy  of  the  optic  nerves.  This  case  is  similar  to  many 
others  that  have  been  reported  in  which  blindness  was  due  to  pressure  upon  the 
optic  nerves  or  chiasm  from  fracture  of  the  sphenoid  bone  or  of  the  apices  of 
the  orbits. 

Hysterical  blin^lness,  without  organic  changes  in  the  eye,  is  not  uncommon 
after  injury.  It  may  be  monocular  or  binocular.  The  victims  of  the  affection 
may  be  divided,  as  de  Schweinitz  has  said,  into  3  classes ;  those  who  simulate  the 
blindness,  those  who  see  unconsciously  but  are  not  capable  of  conscious  vision, 
and  those  who  really  are  transiently  blind — an  apt  classification.  The  blind- 
ness is  only  a  symptom  of  hysteria  and  is  associated  with  other  stigmata 
equally  well  pronounced,  such  as  complete  loss  of  sensibility  over  large  areas 
of  skin. 

Hysteria,  which  may  be  taken  as  the  type  of  the  neuroses  induced  by 
traumatism,  is  not  well  understood,  particularly  in  its  pathology.  It  has  a 
comprehensive  symptomatology  and  well  defined  stigmata.  Variation  in  the 
symptoms  is  common  and  is  often  consistent  with  the  personal  characteristics 
of  the  patient.  It  is  admitted  that  non-traumatic  hysteria,  or  hysteria  arising 
from  causes  within  the  body,  is  more  common  among  women  than  among  men — 
the  proportion  is  usually  given  as  5  to  1 — but  no  statistics  have  been  compiled 
so  far  as  I  am  aware,  estimating  the  relative  frequency  among  men  and  women 
of  traumatic  hysteria.  It  may  be  readily  understood  that  in  consequence  of 
their  daily  occupations  males  furnish  the  greater  contingent.  Moumalle'*  says 
concerning  the  relation  of  the  male  to  the  female,  among  27  cases  of  injury  to 
the  optic  nerve,  24  were  males  and  3  were  females.  Moreover,  the  development 
of  the  affection  depends  more  upon  the  responsibility  for  the  injury  than 
upon  sex,  or  upon  the  character  of  the  individual  or  the  nature  of  the  accident. 

The  presence  of  traumatic  hysteria  seems  to  point  to  the  existence  or 
creation  of  a  new  and  additional  mental  factor  that  need  not  be  reckoned  with 
in  the  other  forms.  For  example,  an  individual  who  had  never  exhibited  any 
of  the  stigmata  of  hysteria  receives  an  injury.  Thereafter  for  some  days, 
weeks  or  months  his  thoughts  and  actions  are  governed  by  an  impulse  or 


3  Arch,  of  Oplithal.,  Vol.  XVIII,  p.  407. 

4  Fur  Casuistik  der  Sehnervenverletzungen,  Giessen,  1901. 


OCULAR  TRAUIVIATISM,  A  CAUSE  OF  THE  NEUROSES.  77 

conception  entirely  foreign  to  his  former  character.  Possibly  an  organic 
lesion  such  as  a  minute  haemorrhage  or  rupture  of  the  brain  tissue  at  the 
psycliical  center  may  be  responsible  for  the  state  of  the  mind  that  leads  to 
the  enormous  development  of  the  ego,  the  exaggeration  of  slight  maladies  or 
positive  misconceptions  and  false  deductions.  The  mental  faculties  are  as  acute 
or  even  more  acute  than  before,  but  the  moral  faculties  have  become  distorted. 
Traumatisms  that  lead  to  hysteria  cause  apparently  a  greater  derangement  in 
the  moral  than  in  the  mental  or  physical  powers.  This  does  not  positively 
exclude  organic  changes  in  the  brain,  for  it  is  known  that  moral  obliquity  may 
have  a  definite  cerebral  cause,  but  renders  such  changes  extremely  improbable. 
As  Burr  says,^  "In  trauma  it  is  not  the  physical  injury  nor  the  fractured  skull 
or  leg  which  causes  the  hysteria,  but  the  profound  mental  disturbance."  More- 
over the  suddenness  of  the  recovery  after  the  award  of  damages  favors  a 
fimctional  rather  than  an  organic  disturbance. 

The  physical  manifestations  of  traumatic  and  idiopathic  hysteria  are 
practically  identical  or,  as  de  Schweinitz  says  (Posey  and  Spiller)  :  "In  the 
eyes  the  manifestations  of  hysteria  which  have  been  described  as  hystero- 
traumatic  are  often  pronoimced,  more  so  frequently  than  those  which  are 
associated  with  hysteria  of  other  origin,  but  they  are  not  pathognomonic." 
Again,  as  stated  above,  the  development  of  the  affection  depends  more  upon  the 
responsibility  for  the  accident  than  upon  sex  or  the  character  of  the  individual 
or  the  nature  of  the  injury.  Heredity  or  the  acquired  tendency  to  the  neu- 
roses, the  state  of  mind  and  health  previous  to  the  injury,  may  have  prepared  the 
individual  for  the  appearance  of  a  neurosis  consequent  upon  an  injury ;  but  it  is 
manifest  that  no  unusual  symptoms  would  have  been  observed  had  no  injury 
occurred,  and  the  tendency  would  have  passed  unnoticed.  The  effect  of  ocular 
traumatism  upon  the  nervous  system  is  shown  in.  the  mental  disturbance  follow- 
ing operations  in  which  the  ball  is  opened.  We  are  all  familiar  with  the  mild 
delirium  subsequent  to  cataract  operation.  Several  causes  contribute  to  this 
condition,  such  as  the  shock  of  the  operation  and  the  dread  of  it,  the  con- 
signment of  the  patient  to  the  dark  by  reason  of  the  binocular  bandage  and 
the  loneliness  and  home-sickness  induced  by  the  confinement  and  the  darlmess. 
A  man  of  50  was  iridectomized.  Both  eyes  were  bandaged  and  he  was  placed 
in  bed  in  a  quiet  room.  In  24  hours  he  was  wildly  delirious  and  required  a 
straight  jacket  and  the  constant  presence  of  attendants.  He  was  removed  to 
his  home  and  in  an  hour  he  came  to  his  senses.  No  amoimt  of  reasoning  or 
explanation  seems  to  suffice  to  quiet  the  nervousness.  The  thought  of  the 
restoration  of  vision  and  the  resumption  of  occupation  is  submerged  under  the 
intense  mental  excitement  following  the  surgical  procedure.  In  some  persons 
the  same  mental  incapacity,  lack  of  judgment  and  delusions  succeed  trivial 
ocular  injuries,  and  these  persons,  ordinarily  intelligent,  are  beyond  the  reach 
of  argument.  Some  authors  believe  that  such  symptoms  are  found  only  in 
weak  and  nervous  people  or  those  who  are  mentally  deficient,  although  in  a 
latent  form  and  hitherto  unknown  to  physician  or  patient.     In  some,  pain  is 


5  Int.  Clinics,  Vol.  IV,  Sixth  Series. 


78  OCULAE  TRAUMATISM,  A  CAUSE  OP  THE  NEUROSES. 

the  cause  of  the  nervous  symptoms,  in  others  the  accident  itself,  and  in  others 
we  find  no  explanation.  A  striking  instance  of  the  first  is  reported  by  Barkan.^ 
A  piece  of  glass  from  an  exploding  bottle  struck  a  healthy  man  in  the  eye. 
While  the  glass  was  being  removed  he  fell  unconscious  and  vomited.  After 
the  return  of  consciousness  he  was  blind  in  both  eyes  and  remained  so  for  a 
week.  Then  light  perception  returned  to  be  lost  in  another  week.  The  pupils 
were  moderately  dilated  with  uncertain  reactions.  There  was  restoration  of 
light  perception  in  the  central  part  of  the  field  which  gradually  became  larger 
until  full  acuity  of  vision  was  regained.  In  other  cases  the  mental  condition 
courteously  known  as  hysteria  is  a  purely  voluntary  one,  and  is  initiated  and 
prolonged  in  the  hope  of  obtaining  pecuniary  award,  the  severity  of  the  symp- 
toms and  their  continuance  being  proportionate  to  the  gullibility  and  wealth 
of  the  responsible  party.  Burr'''  aptly  writes:  "Much  doubt  has  been 
cast  on  the  causative  influence  of  trauma  because  of  the  large  number  of  cases 
which  come  before  the  Courts  claiming  damages,  there  being  a  well  known 
type  of  conscience  that  considers  getting  money  from  corporations  as  highly 
praiseworthy."  The  mental  state  is  fostered  by  unscrupulous  lawyers  and 
physicians  who  for  purposes  of  their  own  encourage  the  victim  to  become  a 
fraud  and  stimulate  him  to  remain  one.  I  do  not  refer  to  the  acts  of  conscien- 
tious men,  patients,  lawyers  or  doctors,  of  which  there  are  a  plenty,  who  testify 
in  accordance  with  their  convictions,  but  to  those  who  deliberately  twist  their 
knowledge  of  law  and  medicine  for  their  own  gain.  The  most  common  classes 
of  law  suits  are  those  in  which  the  experts  on  neither  side  consciously  violate 
truth  and  ethics,  but  state  their  opinions  on  insufficient  knowledge  and 
experience — opinions  that  are  exactly  opposed.  The  more  prominent  the 
medical  witnesses  the  greater  the  uncertainty  of  judge  and  jurors  as  to  the 
justice  in  the  case.  It  is  a  matter  of  daily  record  with  which  you  are  as 
familiar  as  I  am,  that  medical  experts,  equally  wise,  equally  prominent,  equally 
experienced,  equally  conscientious,  are  ranged  against  each  other  and  take 
opposite  sides  in  the  disputation.  It  has,  perhaps,  not  occurred  to  you  that 
these  men  become  interested  for  one  or  the  other  side  by  accident  rather  than 
by  design,  according  to  priority  in  selection  by  the  contesting  parties.  We, 
each  of  us,  have  a  judicial  right  to  express  our  opinion  only  when  that  opinion 
is  the  result  of  learning  and  experience.  Personally  one  may  think  as  he 
chooses,  but  when  his  opinion  becomes  public  property  and  carries  weight  either 
pecuniarily  or  punatorially  and  is  relied  upon  to  enforce  justice  and  right,  it 
must  be  the  result  of  intelligent  and  honest  conviction.  It  must  not  be 
accidental  nor  expressed  for  ulterior  or  selfish  motives.  We,  as  members  of  an 
honorable  profession,  repudiate  with  indignation  the  assertion  that  we  can  be 
bought,  and  yet  by  our  practices  we  subject  ourselves  to  criticism.  My  own 
experience  in  the  Court  room  has  been  limited,  and  it  has  not  been  altogether 
agreeable,  for  I  have  found  opposed  to  me  men  whom  I  respect  and  admire  and 
who  I  know  are  not  incited  by  unworthy  motives.     Their  opinions  and  mine 


6  Trans.  German  Phys.,  San  Francisco,  25th  Ann. 
'!  hoc.  cit. 


OCULAR  TRAmiATISM,  A  CAUSE  OF  THE  NEUROSES.  79 

were  in  utter  conflict.  Their  position  was  unintelligible  to  me  as  possibly  mine 
was  to  them.  Of  course,  they  may  have  been  right  and  I  may  have  been  wrong. 
The  verdict  is  no  criterion.  That  depends  rather  on  the  wealth  of  the  cor- 
poration, the  poverty  of  the  claimant  and  the  cleverness  of  the  attorneys  in 
tragically  depicting  the  contrast,  rather  than  upon  the  medical  evidence.  A 
man  was  struck  in  the  right  eye  by  a  fine  fragment  of  glass  from  an  exploding 
electric  lamp.  Three  weeks  after  the  accident  no  trace  of  injury  to  the  eye 
could  be  detected — admitted  by  medical  experts  of  both  sides.  The  man 
claimed  he  was  blind  in  the  eye  that  had  been  struck.  There  was  absolutely 
no  evidence  of  any  deterioration  of  sight.  On  the  contrary  it  was  proven  he 
had  excellent  binocular  vision.  He  subsequently  had  dysentery,  anal  fistula 
and  appendicitis  which  together  made  him  the  wreck  of  a  man.  The  medical 
experts  testified  under  oath  that  they  believed  that  these  abdominal  diseases 
were  the  result  of  ocular  infection — a  perfectly  preposterous  position  when  it 
was  clearly  shown  that  the  eye  had  not  been  infected.  Had  they  claimed  that 
the  man  suffered  from  hysterical  amaurosis  and  the  subsequent  disasters  were 
indirectly  due  to  hysteria  and  the  hysteria  due  to  the  accident,  the  experts  for 
the  defence  would  have  had  a  more  difficult  task,  for  who  can  say  what  hysteria 
is  or  what  may  be  its  complications.  Such  medical  testimony  might  have 
been  expected  from  shysters  and  quacks,  but  not  from  reputable  men.  In 
another  case  a  man  was  riding  in  a  trolley  car  and,  owing  to  a  collision,  a  piece 
of  glass  was  lodged  in  the  conjunctival  sac.  Several  weeks  later  when  I  first 
saw  him  he  stated  he  was  blind  in  the  injured  eye  and  his  oculist  attributed 
the  blindness  to  the  retention  within  the  eye  of  a  piece  of  glass.  The  eyeball 
had  not  been  injured  and  contained  no  glass  or  other  foreign  material.  It 
was  apparently  as  sound  as  the  other  one  and  responded  to  all  the  tests  for 
vision.  He  brought  suit  for  damages  and  had  retained  the  services  of  his 
oculist,  who  was  willing  to  go  into  Court  and  testify  that  the  eye  was  blind  and 
that  it  contained  a  piece  of  glass.  To  one  who  could  use  an  ophthalmoscope  or 
interpret  a  radiograph  his  willingness  could  mean  only  one  of  two  things, — 
either  he  was  ignorant  of  ocular  diseases  or  he  was  a  fraud.  Cases  such  as 
these  are  altogether  too  common.  Medical  testimony  has  come  to  mean 
nothing. 

As  a  remedy,  I  would  advocate  the  exclusion  of  medical  experts,  selected 
by  interested  parties,  from  aU  cases.  Their  evidence  is  no  guide  for  the  jury. 
The  evidence  of  one  expert  is  balanced  by  that  of  another.  The  victim  is 
injured  and  he  is  not  injured;  he  is  sane,  he  is  insane;  he  is  responsible,  he 
is  irresponsible;  he  is  a  fraud,  he  is  an  honest  man. 

If  the  State  or  the  Court  would  appoint  competent  medical  witnesses  at  a 
salary  large  enough  to  preclude  the  chance  of  modification  of  views  by 
pecuniary,  economic  or  social  considerations,  and  confine  the  medical  testimony 
to  the  evidence  of  these  men,  the  difficulties  might  be  overcome  and  the  ends 
of  justice  served. 


80      TUBERCULOSIS  OF  THE  UTERUS,  ETC.,  WITH  PYOMETRA. 


A  CASE  OF  TUBERCULOSIS  OF  THE  UTERUS,  CERVIX  AND  VAGINA, 

WITH  PYOMETRA; 

By  EDWARD  A.  SCHUMANN,  M.D., 
Out-Patient   Surgeon   and  Pathologist,   Gynecean   Hospital,   Philadelphia. 

While  tuberculosis  of  the  female  genital  tract  taken  as  a  whole  is  a  fairly 
common  condition  there  are  certain  manifestations  of  the  disease  which  are  of 
great  infrequency  and  of  marked  interest  both  from  the  clinical  and  from  the 
pathological  viewpoint. 

The  case  which  I  here  report  is  one  of  tuberculosis  of  the  vagina,  cervix 
uteri,  and  of  the  uterine  parenchyma,  the  tubes,  ovaries  and  peritoneum  being 
entirely  unaffected. 

In  genital  tuberculosis  of  the  various  points  of  localization,  that  of  the 
tubes  is  by  far  the  most  common.  Next  to  the  tubes,  the  endometrium  is  most 
frequently  attacked,  though  the  uterine  muscle  is  rarely  invaded.  No  cases 
are  recorded  where  the  infection  has  penetrated  from  the  uterine  mucosa  to 
the  peritoneum  or  vice  versa. 

After  the  endometrium,  the  ovaries,  cervix,  and  vagina  follow  in  order  of 
susceptibility,  with  the  vulva  as  one  of  the  rarest  seats  of  tuberculosis  in  the 
body. 

The  manner  of  inoculation  of  the  genitalia  has  been  much  discussed.  It 
is  now  well  established  that  infection  is  possible,  either  by  the  descending 
route,  in  which  the  infection,  secondary  to  some  preexisting  tuberculous  focus,  is 
transmitted  to  the  genitalia  by  the  blood  or  l}Tnph  currents  or  by  extension  of 
continuity;  or  the  ascending  route  by  which  a  primary  genital  infection  is 
produced  through  coitus  with  a  tuberculous  male,  by  infected  hands  or  clothing, 
or  even  possibly  by  dust  containing  tubercle  bacilli.  The  former  process  is  of 
far  greater  frequency. 

In  my  case  the  primary  focus  consisted  of  an  enormous  growth  of  tuber- 
culous cervical  glands.     The  notes  in  detail  are  as  follows : — 

M.  H.,  a  nulliparous,  married  mulatto  woman  of  33  years  was  referred 
to  me  by  Dr.  J,  T,  Potter,  of  Philadelphia,  and  admitted  to  the  Gynecean 
Hospital,  December  14,  1906.     The  patient's  family  history  was  not  relevant. 

She  had  always  been  of  fragile  health,  and  since  childhood  had  suffered 
from  cervical  adenitis,  the  glands  being  resolved  into  nodular  masses  fully  as 
large  as  oranges,  and  extending  down  both  sides  of  the  neck  to  unite  under 
the  chin.  The  glands  were  so  large  as  to  make  the  existence  of  Hodgkin's 
disease  probable  until  further  investigation  proved  the  contrary.  Four  attempts 
had  been  made  to  extirpate  the  cervical  glands,  but  without  success. 

Examination  of  the  lungs  elicited  no  sign  of  disease  and  the  heart  was 
likewise  normal.  The  patient  was  poorly  nourished  and  her  mucous 
membranes  pale.     Her  chief  complaint  was  of  great  frequency  of  urination. 


1  Read  before  the  Philadelphia  Obstetrical  Society,  Feb.  6,  1908. 


TUBERCULOSIS  OF  THE  UTERUS,  ETC.,  WITH  PYOMETRA.      81 

with  irritation  and  pain  in  the  vagina  and  marked  dysparcunia.  Her  menstrual 
history  was  uneventful,  the  catamenia  being  established  at  14,  and  continuing 
regular  and  normal,  the  flow  profuse  and  lasting  4  to  5  days.  She  had  a 
profuse  leucorrhoea,  and  just  previous  to  admission  she  had  missed  two  periods. 

Vaginal  examination  disclosed  a  tender  and  indurated  vaginal  vault,  the 
cervix  uteri  large,  excavated  and  presenting  a  rough  yellowish,  friable  surface, 
which  bled  on  touch,  and  which  showed  yellow,  sloughing  nodules  scattered  over 
its  surface.  The  uterus  was  large  and  boggy,  absolutely  fixed  in  the  normal 
anterior  position.  The  tubes  and  ovaries  were  adherent.  The  urine  was 
negative  save  for  the  presence  of  a  few  pus  cells. 

The  diagnosis  lay  between  carcinoma  of  the  cervix,  tuberculosis  and 
syphilis  of  the  uterus.  The  latter  was  excluded  by  the  absence  of  any  of  the 
other  characteristic  lesions  of  the  disease  and  by  the  history. 

A  diagnosis  of  tuberculosis  of  the  uterus  was  reached  by  the  presence  of 
the  large  tuberculous  focus  in  the  neck  and  by  the  yellow,  sloughing  masses  in 
the  cervix,  closely  resembling  those  necrotic  tubercles  encountered  elsewhere. 
It  was  impossible  to  eliminate  absolutely  adeno-carcinoma  of  the  cervix  and 
the  ordinary  squamous  epithelioma  of  the  cervix. 

Panhysterectomy  was  then  proposed  and  accepted  and  the  operation  was 
accordingly  performed.  On  entering  the  peritoneal  cavity  the  entire  pelvis  was 
found  to  be  a  mass  of  old,  dense  adhesions,  the  small  intestines  and  the 
sigmoid  being  bound  tightly  to  the  pelvic  organs.  Save  for  the  adhesions  the 
intestines  were  normal. 

The  uterus,  about  twice  the  usual  size,  was  found  embedded  in  adhesions, 
the  indurated  broad  ligament  holding  it  absolutely  fixed.  The  adnexa  were, 
naturally,  tightly  bound  dowa.  The  tissues  were  so  friable  that  in  order  to 
enable  the  ligature  on  the  uterine  artery  to  hold,  it  was  necessary  to  cut  and 
isolate  the  left  ureter.  This  was  done  and  the  end  transplanted  into  the  bladder 
by  the  Baldy  method. 

The  uterus,  adnexa  and  vaginal  vault  were  then  removed,  the  wound 
closed  and  the  patient  returned  to  bed.  After  48  hours,  but  very  little  urine 
having  been  voided,  it  was  suspected  that  the  remaining  ureter  had  been  tied 
and  the  abdomen  was  reopened.  The  right  ureter  was  found  carried  high  on 
the  pelvic  wall  by  the  tuberculous  infiltration  of  the  broad  ligament,  and  con- 
stricted by  a  ligature.  This  was  cut  and  the  ureter  implanted  into  the  bladder 
wall  opposite  its  fellow.  Convalescence  was  uneventful  although  delayed  by  a 
urinary  fistula  which  persisted  for  one  week. 

A  good  prognosis  had  been  given  in  this  case,  based  upon  the  fact  that 
since  the  primary  focus  in  the  neck  had  remained  latent  for  so  many  years, 
and  had  produced  secondary  manifestation  only  in  the  genitalia,  the  lungs 
and  peritoneum  remaining  healthy,  it  was  reasonable  to  hope  that  removal  of 
the  active  secondary  field  would  lessen  the  chances  of  reinfection  from  this 
source,  while  it  would  not  tend  to  light  up  the  latent  focus  in  the  neck. 

The  prognosis  seems  justified,  as  the  patient  is  now,  over  a  year  after 
operation,  in  excellent  health,  having  gained  35  pounds  in  weight. 

The  specimens  obtained  were  the  utenis,  the  vaginal  vault,  and  both 
4 


82      TUBERCULOSIS  OF  THE  UTERUS,  ETC.,  WITH  PYOMETRA. 

appendages.  The  uterus  is  larger  than  normal,  its  surface  rough,  and  covered 
with  remnants  of  old,  dense  adhesions,  the  peritoneum  rough  and  ragged.  It  is 
soft  and  boggy  in  consistency.  On  section  the  uterine  muscle  is  much  thinned 
out,  the  cavity  of  the  organ  dilated  (5-4-3cm.)  and  filled  with  tliick  pus,  nearly 
one  ounce  being  released  when  the  uterine  cavity  is  entered. 

The  entire  mucosa  is  wanting,  it  being  replaced  by  a  thick  layer  of  necrotic 
tissue.  The  inflammatory  tissue  invades  the  uterine  muscle  for  the  distance 
of  2  or  3  mm.,  but  in  no  case  can  gross  inflammatory  change  be  detected  on  the 
peritoneal  side  of  the  uterine  muscle.  The  cervix  is  thickened,  excavated  out 
in  a  crater-like  cavity  lined  with  a  grayish,  necrotic  membrane.  The 
cervical  tissues  are  not  deeply  invaded  by  the  inflammatory  process,  only  the 
superficial  layers  being  involved. 

The  internal  os  is  closed  by  inflammatory  exudate,  the  pyometra  being 
absolutely  walled  off. 

Both  tubes  and  ovaries  are  the  seat  of  old  catarrhal  inflammation,  involving 
more  especially  their  peritoneal  surfaces,  which  are  covered  and  matted 
together  by  adhesions.  The  tubal  mucosa  seems  normal.  The  ovaries  show 
some  perioophoritis  but  are  otherwise  normal.  The  portion  of  vaginal  vault 
excised  seems  thickened  and  indurated,  but  presents  no  areas  of  ulceration  or  the 
like. 

Histological  Examination. 

The  Vaginal  Vault. — Here  the  epithelial  covering  is  practically  intact, 
being  absent  in  a  few  areas  only.  The  stroma  is  injected,  the  seat  of  a  dense 
round  cell  infiltration,  and  occasionally  a  typical  tubercle  is  encountered.  The 
blood-vessels  are  numerous  and  distended. 

The  Cervix. — The  entire  cervical  mucous  membrane  is  destroyed,  the 
cervix  being  lined  by  a  thick  necrotic  tissue,  showing  no  cellular  arrangement. 
All  traces  of  glands  are  lost.  The  connective  tissue  of  the  cervix  is  densely 
packed  with  typical  tubercles  in  various  stages  of  development,  most  of  them 
consisting  of  a  central  giant  cell  surrounded  by  large  epithelioid  cells,  and 
these  again  surrounded  by  areas  of  dense  round  cell  infiltration. 

Some  of  the  tubercles  have  gone  on  to  caseation,  others  are  in  the  develop- 
mental stages.  In  the  deeper  portion  of  the  cervix  the  tubercles  become 
smaller  and  more  scattered,  until  at  the  external  surface  the  stroma  is  nearly 
normal. 

The  Uterus. — The  entire  mucosa  is  destroyed,  being  replaced  by  an 
amorphous  necrotic  tissue  similar  to  that  lining  the  cervix.  At  the  lower 
uterine  segment  the  muscle  is  studded  with  tubercles,  some  with  the  central 
giant  cells,  others  mere  nests  of  epithelioid  cells  surrounding  areas  of  caseation. 

As  the  fundus  is  approached  the  tubercles  become  more  scarce  and  atypical, 
and  in  the  deep  subperitoneal  layer  of  the  fundus  no  tubercles  are  noted,  some 
oedema  of  the  uterine  wall,  and  a  moderate  degree  of  roimd  cell  infiltration 
being  the  only  trace  of  disease  noted.  Nowhere  can  any  tuberculous  glands  be 
made  out. 

Tubes. — The  tubes  show  hypertrophy  of  their  muscular  coat,  some  round 
cell  infiltration  of  their  walls,  but  no  evidence  of  tuberculosis. 


THE  THYROID  PREPARATIONS  IN  PRACTICE.  83 

Ovaries. — Show  a  perioophoritis. 

The  diagnosis  in  detail,  then,  was  papillary  tuberculosis  of  the  cervix, 
caseous  tuberculosis  of  the  fundus  uteri  with  invasion  of  the  muscular  coat, 
and  early  ulcerative  tuberculosis  of  the  vagina.  The  points  to  be  especially 
emphasized  in  the  above  case  are  as  follows : — 

1.  The  diagnosis,  which  is  practically  impossible  save  by  exclusion  and 
by  the  examination  of  excised  tissue. 

2.  The  involvement  of  the  entire  genital  tract  with  the  exception  of  the 
tubes  and  ovaries.  This  is  unusual  in  a  case  of  secondary  infection,  since  the 
blood  and  lymph  currents  carry  the  bacteria  to  the  uterus  first,  and  then  out 
through  the  broad  ligament  to  the  tubes. 

3.  The  treatment:  It  is  the  opinion  of  the  writer  that  genital  tuber- 
culosis, especially  where  primary,  is  a  perfect  indication  for  radical  surgical 
measures.  It  would  seem  that  to  merely  curette  a  uterus  known  to  be  the  seat 
of  a  tuberculous  endometritis  or  to  remove  one  infected  tube,  leaving  the  other, 
would  be  to  invite  a  continuance  of  the  disease  in  neighboring  structures. 

It  is  true  that  this  view  is  opposed  by  many  men — Sippel,  Walther,  Munch- 
meyer,  and  others  who  advocate  most  conservative  measures.  The  majority, 
however,  Doderlein,  Schauta,  Murphy,  etc.,  look  on  conservatism  in  uterine 
tuberculosis  as  merely  palliative  and  advise  complete  removal  of  infected  or 
suspicious  structures. 

It  must  also  be  remembered  that  genital  tuberculosis  is  rarely  inoperable. 

Had   my   case   been    one   of   carcinoma,   panhysterectomy   would   have   been 

impossible  in  view  of  the  condition  of  the  tissues,  whereas  the  changes  due  to 

tuberculosis  offer  great  surgical  opportunities. 
348  South  Fifteenth  Street. 


THE  THYROID  PREPARATIONS  IN  PRACTICE.' 

By  CHARLES  E.  de  M.  SAJOUS,  M.D. 

PHILADELPHIA. 

Probably  the  most  striking  evidence  of  the  value  of  our  remedies,  and 
one  which  controverts  most  emphatically  the  pessimistic  tendency  of  our  day, 
is  that  afforded  by  the  use  of  thyroid  extract  in  cretinism  or — a  better  term — 
infantile  myxoedema.  As  Osier  wrote  some  years  ago,  "no  type  of  human 
transformation  is  more  distressing  to  look  at  than  an  aggravated  case  of 
cretinism.  The  stunted  stature,  the  semi-bestial  aspect,  the  blubber  lips, 
retrousse  nose,  sunken  at  the  root,  the  wide-open  mouth,  the  lolling  tongue, 
the  small  eyes,  half-closed  with  swollen  lids,  the  stolid,  expressionless  face, 
the  squat  figure,  the  muddy,  dry  skin,  combine  to  make  the  picture  of  what  has 
been  well  termed  the  'pariah  of  nature.'  Not  the  magic  wand  of  Progress, 
or  the  brave  kiss  of  the  daughter  of  Hippocrates  ever  effected  such  a  change 
as  that  which  we  are  now  enabled  to  make  in  these  unfortunate  victims,  doomed 

iRead  by  invitation  before  the  J.  M.  Anders  Medical  Society,  Philadelphia. 


84  THE  THYROID  PREPARATIONS  IN  PRACTICE. 

heretofore  to  live  in  hopeless  imbecilit}^,  an  unspeakable  affliction  to  their 
parents  and  to  their  relatives.  Within  a  month  to  six  weeks  after  the  adminis- 
tration of  thyroid,  loss  in  weight  is  noticed,  due  to  disappearance  of  the 
myxcedematous  condition  and  fat.  The  face  becomes  smaller,  the  pufiiness 
about  the  eyes  abates.  The  projecting  abdomen  diminishes  in  size,  the  child's 
figure  improves  in  shape.  The  hair  becomes  finer  and  more  abundant,  and 
the  skin  loses  its  roughness  and  yellow  hue."  Soon  also  the  mental  capacity 
improves  and  ultimately  a  normal  average  child  is  evolved  out  of  the  idiotic 
dwarf  that  was. 

How  is  this  wonderful  change  accomplished?  Physiology  tells  us  that 
the  thyroid  gland  and  its  glandules,  the  parathyroids,  are  of  "great  metabolic 
importance,"  but  how  do  they  influence  the  cellular  exchanges  and  nutrition 
to  a  degree  sufficient  to  promote  growth  and  development  of  all  tissues  includ- 
ing the  brain  ?  As  stated  by  a  French  physiologist,  Laulanie  :2  "For  the  time 
being  one  can  perceive  no  solution  of  this  problem." 

This  does  not  mean  that  physiologists  have  not  contributed  much  to  our 
knowledge  of  tbese  organs.  Indeed,  we  owe  them  the  great  majority  of  sound 
data  at  our  disposal,  but  as  one  of  their  number.  Professor  Pawlow,  of  St. 
Petersburg,  urged  some  years  ago:  "In  many  instances  the  physician  gives  a 
more  correct  verdict  concerning  physiological  processes  than  the  physiologist 
himself,"  clinical  medicine  being  in  his  opinion,  "a  rich  mine  of  physiological 
facts."  This  is  particularly  applicable  to  our  knowledge  of  the  functions  of 
the  ductless  glands,  and  it  is  the  result  of  an  effort  in  the  line  suggested  by 
Prof.  Pawlow,  that  I  wish  to  submit  to  you  to-night.  Indeed  it  has  appeared 
to  me  that  clinical  medicine  could  furnish  data  which  added  to  the  many 
contributed  by  physiologists  would  make  it  possible  to  explain  not  only  the 
functions  of  the  thyroid  apparatus,  but  also  those  of  other  glands,  which 
secrete  their  product  into  the  blood  itself. 

A  satisfactory^  explanation  should  account  for  all  phenomena  evoked  by  a 
given  remedy;  in  the  case  of  thyroid  extract,  clinical  observation  renders  it 
necessary  to  explain  many  such,  not  only  those  connected  with  increased  nutri- 
tion, strength  and  growth,  but  also,  phenomena  which  appear  quite  antagonistic 
to  these:  emaciation,  general  vaso-dilation,  increased  combustion  of  physiolog- 
ical wastes,  and  augmentation  of  the  bacteriolytic  and  antitoxic  power  of  the 
blood.  This  is  certainly  a  large  contract  and,  I  may  add,  one  wliich  submits 
any  explanation  submitted  to  a  very  severe  test. 

You  will  be  spared,  however,  gentlemen,  the  experimental  and  clinical 
data  which  have  served  to  elaborate  the  views  I  have  to  offer:  Keferring  you 
to  the  two  portly  vohimos  in  which  they  are  recorded,  I  will  merely  submit  the 
conclusions  reached. 

It  has  long  been  kno\\Ti  that  the  functions  of  several  ductless  glands  were 
more  or  less  connected.  The  nature  of  this  relationship  has,  however, 
remained  obscure.  My  own  labors  have  shown  that  three  of  these,  the  thyroid 
(including  the  parathyroids),  the  pituitary,  and  the  adrenals,  were  related 


2Lau]ani6:   Elements  de  Pliysiologie,  2d   Ed.,  p.  485,  1905. 


THE  THYROID  PREPARATIONS  IN  PRACTICE.  85 

as  follows :  ( 1 )  that  the  secretions  of  the  thyroid  and  parathyroids,  acting 
jointly,  increase  the  vulnerability  or  sensitiveness  of  all  tissue-cells,  wastes, 
bacilli,  toxins,  etc.,  to  oxidation,  by  a  direct  action  on  their  phosphorus,  thus 
constituting  the  substance  now  known  under  various  names:  "opsonin," 
"agglutinin,"  "precipitin,"  "sensibilisatrice,"  etc.;  (2)  that  among  the  tissues 
thus  sensitized  is  the  governing  center  of  the  adrenals  which  center  I  have 
traced  to  the  pituitary  body;  (3)  that  the  adrenal  secretion  carried  to  the 
lungs  with  the  blood  of  the  inferior  vena  cava,  is  the  substance  which  takes 
up  the  oxygen  of  the  air;  (4)  that  the  adrenal  secretion,  when  thus  laden 
with  oxygen,  becomes  the  oxidizing  constituent  of  the  haemoglobin  which  sus- 
tains the  body-heat,  metabolism  and  nutrition;  and  (5)  that  the  power  of 
the  blood  to  destroy  bacteria,  their  toxins,  toxic  waste-products  and  other 
poisons  corresponds  with  the  proportion  of  thyroparathyroid  and  adrenal 
secretion  it  contains.  In  short,  the  thyroid,  the  pituitary  body,  and  the 
adrenals  thus  connected  by  nerve-paths  act  jointly  to  enhance,  when  needed, 
general  oxidation  and  produce  a  heretofore  unexplained  phenomenon,  fever. 

When,  in  the  light  of  the  above,  we  administer  desiccated  thyroid,  which 
combines  the  actions  of  the  thyroid  and  parathyroids,  corresponding  effects 
are  produced :  It  renders  the  phosphorus  of  all  tissues,  and  all  free  substances 
such  as  bacteria,  wastes,  toxins,  etc.,  containing  phosphorus,  more  inflammable 
or  sensitive  to  the  action  of  the  oxygen  in  the  blood.  As  this  applies 
particularly  to  nerves  and  nerve-centers  (all  of  which  are  especially  rich  in 
phosphorus)  the  adrenal  center,  and  therefore  the  adrenals  themselves,  are 
excited  and  the  adrenal  secretion  being  the  agent  which  takes  up  the  oxygen  of 
the  air  to  sustain  the  blood's  oxygenizing  power,  the  supply  of  oxygen  is  also 
increased.  All  the  various  phosphorus-laden  substances  are  thus  not  only 
rendered  more  readily  oxydizable  by  thyroid  extract,  but  this  remedy  also 
provides  indirectly  the  required  oxygen.  This  is  not  all,  however.  As  the 
functions  of  all  organs  are  enhanced  by  this  process,  the  pancreas  and  the 
leucocytogenic  organs  are  also  stimulated,  and  trypsin  and  phagocytes,  which 
are  the  active  destroyers  of  pathogenic  organisms,  toxins  and  other  poisons, 
are  also  increased.  Briefly,  under  the  influence  of  thyroid  preparations,  we 
have  in  the  blood — and  demonstrable  therein — all  the  active  agents  concerned 
with  metabolism,  nutrition  and  immunity  the  identity  and  source  of  which 
have  remained  obscure:  an  increase  (1)  of  adrenal  oxidizing  substance  (the 
albuminous  constituent  of  hajmoglobin  and  Ehrlich's  amboceptor)  ;  (2)  of 
thyroid  sensitizing  substance  (Wright's  opsonin) ;  (3)  of  trypsin  (Ehrlich's 
complement  and  Metchnikoff's  cytase)  ;  and  (4)  bacteriolytic  leucocytes 
(Metchnikofll's  phagocytes). 

The  eifects  of  thyroid  extract  in  cretinism  can  now  be  accounted  for — 
notwithstanding  their  great  number:  The  rise  of  temperature  is  due  to  the 
increased  oxidation  brought  about  by  the  thyroid  and  adrenal  oxidizing  sub- 
stances acting  jointly;  the  enhanced  metabolism  is  a  normal  result  of  the 
augmentation  of  general  oxidation,  while  the  increased  appetite  is  due  to  the 
resulting  greater  demand  for  food-stuffs.  The  marked  improvement  in 
general  nutrition  and  strength  is  a  self-evident  result  of  the  assimilation  of 


86  THE  THYROID  PREPARATIONS  IN  PRACTICE. 

a  greater  proportion  of  food-materials,  and  the  rapid  growth  likewise.  The 
cerebrospinal  system  is  particularly  influenced  owing  to  its  wealth  in  phos- 
phorus, hence  the  development  of  intelligence.  All  organs  being  the  seat  of 
active  metabolic  activity  and  nutrition,  the  intestinal,  renal,  cardiac  and 
cutaneous  and  hepatic  fimctions  are  all  enhanced.  Even  the  hair  grows 
bountifully  not  only  in  cretinisms,  but  when  its  loss  is  due  to  general  adynamia. 
It  counteracts  premature  senility  in  all  its  phases  by  restoring  to  the  organism 
the  one  constituent  which  sustains  the  functional  efficiency  of  all  its  parts. 

This,  I  must  here  emphasize,  is  the  aggregate  of  effects  obtained  with 
small  doses,  at  most,  2  grains  of  the  desiccated  thyroid  (which  represents  10 
grains  of  the  gland  proper),  three  times  a  day.  When  larger  doses  are  given 
another  order  of  phenomena  is  awakened :  those  of  excessive  burning  up,  as 
it  were,  of  the  tissues.  The  inflammability  of  all  phosphorus-laden  elements 
being  markedly  enhanced  while  the  quantity  of  oxidizing  substance  is  as  greatly 
increased,  the  tissue  elements  are  broken  down  more  rapidly  than  they  are 
built  up,  beginning  with  the  fats,  and  the  patient  becomes  emaciated.  Hence 
the  efiiciency  of  thyroid  extract  in  obesity,  but  only  in  unsafe  doses,  I  may 
add,  when  the  heart,  even  though  apparently  normal  under  ausculation,  hap- 
pens to  be  weak. 

No  less  wonderful,  in  my  opinion,  than  the  role  of  thyroid  preparations 
in  cretinism  and  myxoedema,  is  their  influence  on  the  immunizing  mechanism 
of  the  body,  which  I  pointed  out  six  years  ago,  when  I  described  this  mech- 
anism. You  have  heard  much  of  Prof.  A.  E.  Wright's  illuminating  labors, 
his  results  with  tuberculin,  vaccines,  etc.,  and  his  opsonin  index;  but  let  me 
assure  you  that  when  thyroid  preparations  are  judiciously  employed,  that 
is  to  say,  when  their  action  is  controlled  by  giving  only  carefully  adjusted 
doses,  and  the  concomitant  use,  if  needed,  of  other  agents — iron  for  example 
to  supply  the  hsmatin  necessary  to  build  up  the  hgemoglobin  molecule  when 
with  thyroid  we  wish  to  increase  the  albuminous  moiety  of  that  molecule, 
strychnine  when  the  blood-pressure  is  too  low  to  insure  adequate  tissue  nutri- 
tion, etc. — quite  as  much  can  be  done,  and  with  greater  scientific  accuracy 
and  safety,  than  with  vaccine  therapy.  Thyroid  preparations,  with  proper 
adjuvants — all  familiar  drugs  of  our  pharmacopoeia — supplies  directly  in  many 
instances  what  vaccines  supply  only  indirectly. 

The  desiccated  thyroid  of  the  sheep,  which  appears  in  our  pharmacopoeia, 
one  grain  of  which  represents  five  grains  of  the  fresh  gland,  is,  on  the  whole, 
the  most  reliable  preparation  at  our  disposal.^ 

The  diseases  in  which  thyroid  extract  may  be  used  advantageously  and  its 
action  therein,  are  briefly  as  follows: 

1.  Disorders  of  Nutrition.  The  diseases  included  in  this  class  which  are 
beneflted  by  thyroid  extract  are  obviously,  in  the  light  of  the  foregoing  state- 


3  The  average  dose  recommended  in  the  pharmacopoeia,  4  grains,  is  too  large.  In 
most  adults  I  rarely  find  it  necessary — except  in  the  treatment  of  obesity — to  give 
more  than  3  grains  during  each  meal,  beginning  with  1-gi'ain  doses  and  increasing  very 
gradually. 


THE  THYROID  PREPARATIONS  IN  PRACTICE.  87 

ments,  those  in  which  general  oxygenation  and  metabolism  are  deficient,  the 
most  exaggerated  types  of  which  are  cretinism  and  myxoedema.  It  is  also 
effective,  however,  in  those  disorders  in  which  pallor  and  general  asthenia  are 
present — in  ansemia  and  neurasthenia  for  example.  The  addition  of  a  single 
grain  of  the  desiccated  extract  daily  to  strychnine,  and  iron,  increase  strikingly 
their  efficiency.  It  has  been  found  harmful  in  some  cases  of  acromegaly,  but 
when  we  recall  that  the  first  stage  of  this  disease  is  due  to  overactivity  of  the 
pituitary  body  and  ovemutrition,  it  becomes  apparent  that  it  is  only  useful  in 
the  advanced  or  asthenic  stage,  when  the  pituitary  is  breaking  down. 

2.  Disorders  due  to  Toxic  Waste-Products.  These  disorders  are  closely 
allied  to  the  former.  But  here  the  deficiency  of  oxidation  manifests  itself  by 
an  inadequate  breaking  down  of  waste-products  and  these  by  accumulating  in 
the  blood  provoke  the  many  disorders  grouped  in  the  so-called  "gouty  diathesis" 
which  directly  or  remotely  include  migraine,  asthma,  some  forms  of  acne  and 
melancholia.  The  wastes  that  the  foetus  adds  to  those  of  a  pregnant  woman 
are  often  sufficient  to  provoke  either  of  the  disorders  just  enumerated.  Tetany, 
tetanus,  puerperal  eclampsia,  epilepsy  before  gliosis  has  been  allowed  to 
develop,  are  all  due,  at  least  in  part  to  toxic  wastes,  which  the  blood  has 
failed,  owing  to  inadequate  activity  of  the  thyroid  and  adrenals,  to  destroy. 
Chronic  rheumatism  is  another  disease  of  this  class  which  slowly  but  surely 
yields  to  small  doses  of  thyroid.  A  curious  action  of  this  agent  in  this  con- 
nection is  its  gradual  reduction  of  the  accompanying  hydrarthrosis;  but  this 
effect  is  readily  explained  when  it  is  recalled  that  certain  wastes  cause  a  marked 
rise  of  the  vascular  tension ;  the  remedy,  by  destroying  the  wastes  causes  the 
vessels  to  resume  their  normal  calibre  and  the  joints,  are  thus  freed  of  the 
excess  of  fluid  forced  into  them. 

3.  Infectious  Diseases.  In  true  infectious  tonsillitis,  desiccated  thyroid 
clears  the  field  very  promptly.  It  does  so  of  course  by  enhancing  the  bacte- 
ricidal and  antitoxic  powers  of  the  blood  and  glandular  secretions.  The 
bacteria  being  rendered  more  sensitive,  that  is  to  say,  more  easily  digestible, 
they  readily  become  the  prey  of  the  phagocytes  which  are  extremely  numerous 
in  the  tonsils.  Pulmonary  tuberculosis,  before  the  disease  is  sufficiently 
advanced  to  compromise  the  whole  mechanism  of  respiration,  that  is  to  say, 
during  the  first  and  second  stages,  is  especially  vulnerable  to  the  action  of 
thyroid.  The  tubercle  bacillus  which,  as  you  know,  is  also  pathogenic  when 
dead,  owes  its  morbid  action  to  an  endotoxin  rich  in  phosphorus;  being  thus 
rendered  extremely  inflammable  while  the  blood's  oxidizing  power  is  enhanced 
simultaneously,  this  pathogenic  organism  is  promptly  destroyed.  This  applies 
also  to  lupus.  In  syphilis,  the  use  of  thyroid,  based  on  the  views  I  have 
advanced,  has  been  termed  "marvelous"  by  other  observers.  It  has  been  used 
with  success  in  acute  infections,  including  the  exanthemata  which  may  often 
be  curtailed  by  its  judicious  use. 

4.  Diseases  due  to  Deficient  Reparative  Power. — Another  very  interesting 
phase  of  the  action  of  thyroid  preparations,  which  is  made  clear  by  my  inter- 
pretation of  its  mode  of  action,  is  its  influence  on  the  processes  of  repair. 
An  osteomyelitis  of  long  standing  will,  after  a  few  days,  change  its  aspect  and 


38  THE  THYROID  PREPARATIONS  IN  PRACTICE. 

proceed  to  recovery,  necrotic  tissues  and  bone  being  gradually  eliminated. 
Surgical  aid  for  the  removal  of  this  detritus,  which  before  had  afforded  no 
benefit,  is  now  followed  by  prompt  healing.  Osteomalacia  and  rickets  are 
similarly  influenced.  A  striking  effect  is  in  delayed  union  of  fractures; 
cases  which  had  remained  several  weeks  without  giving  the  least  evidence  of 
repair,  seem  endowed  with  new  life,  and  the  union  is  soon  complete. 

Of  very  great  importance  in  this  connection  is  the  influence  of  thyroid 
preparations  in  cancer.  I  pointed  out  in  1903 — a  view  which  has  been  con- 
flrmed  since  by  independent  experimental  evidence  contributed  by  Ehrlich  and 
others — that  this  dread  disease  was  due  to  deficient  immimizing  activity,  "the 
blood  being  deficient,"  as  I  then  wrote,  "in  the  four  constituents  which  should 
insure  destniction  of  the  morbid  cellular  elements" — the  identical  ones,  we 
have  seen,  which  thyroid  preparations  directly  and  indirectly  supply  to  the 
blood.  Many  cases  are  on  record  in  which  thyroid  preparations  have  failed  to 
do  good;  worse  than  this,  it  may  be  said  that  in  these  cases  it  actually  did 
harm!  But  study  these  cases  as  I  have,  and  you  will  see  that  the  clinicians 
who  obtained  such  results  acted  on  the  belief  that  since  a  small  quantity  does 
good,  a  large  quantity  must  do  more  good.  The  results  under  such  conditions 
are  self-evident :  the  doses  administered  were  not  the  small  ones  which  enhance 
nutrition  and  the  activity  of  the  reparative  processes,  including  the  preliminary 
breaking  down  of  cellular  aggregates  that  are  useless  to  the  needs  of  the  body, 
but  the  large  doses  that  destroy  not  only  the  malignant  growth  itself,  but  the 
body  as  well. 

And  the  action  of  thyroid  preparations  exemplifies,  in  the  light  of  my 
views,  the  logical  aim,  the  Medicine  of  the  future,  a  Medicine  quite  as  eificient 
in  its  results  as  modem  Surgery.  Dr.  Eobert  T.  Morris  wrote  recently: 
"About  the  middle  of  the  last  century  a  number  of  surgeons  were  calling 
attention  to  the  desirability  of  rapid  operating,  and  promulgating  the  idea  that 
patients  recovered  more  quickly  when  the  attack  of  surgery  had  been  of  short 
duration.  The  idea  was  based  upon  ordinary  observation,  ratlier  than  upon 
science,  at  that  time.  Into  the  field  came  Pasteur,  Semmelweiss,  Lister.  The 
attention  of  the  whole  surgical  world  was  diverted  toward  questions  of  anti- 
sepsis and  of  asepsis.  The  patient  himself  was  forgotten  in  our  skilled 
maneuvers  against  the  bacterium.  Tait  stood  out  alone  upon  the  plain  in  the 
midst  of  the  whirlwind,  and  his  statistics  were  too  good  to  be  generally  accepted. 
He  stood  upon  his  ipse  dixit  rather  than  upon  a  basis  of  scientific  explanation, 
which  to-day  can  be  given.  The  dominant  idea  became  that  of  preventing 
nature  from  growing  her  favorite  colonies  of  bacteria  at  our  expense,  and  we 
were  to  accomplish  the  task  by  our  artifices.  That  is  the  dominant  idea  right 
now.  It  is  crude  and  incomplete,  and  is  shortly  to  be  rounded  out  by  the 
idea  of  conserving  the  natural  immunity  of  the  patient,  and  of  holding  his 
opsonic  index  up,  even  as  the  hands  of  Moses  were  held  up.  The  patient 
himself  is  to  be  our  best  ally,  and  in  our  pride  of  achievement  with  artifices 
against  the  bacterium,  we  are  not  much  longer  to  disregard  such  an  ally  as 
nature  gives  us  in  the  patient." 


ARTERIOSCLEROSIS. 


ASTHMA. 


89 


CjJclopaedJa  of  Current  I^itcrature 


ARTERIOSCLEROSIS,  PATHOGENESIS  OF. 

The  recent  increase  of  attention  to 
the  clinical  study  of  the  peripheral  cir- 
culation is  attributed  by  the  writer  to  the 
introduction  of  mechanical  appliances  for 
the  measurement  and  registration  of 
blood-pressure.  Atheroma,  it  is  affirmed, 
is  a  purely  local  affection  of  the  arterial 
wall,  the  lumen  of  the  vessel  being 
narrowed,  while  its  walls  bulge  and  are 
weakened  and  distorted.  Arteriosclero- 
sis consists  in  thickening  of  the  whole 
circumference  of  the  arterial  wall  along 
considerable  stretches  of  the  vessel  and 
usually  over  a  large  vascular  area.  The 
two  diseases  are  quite  distinct  from  each 
other  as  to  mode  of  origin,  area  of  dis- 
tribution and  ultimate  effects  on  arterial 
walls  and  circulation. 

The  exact  cause  of  arteriosclerosis  has 
not  yet  been  positively  determined. 
Theories  abound  which  differ  materially 
from  each  other,  but  the  author  regards 
as  most  probable,  in  view  of  the  absence 
of  uniformity,  in  conjunction  with  the 
correlation  of  the  morbid  changes  in 
the  disease,  that  such  changes  represent 
stages  in  the  operation  of  a  single  patho- 
genetic process,  which  commences  with 
increase  of  function  and  hypertrophy  of 
the  arterial  muscular  coat,  progresses 
with  functional  failure  and  degeneration 
of  the  muscular  substance,  and  culmi- 
nates in  hyperplasia  of  the  fibrous  tissue 
elements  of  the  arterial  wall.  E.  H. 
Colbeck  (Practitioner,  December,  1908). 

ASTHMA. 

The  asthmatic  paroxysm  from  start  to 
finish — the  spasm  of  the  bronchial  and 
inspiratory  muscles,  the  infiltration   of 


the  lungs,  the  carbonsemia,  the  leucocyto- 
sis,  the  output  of  mucous  bodies,  spirals, 
eosinophiles,  and  the  rest — is  truly  and 
strictly  a  process  of  defense.  The  dis- 
ease, therefore,  or  specific  source  of 
irritation,  is  for  the  time  being  in  the 
lungs;  and,  whatever  its  nature,  it 
seems  early  to  excite  contraction  of  the 
bronchial  muscles,  probably  much  in  the 
same  way  as  impure  blood  is  believed  to 
excite  contraction  of  the  arterioles.  In 
the  absence  of  a  specific  organism,  it  is 
the  secretion — the  expectoration — and 
the  blood  changes,  on  which  the  diag- 
nosis is  to  be  relied,  and  not  the  spasm. 
After  cessation  of  the  spasm  the  disease 
is  still  there.  Eeflex  bronchial  spasm 
can  be  set  up  in  many  other  ways,  and 
especially  by  irritation  of  the  nasal 
mucosa.  The  causative  agent  of  asthma 
is  merely  a  matter  of  speculation.  The 
long  duration  of  the  affection  is  not 
necessarily  against  its  being  microbial. 
It  may,  however,  be  a  toxine  or  leuco- 
mania,  which  is  either  of  distinctly 
pathological  origin  or  else  a  product  of 
normal  metabolism,  which  gradually 
accumulates  in  the  blood  by  reason  of 
some  defect,  congenital  or  acquired,  in 
the  excretory  function  of  the  lungs. 
There  is  little  doubt  that  the  lungs  are 
avenues  for  the  excretion  of  unloiown 
poisons.  Asthma  commences  usually 
about  3  or  3  a.  m.,  when  the  opsonin  or 
preopsonin  content  of  the  blood  reaches 
its  minimum ;  there  is  perhaps  a  parallel 
instance  in  cramp,  which  is  supposed  to 
be  due  to  a  toxin  acting  on  the  muscles. 
During  the  actual  attack  of  asthma  the 
most  that  can  be  done  is  to  relieve  the 
dyspnoea.     Any    attempt    to    check    it 


90 


BURNS,  TREATMENT  OF. 


DYSMENORRH(EA. 


suddenly  by  powerful  agents  is  not  good 
practice.  It  is  best  to  mitigate  the 
spasm  by  agents  which,  like  the  nitrites 
and  potassium  iodide,  do  not  at  the  same 
time  imperil  the  natural  order  of  cure. 
Morphine,  cocaine,  etc.,  are  apt  to  sup- 
press the  secretion,  and  act  prejudicially 
by  diverting  the  disease  into  fresh  chan- 
nels. The  supposition  that  asthma  is  an 
incurable  disease  should  be  dismissed. 
Careful  research  should  first  be  made  for 
any  irritative  lesion  capable  of  exciting 
bronchial  spasm.  The  nose,  nasopharynx 
and  the  stomach  are  of  chief  concern. 
Next  it  should  be  noted  that  asthmatics 
exhibit  idios}Ticrasies  in  respect  to 
environment  just  as  they  do  to  drugs. 
Some  do  well  in  cities,  others  in  the 
open  countries.  The  lungs  must  be 
properly  ventilated,  and  regulated  hill 
climbing  is  an  excellent  form  of  pul- 
monary exercise.  Swimming  is  an  ideal 
form  of  exercise  for  asthmatics.  Asthmat- 
ics do  not  bear  large  or  full  meals,  nor 
any  food  that  is  slow  and  difficult  of 
solution  in  the  stomach,  but  they  do  well 
on  animal  foods  of  the  lighter  kind  and 
in  moderate  quantity.  Few  asthmatics 
can  tolerate  alcohol  in  any  form.  A 
peculiar  anaemia  often  characterizes  the 
asthmatic  diathesis,  and  for  this  iron, 
with  or  without  arsenic,  is  often  bene- 
ficial. A.  G.  Auld  (British  Medical 
Journal,  December  26,  1908). 

BURNS,  TREATMENT  OF,  GENERAL. 

The  general  sjTiiptoms  are  the  most 
important  in  bums  of  any  extent.  Such 
symptoms  may  originate  in  the  brain,  in 
the  heart,  or  in  the  kidneys.  It  is  pos- 
sible that  the  effect  of  heat  upon  the  skin 
results  in  the  development  of  toxins, 
which  affect  the  general  system  of  the 
patient.  The  heart  is  usually  weak  and 
fast,    the    vessel    tone    diminished,    the 


temperature  may  fall  and  haemolysis  may 
take  place.  To  meet  these  conditions 
intravenous  injections  of  heart  stimu- 
lants may  have  to  be  used,  and  much 
fluid  should  be  administered  to  the 
patients  by  the  mouth  and  per  rectum. 
There  is  no  contraindication  to  the  use 
of  opiates,  for  the  intense  suffering  of 
the  patient  has  a  very  bad  effect  upon  his 
condition  and  must  be  relieved. 

The  best  treatment  for  the  local  lesion 
is  that  of  Tschmarke  and  consists  of 
cleaning  the  burned  areas  as  thoroughly 
as  is  done  for  a  surgical  operation.  As 
a  rule,  either  local  or  general  anesthesia 
is  required  to  accomplish  this,  the  pain 
being  intense.  The  surface  is  then 
covered  with  abundant  layers  of  gauze, 
the  upper  layers  of  which  have  to  be 
frequently  changed  because  of  the  secre- 
tion from  the  wounds.  Such  cleaning 
of  the  burned  surface  prevents  the  death 
of  small  portions  of  epithelium  lining 
the  glands,  because  infection  is  prevented 
and  these  islands  of  epithelium  become 
the  starting  points  for  the  growth  of  new 
skin.  If  infection  of  burned  areas  has 
occurred,  alcohol  compresses  and  then 
incision  and  evacuation  of  pus  is  indi- 
cated. The  contractures  that  often 
remain  after  severe  burns  must  be 
treated  by  plastic  surgical  procedures. 
Pels-Leusden  (Deutsche  medizinische 
Wochenschrift,  November  26,  1908; 
Medical  Record,  December  26,  1908). 

DYSMENORRHOEA. 

The  condition  of  the  endometrium  is 
dependent  upon  ovulation  and  many 
appearances  that  previously  were  looked 
upon  as  pathological  are  simply  the 
physiological  conditions  present  in  the 
menstrual  or  post-menstrual  time.  This 
recent  view  diminishes  the  number  of 
anatomical  lesions  which  can  be  held 
responsible  for  the  symptom  dysmenor- 


GLYCOSURIA  IN  PREGNANCY. 


GOUT  AND  THYMINIC  ACID. 


91 


rhoea.     The  writer  defines  menstruation 
as  the  abortion  of  an  unfertilized  ovum; 
o\ailation  should  naturally  be  followed  by 
impregnation,  but  as  it  does  not  every 
time   in    the   human    race    the    various 
phenomena  of   ovulation  must  be  con- 
quered, which  adaptation   is   outwardly 
shown  by  the  function  of  menstruation. 
A  nervous  individual  may  react  abnor- 
mally to  the  impulses  of  ovulation;    in 
her  the  phenomena  of  conquering  such 
impulses  may  not  occur  and  the  result  is 
one  of  the  forms  of  nervous  dysmenor- 
rhoea.     Another    form    is    due    to    the 
faulty  development  of  the  uterus  with 
coexistent  abundant  sexual  excitement; 
the  latter  leads  to  changes  in  the  ovaries 
and   in   the    endometrium    and   to    the 
s}Tnptom  of  dysmenorrhoea,  which  in  this 
case  depends  upon  both  anatomical  and 
functional  disturbances.     The  third  form 
is  the  purely  mechanical  one  due  to  some 
local  disease  or  anomaly  of  the  uterus  or 
of  the  neighboring  organs.     The  nervous 
forms  of  dysmenorrhoea  are  to  be  treated 
by  measures  affecting  the  general  health 
or  by  directing  the  treatment  upon  some 
possible  source  of  peripheral  irritation, 
attention  to  which  may  have  a  salutary 
psychic  effect.     The  latter  mode  of  treat- 
ment may  include  the  cocainization  of 
the  nasal  mucosa,  a  procedure  by  which 
Fliess    claimed    to    cure    all    cases    of 
dysmenorrhoea    whatever.     In    all    dys- 
menorrhoeas  of  virgins  the  patient  must 
be  examined  for  neurasthenia   and  the 
latter  disease  treated,  if  present,  rather 
than  the  symptom  of  it  in  the  genital 
sphere.     In  case  neurasthenia  symptoms 
are  absent  a  gynecological  examination 
and  eventually  operative  treatment  in  the 
form  of  a  curettage  may  be  tried.     Veit 
(Miinchener  medizinische  Wochenschrift, 
November  24,   1908;    Medical   Eecord, 
January  2,  1908). 


GLYCOSURIA  IN  PREGNANCY,  CLINICAL 
SIGNIFICANCE  OF. 
A  positive  reaction  with  Fehling's 
solution  during  pregnancy  is  usually  due 
to  lactosuria,  or  to  transient,  alimentary, 
or  recurrent  glycosuria.  In  such  cases 
lactosuria  is  probably  associated  with 
premature  activity  of  the  breasts.  If 
glycosuria  in  such  cases  is  alimentary  it 
may  be  disregarded.  Otherwise  it  may 
be  transient  or  recurrent,  or  may  indicate 
true  diabetes.  Glycosuria  late  in  preg- 
nancy, not  exceeding  two  per  cent., 
unaccompanied  by  s}Tiiptoms,  is  usually 
transient,  but  may  persist  to  the  end  of 
pregnancy.  It  is  usually  of  slight 
clinical  significance,  but  the  patient 
should  be  carefully  watched.  If  much 
sugar  is  observed  early  in  pregnancy,  it 
may  be  impossible  to  make  a  diagnosis 
until  after  delivery.  The  condition  will 
then  disappear  in  glycosuria  cases,  but 
persist  in  true  diabetes.  Pregnancy  may 
occur  in  diabetic  women,  or  diabetes  may 
become  manifest  during  pregnancy. 
Either  complication  is  serious;  some 
patients  will  survive,  others  will  die,  in 
coma  or  collapse  at  the  end  of  pregnancy 
or  during  or  after  labor.  If  the  quantity 
of  sugar  is  large  and  cannot  be  controlled 
by  diabetic  and  medicinal  treatment, 
induction  of  abortion  or  premature  labor 
will  be  indicated,  even  though  serious 
symptoms  may  be  absent.  J.  W.  Wil- 
liams (American  Journal  of  Medical 
Sciences,  January,  1909). 

GOUT,    TREATMENT    OF,    BY    THYMINIC 
ACID. 

The  use  of  thyminic  acid  for  the 
elimination  of  uric  acid  (as  in  gout)  has 
its  support  on  a  solid  scientific  basis. 
The  synthetic  manufacture  of  thyminic 
acid  is  now  an  accomplished  fact,  and  the 
writer  has  obtained  most  excellent  results 
by  its  use   in   cases  of  gout.     By  the 


92 


HEMORRHOIDS,  NEW  OPERATION  FOR. 


oxidation  of  the  purin  bodies  thyminic 
acid  is  produced  as  well  as  uric  acid,  and 
these  two  substances  form  a  combination 
in  which  the  uric  acid  loses  its  identity 
and  can  no  longer  be  precipitated.  It  is 
as  a  constituent  of  this  compound  that 
uric  acid  circulates  in  normal  blood.  In 
gout  the  amoimt  of  uric  acid  in  the  blood 
may  not  exceed  the  normal,  the  trouble 
being  that  its  combination  with  thyminic 
acid  has  not  taken  place  or  has  become 
imstable.  If  thyminic  acid  can  be  intro- 
duced into  the  blood  by  ingestion  or 
other  method  in  sufficient  quantities  to 
retain  the  free  uric  acid  in  circulation, 
the  method  of  rendering  the  latter  soluble 
is  found. 

Turning  to  the  clinical  results  of  the 
treatment  of  the  gouty  state  by  thyminic 
acid,  the  writer  is  convinced  that  we 
possess  a  very  valuable  and  powerful 
agent,  especially  in  the  prevention  of 
recurrent  attacks  of  acute  gout  and  in  the 
cure  or  amelioration  of  the  more  chronic 
forms,  and  of  the  many  ailments  that 
are  marked  by  the  excessive  formation  of 
uric  acid  within  the  system.  It  is  in  the 
prevention  of  attacks  of  acute  gout,  in 
the  obesity  so  often  allied  with  the  gouty 
state,  in  gouty  eczema,  asthma,  glyco- 
suria, and  stomachic  derangements  that 
thyminic  acid  attains  its  maximum  of 
usefulness.  A  small  dose  (four  grains) 
taken  daily  after  meals  for  a  prolonged 
period,  say  of  three  months,  and  then 
every  alternate  week  will,  in  most  cases, 
entirely  avert  the  onset  of  acute  symp- 
toms. When  an  acute  attack  of  arthritic 
gout  is  actually  in  evidence,  thyminic 
acid  is  not  invariably  successful,  and  the 
author  prescribes  mercurials  with  col- 
chicum,  or  colchicine  with  asperin; 
then  as  the  symptoms  abate  large  doses  of 
thyminic  acid  are  given  in  conjimction 
with  local  treatment  by  the  x-ray  light 
bath,  and  the  pain  and  swelling  quickly 


subside.  It  is  a  decided  proof  of  the 
efficacy  of  the  drug  that  it  renders  inert 
any  excess  of  uric  acid,  which  in  some 
peculiar  way  alcohol  in  any  form  often 
produces.  E.  Fenner  (Lancet,  Decem- 
ber 19,  1908). 

H.a:MORRHOIDS,  NEW  OPERATION  FOR. 

After  the  usual  preparation  of  the 
patient,  the  tumors  are  exposed  suc- 
cessively and  held  between  the  thumb 
and  the  finger  or  with  forceps.  An 
incision  is  then  carried  in  the  long 
axis  of  the  bowel  through  the  mucous 
membrane,  care  being  taken  so  as  not 
to  wound  the  blood-vessels.  The  blood- 
vessels being  now  exposed,  they  are 
grasped  with  forceps  and  traction  ap- 
plied. This,  as  a  rule,  will  liberate  the 
vessels;  if  not,  the  use  of  a  small,  blunt 
spoon  or  curette  will  materially  assist  in 
breaking  up  inflammatory  adhesions  of 
the  connective  tissue.  When  by  this 
method  the  hgemorrhoidal  vessels  are 
thoroughly  exposed  through  the  cut  in 
the  mucous  membrane,  a  ligature  of 
small-sized  catgut  is  applied  above  and 
below.  Now  the  vessels  are  extirpated 
with  scissors  or  knife.  The  incision  in 
the  mucous  membrane  is  closed  with  like 
suture  material.  It  is  found,  however, 
that  unless  the  incision  is  large  it  heals 
just  as  readily  without  suturing,  being 
hermetically  sealed  with  a  blood-clot. 
Should  too  much  redundant  tissue 
remain,  it  may  be  removed,  carrying  the 
incision  in  the  form  of  an  ellipse  and 
closed  as  before.  It  is  surprising,  how- 
ever, how  much  the  mucous  membrane 
will  shrink  after  removal  of  the  vessels. 
The  only  dressing  used  is  a  sterile  pad 
over  the  anal  region.  The  operation  is 
best  performed  without  the  use  of  spong- 
ing, a  drip  of  boric  acid  solution  being 
employed  to  keep  the  field  clean.  The 
operation  is  not  applicable  to  the  friable 


RHEUMATIC  MYOCAKDITIS. 


BOOK  REVIEWS. 


93 


or  capillary  form,  nor  to  the  so-called 
connective  tissue  or  cutaneous  haemor- 
rhoids. It  is  at  once  thoroughly  surgical 
as  well  as  simple.  Little  hasmorrhage 
during  the  operation  and  the  danger  of 
secondary  haemorrhage  are  reduced  to  a 
minimum.  It  is  a  comfortable  operation 
for  the  patient;  there  is  practically  no 
pain.  The  edges  of  the  wound  are 
thoroughly  coaptated,  causing  prompt 
healing  and  the  absence  of  a  cicatrix. 
The  cause  is  removed,  not  merely  a 
bunch  of  mucous  membrane,  as  is  often 
the  case  with  other  operations.  C.  W. 
Heitzman  (New  York  Medical  Journal, 
December  12,  1908). 

RHEUMATIC  MYOCARDITIS. 

The  so-called  rheumatic  nodules  of  the 
heart  have  attracted  considerable  interest 
since  their  first  description  by  Aschoff 
and  Tawara  two  years  ago.  The  author, 
in  a  study  of  eight  hearts  of  patients 
dying  of  the  effects  of  rheumatism, 
found  these  nodules  in  all  of  them.  In 
one  case  he  investigated  their  distri- 
bution by  means  of  serial  sections,  and 
found  the  greatest  number  were  situated 


in  the  left  ventricle  near  the  apex  and 
near  the  mitral  ring,  and  near  the  root  of 
the  aorta.  They  were  generally  dis- 
tributed along  the  branches  of  the 
coronary  arteries.  The  nodule  itself  is 
apparently  specific  for  rhemnatism  and 
consists  of  large  spindle  cells,  often  with 
several  or  many  nuclei  and  probably  of 
the  nature  of  fibroblasts.  They  are  taken 
to  be  inflammatory  in  nature.  The  other 
lesions  were  of  less  importance  and  con- 
sisted of  fatty  clianges  in  the  muscle 
fibres  and  foci  of  polynuclear  leucocytes, 
the  latter  probably  due  to  passive  con- 
gestion. The  author  also  presents  tables 
showing  that  the  majority  of  fatal  cases 
of  rheumatic  carditis  in  children  do  not 
have  valvular  lesions  sufficient  to  account 
for  the  hypertrophy  and  dilatation 
present.  He  considers  that  the  latter  are 
due  chiefly  to  the  myocardial  lesions  and 
not  to  the  relatively  insigniflcant  changes 
in  the  valves.  The  mitral  systolic  mur- 
mur so  often  met  with  during  life  is 
ascribed  to  relative  mitral  insufficiency, 
the  result  of  myocardial  weakness.  C. 
Coombs  (Quarterly  Journal  of  Medicine, 
October,  1908). 


5ool(  I^eviews 


International  Clinics.  A  Quarterly  of  Illustrated  Clinical  Lectures  and  especially  pre- 
pared Original  Articles  on  Treatment,  Medicine,  Surgery,  Neurology,  Pediatrics, 
Obstetrics,  Gynsecology,  Ortliopsedics,  Pathology,  Dermatology,  Ophthalmology,  Otiology, 
Rhinology,  Laryngologj',  Hygiene,  and  other  topics  of  interest  to  students  and  practi- 
tioners. By  leading  members  of  the  medical  profession  throughout  tlie  world.  Edited 
by  W.  T.  Longcope,  M.D.,  Philadelphia,  U.  S.  A.,  Volume  III.  Eighteenth  Series,  1908. 
Philadelphia  and  London:    J.  B.  Lippincott  Company,  1908. 

Tliis  volume  contains  a  large  number  of  clinical  lectures  by  American  and  foreign 
authors,  chiefcst  among  which  and  of  special  interest  are  those  by  Sir  Dyce  Duckworth,  on 
"Sciatica;"  Allison  Scott,  on  "Perforation  of  the  Intestines  in  Typhoid  Fever;"  "Melanotic, 
Neoplasms,"  by  John  H.  Gibbon  and  Duncan  Despard;  Eidred  M.  Conner,  on  "The  Modern 
Treatment  of  Fracture  by  Means  of  Direct  Internal  Splintage;"  A.  Schwab,  on  the  "Disin- 
fection of  the  Uterine  Cavity  in  Puerperal  Infection;"  Mason  Knox,  Jr.,  on  the  "Diurrlucal 
Disorders  of  Infants;"  Jcliffe  Smith,  on  "General  Paresis;"  James  Shcrren,  on  the  "Diag- 
nosifi  of  Injuries  of  the  Peripheral  Nerve  from  Tliose  of  the  Spinal  Cord;"    "On  the  Treat- 


94  BOOK  REVIEWS. 

ment  of  Traumatic  Perforation  of  the  Cornea,"  by  Charles  Delope;  "On  Leuksemie  Retinitis," 
by  Rochon-Duvifineaud ;  "Adenoid  Vegetations  in  tlie  Naso-Pharynx,"  by  Morrison  Ray;  and 
"Studies  upon  the  Etiology  of  Appendicitis,"  by  Richard  Kretz.  The  volume  is  well  illus- 
trated with  numerous  photographs  and  drawings  from  original  preparations,  and  it  has  a 
very  serviceable  index. — B.  C. 

BoEDERLAND  Stxjdies.     By  George  M.  Gould,  M.D. 

From  time  to  time  Dr.  Gould  has  sat  himself  down  and  turned  loose  the  vials  of  his 
righteous  wrath,  condemning  this  or  that  abuse,  folly  or  danger  agent.  He  always  carries 
the  reader  along  with  him,  if  not  fortified  by  irremediable  prejudices,  and  rouses  to  the  very 
depths  all  the  fountains  of  altruism  which  each  one  may  have.  Wliat  he  says  is  always 
sincere  and  true,  as  he  sees  it,  and  most  times  correct.  The  pity  of  it  is  that  not  more 
people  take  the  trouble  to  listen  and  profit  by  such  good  scoldings.  And  they  are  always 
couched  in  such  charming  phraseology. — J.  M.  T. 

The  Efficient  Life.  By  Luther  H.  Gulick,  Director  of  Physical  Training  in  New  York 
Public  Schools.  New  York:  Doubleday,  Page  &  Co.,  1908.  Price,  $1.20. 
Dr.  Gulick  is  particularly  well  equipped  to  speak  authoritatively  on  all  subjects  con- 
nected with  training  of  the  body,  so  that  it  shall  be  a  better  temple  for  the  soul.  He  has 
given  us  in  this  little  book  (which  has  hitherto  escaped  our  personal  attention),  a  series 
of  essays  on  how  to  live  sanely  and  wholesomely,  which  cannot  fail  to  be  of  use  to  any  one 
who  will  read  them  attentively.  While  it  is  not  a  systematic  presentation  of  the  subject  of 
bodily  hygiene,  it  nevertheless  affords  many  useful,  practical  and  scientific  hints,  and  indi- 
cates principles  of  right  action.  The  style  employed  is  rather  exhortatory,  and  doubtless 
by  this  means  the  attention  of  the  casual  reader  is  better  seized  upon.  The  book  lacks  finish 
and  completeness,  but  perhaps  it  is  not  meant  to  exhibit  either.  The  reviewer  sincerely 
hopes  that  this  book  may  have  not  only  a  wide  circulation,  but  many  attentive  and  obedient 
readers. — J.  M.  T. 

Diseases  of  the  Nose  and  Throat.  By  D.  Braden  Kyle,  M.D.,  Professor  of  Larj^ngology 
and  Rhinology,  Jefferson  Medical  College,  Philadelphia.  Fourth  edition,  thoroughly 
revised  and  enlarged.  Octavo  volume  of  725  pages,  with  215  illustrations,  28  in  colors. 
Philadelphia  and  London:  W.  B.  Saunders  Company,  1907.  Cloth,  $4.00,  net;  Half- 
morocco,  $5.50,  net. 

The  appearance  of  the  fourth  edition  of  this  work  within  a  comparatively  few  years 
attests  to  its  popularity  among  the  members  of  the  profession.  Much  of  this  well-earned 
recognition  is  undoubtedly  due  to  the  author's  ability  to  treat  the  various  subjects  of  the 
text  in  a  manner  whicli  is  comprehensive  and  illuminating  to  the  reader,  and  which  is  in 
keeping  with  his  position  as  a  teacher  and  a  writer. 

A  thorough  revision  has  been  made,  and  the  new  matter  added  includes  the  following 
subjects:  "Taking  Cold;"  "Lithemic  Rhinitis;"  "Chemic  Ulcers;"  "Fibromyoraa  of  the  Naso- 
pharynx;" "Telangiectoma;"  "Syphilis  of  the  Septum;"  "Empyema  of  the  Antrum  in  the 
Young;"  "Bone  Cysts  of  the  Accessory  Sinuses;"  "Rhino-pharyngitis  Mutilans;"  "Gangrene 
of  the  Tonsils;"  "Glandular  Pharyngitis  Lateralis;"  "Vincent's  Angina;"  "Angina  Ulcerosa 
Benigna;"  "Cyanotic  Pharyngitis;"  "Angioneurotic  Edema;"  "Pharyngeal  Aneurysm;" 
"Cough;"  "Purpura  Haemorrhagica;"  "Congenital  Stridor;"  "Scleroma  of  the  Larynx;"  "Bron- 
choscopy;" "Voice,  Speech,  Defects  of  Speech,  and  Relation  of  Voice  to  Hearing;"  "Func- 
tional Aphonia  and  Surgery  of  the  Larynx."  Other  subjects  have  been  altered  and  necessary 
additions  made. 

In  contrast  to  many  of  the  recent  books,  careful  attention  has  been  given  to  etiology 
and  pathology  of  the  different  diseases,  while  additional  data  are  given  to  the  chemistry  of 
the  saliva  and  nasal  secretions,  and  its  relation  to  diagnosis  and  treatment  of  various  dis- 
eases. The  cuts  throughout  the  book  are  good,  and  many  of  the  drawings  are  particularly 
worthy  of  mention.  As  a  further  help  to  the  reader,  the  contents  of  each  chapter  is  out- 
lined at  its  beginning. 


BOOK  REVIEWS.  95 

Considering  the  prominence  of  the  author  and  the  increased  value  of  the  new  edition, 
this  work  should  continue  to  be  an  important  asset  to  a  doctor's  library. — R.  B.  S. 

On  Means  fob  the  Pbolongation  of  Life.     Third  edition.     By  Sir  Hermann  Weber,  M.D., 

F.R.C.P.     London:     John  Bale,  Sons  and  Danielsson,  Ltd.,  1908. 

In  this  third  edition  of  Sir  Hermann  Weber's  well-known  monograph,  we  have  the  sub- 
ject brought  well  up  to  date,  and  with  a  degree  of  wisdom  and  symmetry  exhibited  by  none 
of  the  other  authors  who  have  attempted  to  deal  with  it.  He  has  had  the  benefit  of  recent 
lucubrations,  such  as  those  of  Metchnikofl',  Sir  Crichton-Browne  and  Sir  Lauder  Brunton. 
None  the  less,  what  was  said  by  the  author  long  ago  needs  little  change,  and  whosoever  will 
read  this  extremely  agreeable  little  book,  will  certainly  learn  much  to  his  advantage. 

—J.  M.  T. 

The  Art  of  Natue^u.  Sleep.  With  Definite  Directions  for  the  Wholesome  Cure  of  Sleep- 
lessness. Illustrated  cases  from  clinics  in  Northampton  and  elsewhere.  By  Lyman  P. 
Powell,  Rector  of  St.  John's  Church,  Northampton,  Mass. 

It  is  evidence  of  a  wholesome  movement  to  see  elerygmen  thinking  and  speaking  upon 
subjects  overlying  their  sphere  of  jurisdiction,  and  yet  technically  lying  within  that  of 
medicine.  Sometimes  they  exhibit  marvelously  little  physiologic  knowledge,  but  their  prac- 
tical knowledge,  when  judiciously  sifted,  may  serve  good  ends.  It  is  only  too  true  that  the 
average  medical  men,  including  professors  of  physiology,  know  amazingly  little  of  physiology 
and  their  observations  will  not  stand  washing,  so  that  many  subjects,  such  as  sleep,  are  fair 
game  for  shrewd  inferences  based  on  empiricism.  However,  tliere  is  no  accurate  science  yet 
of  right  conduct,  and  this  must  needs  grow  by  gropings  and  many  utterances,  some  of 
which  are  wise  and  some  only  partly  so.  The  real  explanation  of  the  phenomena  of  sleep  is 
woefully  misunderstood,  and  only  studied  with  accuracy  by  Sajous  in  Vol.  II  "Internal 
Secretions."— J.  M.  T. 

A  Manual  of  the  Diseases  of  the  Nose  and  Throat.  By  Cornelius  Godfrey  Coakley,  A.M., 
M.D.,  Professor  of  Laryngology  in  the  University  and  Bellevue  Hospital  Medical  College, 
New  York  City;  Laryngologist  to  Columbus  Hospital,  the  University  and  Bellevue  Hos- 
pital Medical  College  Clinic;  Consulting  Laryngologist  to  the  New  York  Board  of 
Health;  Member  of  the  New  York  Academy  of  Medicine,  Society  of  the  Alumni  of  the 
Bellevue  Hospital,  Medical  Society  of  New  York,  Medical  Society  of  the  State  of 
New  York,  American  Laryngological,  Rhinological  and  etiological  Society,  etc.,  etc. 
Fourth  edition,  revised  and  enlarged.  Illustrated  with  126  engravings  and  7  colored 
plates.     New  York  and  Philadelphia:     Lea  &  Febiger,  1908. 

The  demand  for  this  handy  little  work  among  students  and  practitioners,  for  whom  it 
is  intended,  is  signified  by  the  necessity  for  a  new  edition.  Few  noticeable  changes  have  been 
made,  although  the  text  has  been  carefully  reviewed  and  necessary  changes  instituted  to  con- 
form to  the  advances  in  diagnosis  and  treatment.  The  former  articles  on  "Spurs  and  Deflec- 
tion of  the  Septum"  have  been  considered  under  a  single  head,  "Deformity  of  the  Septum," 
with  the  hope  that  it  will  greatly  simplify  the  subject.  A  chapter  on  "Therapeutics"  has 
been  added,  which  will  increase  the  value  of  the  work.  The  author's  careful  investigations 
of  the  accessory  sinuses  of  the  nose  and  his  large  experience  in  the  treatment  of  tlie  diseases 
of  these  cavities  is  manifested  in  his  skillful  discussion  of  the  subject. 

With  the  revision  of  the  text  and  the  addition  of  modern  methods  in  treatment,  this 
small  volume,  which  has  reached  its  fourth  edition,  should  continue  to  be  a  popular  one 
among  students  of  this  specialty. — R.  B.  S. 

Climate:  Considered  Especially  in  Relation  to  Man.  By  Robert  DeCourcy  Ward,  Assistant 
Professor  of  Climatology,  Harvard  L'uiversity.  Illustrated.  New  York:  G.  P.  Putnam's 
Sons.     London:    John  Murray,  1908. 

Climate  has  hitherto  been  regarded  by  medical  men  as  of  interest  chiefiy  in  regard  to 
those  who  have  some  pulmonary  or  cardiac  derangement,  as  modifying  for  better  or  worse  the 
conditions  of  life,  and  especially  in  regard  to  life  out-of-doors.     The  subject  is  now  recognized 


96  BOOK  REVIEWS. 

to  be  of  much  wider  import,  since  we  have  learned  the  gravity  of  the  influence  of  light  zones 
and  heat  zones  upon  races.  The  study  becomes  one  which  is  no  longer  an  extra  or  auxiliary 
medical  subject,  but  of  immediate  importance.  We  have  seen  many  books  dealing  with  the 
subject,  but  none  which  presents  the  various  fundamental  problems  so  clearly  and  practically 
as  this  by  Professor  Ward.  Not  only  is  the  selection  of  a  suitable  climate  essential  to  those 
of  us  who  are  blondes,  but  we  must  estimate  the  variants  in  the  component  factors  of  our 
race — e.g,,  brunettes,  reds,  blacks,  yellows,  and  the  various  intermediates.  To  be  sure, 
medicine  is  a  complex  subject,  and  it  has  been  made  more  so  by  its  exponents.  Members  of 
the  profession  deplore  the  presentation  of  new  problems.  There  is  no  excuse,  however,  in 
omitting  to  learn  the  fundamental  acceptable  principles  with  which  all  should  be  familiar. 
If  only  medical  practitioners  who  desire  to  be  really  wise  would  acquire  the  habit  of  search- 
ing out  the  essential  principles  and  ignore  the  endless  pseudo-scientific  inferences  with  which 
they  are  too  often  fed,  they  would  quickly  regain  much  lost  potentiality.  Climate  is  every- 
where, and  few  are  bad  at  first,  while  each  can  be  bettered  by  local  regulations. — J.  M.  T. 

Emergency  Surgery.     For  the  General  Practitioner.     By  John  W.  Sluss,  A.M.,  M.D.,  Pro- 
fessor of  Anatomy,  Indiana  University  School  of  Medicine;    Member  of  National  Asso- 
ciation Military  Surgeons,  etc.,  etc.     584  Illustrations,  Some  of  them  Printed  in  Colors. 
Chapters,  26;  Pages  692.     Philadelphia:     P.  Blakiston's  Sons  &  Co.,  1908. 
It  is  fitting  that  a  general   practitioner  should  review  this  book,  which   is  specifically 
devised  for  his  use.     Whether  there  may  be  other  such  books  is  not  within  our  knowledge, 
but  one  of  this  character  will  certainly  prove  of  great  use.     It  is  convenient  in  shape,  size 
and  general  make-up.     Tlie  illustrations  are  good,  abundant  and  graphic.     In  fact,  the  book 
deserves  a  wide  circulation. — J.  M.  T. 

Functional  Nervous  Disorders  in  CiiiLDnooD.     By  Leonard  Guthrie,  M.A.,  M.D.,  F.R.C.P. 

Oxford  Medical  Publications.     London:    Henry  Frowde.     Hodder  and  Stougliton,  1907. 

A  word  should  be  said  concerning  the  publications  of  the  Oxford  University  Press. 
Tliese  are  uniformly  neat,  well-balanced  books,  possessing  the  great  merit  of  being  light  in 
weight  and  comfortable  to  the  hand.  We  have  three  of  these  for  review  in  this  issue.  The 
one  on  "Functional  Disorders  in  Childhood"  has  been  in  our  hands  sometime,  but  the  delay 
in  reviewing  has  been  caused  by  the  fascination  of  the  subject  and  the  charm  of  the  author's 
presentation,  which  has  led  us  to  read  the  book  deliberately.  The  reviewer  may  make  his 
feeling  toward  this  book  clear  by  stating  his  sincere  wish  that  he  could  have  produced  the 
book  himself.  It  deals  with  an  exceedingly  important  subject,  which  is  presented  only 
fragmentarily  in  the  text-books  and  in  the  biologic  literature.  Dr.  Guthrie  has  given  us  an 
altogether  charming,  learned,  practical  and  withal  highly  literary  product.  It  is  a  tempta- 
tion to  quote  from  him  extensively,  but  space  forbids.  The  introduction  alone  gives  much 
important  information.  This  is  followed  by  a  chapter  on  the  "Efi'ects  of  Emotion  on  Health." 
The  third  chapter  deals  with  the  "Nervous  System  in  Childhood;"  fourth,  "Types  of  Neurotic 
Subjects,"  and  those  which  follow  deal  with  hypersensitiveness  of  special  sense  organs,  and 
a  number  of  psychologic  problems,  which  are  treated  at  length  only  in  such  books  as  G. 
Stanley  Hall's  splendid  treatise,  "Adolescence."  Then  follow  remarks  on  the  "Disorders  of 
the  Sympathetic  Nervous  System,"  "Spasmodic  Affections,"  etc.,  etc.  All  the  subjects  are 
admirably  presented,  and  in  such  a  manner  that  it  cannot  fail  to  interest  all  those  who  have 
closely  at  heart  the  welfare  of  the  embryonic  citizen. — J.  M.  T. 

Glandular  Enlargement  and  Other  Diseases  of  the  Lymphatic  System.     By  Arthur 
Edmunds,  M.B.,  M.S.    (Lond.),  F.R.C.S.    (Eng.),  Surgeon  to  the  Great  Northern  Central 
Hospital,  etc.     London:    Henry  Frowde,  Oxford  University  Press;    Hodder  and  Stoughton, 
1908. 
This  is  a  valuable  book,  dealing  with  a  specific  subject,  yet  exhibiting  points  of  contact 

with  the  whole  realm  of  practical  medicine.     The  subject  has  been  considered  from  both  the 

practical  and  the  surgical  standpoints,  and  the  anatomy  is  peculiarly  well  presented.     The 

few  illustrations  are  excellent. 


Monthly   Cyclopaedia 

AND 

Medical  Bulletin 


(PUBLISHBD   THB  LaST  OF   EACH   MONTH) 


Medical  Bulletin  Section 


Vol.n.  PHILADELPHIA,  FEBRUARY,  1909.  No.  2. 


Clinical  Lectures 


DIABETES  MELLITUS  AND  CATARRHAL  JAUNDICE. 

By  JOHN  V.  SHOEIMAKER,  M.D.,  LL.D., 

Professoi-  of  Materia  Medica,  Therapeutics,  Clinical  Medicine  and  Diseases  of  the  Skin 
in   the  Medieo-Chirurgical   College   and  Hospital   of   Philadelphia. 

DIABETES  MELLITUS. 

Gentlemen  :  The  case  before  you  this  morning  is  interesting  because  he 
is  suffering  from  a  disease  which  affects  the  male  sex  more  frequently  than  the 
female  and  it  usually  occurs  between  thirty-five  and  sixty  years  of  age. 

He  is  forty-eight  years  old;,  nativity  America,  and  is  employed  as  a  con- 
ductor on  a  freight  train. 

Family  History. — His  father  died  at  the  age  of  thirty-two  from  pneu- 
monia and  his  brother  died  at  the  age  of  fifty-two  of  diabetes.  His  mother 
is  eighty-two  years  old  and  is  apparently  in  good  health.  At  the  present 
time  his  sister  is  living  but  is  suffering  from  diabetes.  She  is  thirty  years  old. 
His  grandparents  all  died  of  old  age. 

Social  History. — He  is  married  and  has  one  daughter  who  is  enjoying 
good  health.     His  uncles  and  aunts  are  all  well  and  none  of  them  have  diabetes. 

Habits. — His  habits  are  good  except  that  he  smokes  excessively.  He  is 
a  total  abstainer  from  all  kinds  of  alcoholic  beverages. 

Present  Hlness. — About  two  years  ago  he  first  noticed  that  he  was  voiding 
large  quantities  of  urine  and  was  compelled  to  get  up  from  two  to  three  times 
at  night  in  order  that  he  might  urinate  and  thus  relieve  himself  of  the  uncom- 
fortable feeling.  He  states  that  he  also  experiences  a  constant  burning  thirst 
and  this  necessitates  the  ingestion  of  large  quantities  of  water  at  frequent 
intervals  night  and  day.  Soon  itching  of  the  skin  made  its  appearance  and 
his  appetite  became  abnormally  large,  sometimes  insatiable.  His  digestion 
at  first  was  good  but  dyspeptic  symptoms  soon  made  their  appearance,  such 

5  (97) 


98  DIABETES  MELLITUS. 

as  acid  eructations,  flatulence  and  epigastric  pain.  He  complains  of  constipa- 
tion and  sometimes  brief  intervening  attacks  of  diarrhoea  occur.  Later, 
extreme  languor  and  weakness  were  characteristic.  He  observed  that  he  was 
gradually  losing  in  weight  and  was  growing  weaker.  In  less  than  a  year  he 
had  lost  fifty-two  pounds,  having  weighed  one  hundred  and  ninety-five  pounds 
at  first,  and  now  he  weighs  one  hundred  and  forty-three. 

His  skin  is  harsh  and  dry  due  to  the  absence  of  perspiration.  He  states 
that  he  was  frequently  troubled  with  boils  which  is  due  to  the  malnutrition  of 
his  diseased  condition.  He  also  complains  that  he  has  very  little  sexual  desire 
since  he  began  to  lose  in  weight  and  at  times  he  notices  a  hazy  condition  before 
his  eyes. 

Urinalysis. — Color,  pale;  sediment,  negative;  specific  gravity,  1038; 
reaction,  acid;  albumin,  positive;  glucose,  positive,  five  per  cent.;  urea, 
increased  in  amount;  acetone,  positive;  diacetic  acid,  positive;  casts,  many, 
hyaline;   leucocytes,  a  few;   erythrocytes,  a  few. 

Diagnosis. — The  diagnosis  of  this  disease  is  easy.  We  diagnose  this  case 
as  diabetes  mellitus  from  the  presence  of  sugar  in  the  urine  as  indicated  by 
Trommer's  test  and  Fehling's  test,  from  the  polyuria,  the  emaciation  and 
debility,  the  inordinate  thirst  and  appetite.  The  diagnosis  is  also  confinned  by 
the  presence  of  acetone  and  diacetic  acid  in  the  urine. 

Etiology. — This  disease  is  attributed  to  a  variety  of  causes.  It  is 
frequently  a  hereditary  disease,  occurring  in  families  where  the  same  disease 
or  obesity  or  gout  have  occurred. 

It  is  less  common  in  the  United  States  than  in  Europe  and  is  more  widely 
prevalent  in  agricultural  countries  than  in  the  cities.  It  is  rare  in  the  negro 
race,  and  the  Hebrew  race  is  especially  susceptible.  It  is  a  disease  especially 
frequent  in  the  better  classes  of  society,  though  the  poor  are  not  exempt. 

This  disease  attacks  the  male  sex  more  frequently  than  the  female  sex.  The 
majority  of  cases  occur  between  the  age  of  thirty-five  to  sixty  years.  Infantile 
diabetes  is  rare,  though  it  has  occurred  in  infants  at  the  breast.  The  disease 
is  more  serious  in  the  young  than  in  the  adult,  recovery  being  rare.  Nervous 
shock  or  strain,  prolonged  mental  anxiety,  excessive  grief,  traumatic  injuries 
with  concussion,  act  as  a  predisposing  cause. 

Overeating  and  sedentary  life  are  causes  of  some  importance,  especially 
the  milder  form.  Diabetes  is  also  attributed  to  certain  chronic  diseases  such 
as  syphilis,  gout,  malaria,  and  it  sometimes  follows  acute  infectious  diseases. 

Diabetes  is  also  attributed  to: 

1.  Pancreatic  disease.  It  has  been  assumed  that  the  total  loss  of  function 
always,  and  partial  loss  sometimes,  leads  to  diabetes. 

2.  Organic  and  functional  diseases  of  the  liver.  This  is  due  to  the  inter- 
ference with  the  glycogenic  function  of  the  liver. 

3.  May  be  caused  by  lesions  of  the  brain  and  spinal  cord.  Puncture  of 
the  floor  of  the  fourth  ventricle,  as  originally  done  by  Claude  Bernard,  will 
produce  diabetes.  Section  of  the  pneumogastric  is  followed  by  vaso-motor 
paralysis  of  the  hepatic  vessels,  disappearance  of  glycogen  from  the  liver  and 
the  appearance  of  sugar  in  the  urine.     Timiors  pressing  against  the  floor  of 


DIABETES  MELLITUS.  99 

the  fourth  ventricle,  lesions  of  this  part  of  the  brain,  abscesses  and  injuries  to 
the  brain  and  spinal  cord,  are  attended  by  diabetes. 

The  sympathetic  nerve  is  an  important  channel  for  nervous  impulses, 
regulating,  as  it  were,  the  opening  and  closing  of  the  blood-vessels.  I  think 
that  this  patient  has  acquired  a  hereditary  diathesis,  as  vrould  lead  one  to  think, 
from  the  condition  of  his  brother  and  sister,  and  that  the  nervous  strain  put 
upon  him  through  the  nature  of  his  work  has  been  sufficient  to  aggravate 
the  diathesis  and  bring  on  the  present  glycosuria. 

Pathology. — Sometimes  there  are  no  altered  conditions  discoverable  either 
with  the  naked  eye  or  with  the  microscope.  But,  however,  the  majority  of  the 
cases  present  various  conditions. 

We  find  the  liver  often  enlarged  and  fatty.  Microscopically  the  liver  cells 
are  found  to  be  enlarged,  nucleated  and  globular  in  outline.  These  changes  are 
more  striking  in  the  peripheral  portion  of  the  lobule.  Since  the  liver  presents 
the  appearance  of  a  hyperaemic  organ,  we  find  the  capillaries  dilated  and  the 
acini  are  enlarged  and  distinct.  Incidental  morbid  states  are  hypertrophic 
and  atrophic  cirrhosis. 

The  pancreas  shows  morbid  changes  in  more  than  one-half  of  the  cases 
of  diabetes.  The  most  frequent  lesion  is  granular  atrophy.  Associated  with 
diabetes,  calculus  with  atrophy  of  this  organ  have  been  found.  Other 
coincident  conditions  of  the  pancreas  associated  with  diabetes  are  cancer, 
occlusion  of  the  pancreatic  duct,  and  atrophy  from  pressure  and  cystic  degen- 
eration. 

The  lesions  of  gout  (arteriosclerosis  and  cirrhotic  kidneys)  may  be  of  the 
nature  of  mere  concomitants,  or  may  be  the  direct  results  of  diabetes. 

The  changes  met  with  in  the  kidneys  are  a  well-marked  interstitial 
nephritis  with  fatty  degeneration.  Albuminuria  frequently  develops.  The 
tubal  epithelium  and  the  vessels  of  the  Malpighian  bodies  may  show  a  hyaline 
change.  Other  changes  commonly  met  with  in  the  kidneys  are  hyperaemia 
and  overgrowth  of  epithelium — in  a  word,  those  of  catarrhal  nephritis. 

Pneumonia  and  tuberculosis  are  among  the  frequent  developments  of  late 
stages  of  the  disease  and  which  sometimes  result  in  gangrene. 

Skin  eruptions  such  as  eczema,  furuncles  and  carbuncles  are  frequent  in 
certain  forms  of  diabetes.     Sometimes  gangrene  of  the  extremities  is  common. 

Marked  catarrhal  conditions  and  dilatation  are  the  common  changes  in  the 
stomach. 

The  heart  is  sometimes  hypertrophied. 

The  blood  is  less  alkaline  than  normal  and  contains  an  excess  of  solid 
matter,  particularly  when  great  poljTiria  has  led  to  inspissation.  The  cor- 
puscles show  no  alterations. 

Treatment. — This  patient  should  at  once  discontinue  his  occupation.  He 
must  rest  and  be  free  from  all  mental  worry  or  excitement. 

Medicinally  we  will  first  endeavor  to  correct  his  digestion  by  giving  him  :- 

B;  Argpnti  nitratis, 

Extract!  hyocyami,  of  each gr.   Y^. 

Misce.     Fiat  pilula  No.  j. 

Bigna:     One  such  pill  a  half  hour  before  each  meal. 


100  CATARRHAL  JAUNDICE. 

Also  to  regulate  his  bowels  and  overcome  his  constipation  we  will  give  him 
the  fluid  extract  of  rhamnus  purshiana  from  a  half  to  a  teaspoonful  at  bed- 
time as  required. 

The  treatment  in  all  of  these  patients  must  be  chiefly  dietetic.  His  diet 
for  the  next  week  or  ten  days,  or  at  least  until  his  digestion  is  better,  will  be 
absolutely  nothing  but  milk.  Milk  by  many  physicians  is  forbidden  owing  to 
the  fact  that  it  contains  milk  sugar,  but  it  must  be  remembered  that  it  is  easily 
assimilated.  The  tissues  of  a  diabetic  need  sugar,  but  it  cannot  be  assimilated 
when  in  the  form  of  starch  as  found  in  many  vegetables.  Among  the  vege- 
tables to  be  eaten  are  spinach,  celery,  horseradish,  cress,  dandelion,  pickles, 
cranberries  and  onions. 

In  many  patients  a  more  limited  diet  of  vegetables  must  be  followed.  The 
more  farinaceous  foods  are  always  interdicted.  An  exclusive  proteid  diet  is 
not  always  essential,  yet  in  most  cases  of  diabetes,  eggs,  meats,  fish  and  cheese 
are  very  well  borne,  as  are  the  fats  and  oils.  Acid  fruits  and  oily  nuts  add 
variety  and  are  valuable  in  many  patients.  While  diet  is  very  essential,  yet 
it  alone  is  not  suflicient  to  give  the  patient  immediate  relief.  Drugs  are 
necessary  and  if  properly  employed  will  do  wonders  to  bring  about  happy 
results. 

When  this  patient's  digestion  is  better  and  he  is  in  a  position  to  digest 
solid  foods  he  can  then  digest  and  aj^proximate  a  combmation  which  has 
given  me  most  excellent  results  in  a  number  of  diabetic  patients.  It 
contains : — 

IJ   Codeinse   sulphatis    gr.   v. 

Arseni   trioxidi    gr.  ss. 

Extracti   nucis  vomicae    gr.  iv. 

Extract!   rhamni   purshianse    gr.  xv. 

Extracti    gontiani 3j. 

Misce.     Fiant  capsulse  No.  xx. 

Signa:     One  capsule  after  each  meal  and  at  bed-time. 

He  is  rather  far  advanced  in  this  disease  and  needs  constant  medical 
attention,  and  it  may  so  happen  that  we  will  not  be  able  to  place  him  on  the 
formula  just  given  for  some  time.  We  will,  of  course,  treat  him  on  the  merits 
of  his  symptoms. 

CATARRHAL  JAUNDICE. 

The  next  patient  for  consideration  is  a  case  of  catarrhal  jaundice,  a  disease 
which  is  very  common  in  yovmg  adults. 

The  patient's  name  is  J.  M.,  aged  25  years,  nativity  U.  S.  A. 

Family  History. — The  history  of  his  grandparents  is  unknown.  His 
parents  arc  alive  and  well;  his  father  being  fifty-eight  years  old,  while  his 
mother  is  forty-eight  years  old  and  both  in  good  health.  He  has  two  brothers 
and  three  sisters  all  living  and  enjoying  good  health. 

Personal  History. — He  is  employed  as  a  boss  in  a  coal  breaker,  where  he 
is  exposed  to  cold  and  dampness.  Four  years  ago  he  had  syphilis,  but  out- 
side of  that  he  never  complained  of  any  diseases  other  than  those  of  childhood. 


CATARRHAL   JAUNDICE.  101 

Habits. — He  had  been  a  moderate  drinker  of  alcoholic  liquors  but  has 
given  it  up  entirely  and  he  also  abstains  from  tobacco  in  any  form.  He  par- 
takes of  tea  and  coffee  moderately  and  is  very  fond  of  sweets,  partaking  of 
about  three  pounds  a  week.  For  the  last  fifteen  years  he  has  been  dining  late 
at  night. 

Present  Illness. — In  this  patient  the  disease  commenced  with  constipa- 
tion and  irregular  action  of  the  bowels.  He  complains  of  pain  in  the  legs  at 
night  and  morning.  He  is  also  very  nervous,  suffering  with  headache  and 
vertigo.  After  eating  he  experiences  a  sense  of  fullness  and  is  troubled  with 
flatulence,  fetid  breath,  nausea  and  vomiting. 

Physical  Signs. — His  skin  presents  a  yellowish  color  over  the  entire  body, 
which  is  most  marked  on  his  forehead  and  neck.  Percussion  reveals  an 
increase  in  the  hepatic  area  which  is  confirmed  also  on  palpation. 

Urinalysis. — Color,  straw;  sediment,  negative;  specific  gravity,  1024; 
reaction,  acid;  albumin,  negative;  glucose,  negative;  indican,  marked 
reaction;    bile,  marked  reaction. 

Microscopic  Examination. — Casts,  absent;  leucocytes,  few;  epithelial 
cells,  few;  urates,  few. 

Diagnosis. — The  diagnosis  is  made  from  the  history  of  habitual  constipa- 
tion with  clay-colored  stools,  the  lemon-yellow  color  of  his  skin  and  eyes,  itching 
of  the  skin,  the  presence  of  bile  and  indican  in  the  urine,  the  coated  tongue, 
fetid  breath,  and  attacks  of  indigestion,  all  of  which  are  typical  symptoms  of 
catarrhal  jaundice. 

Differential  Diagnosis. — This  disease  should  be  differentiated  from  acute 
congestion  of  the  liver,  acute  yellow  atrophy  and  ha?matogenous  jaundice. 

Catarrh  of  Bile  Ducts.  Acute  Congestion  of  Liver. 

1.  Jaundice  well  marked.  1.  Jaundice  slight. 

2.  Slight  enlargement  of  liver.  2.  Liver  considerably  enlarged. 

3.  Tenderness  on  pressure  very  slight.  3.  Tenderness  on  pressure. 

4.  Gastro-dnodenitis    precedes    the    hepatic  4.  Gastro-duodenitis    succeeds    the   hepatic 

symptoms.  symptoms. 

5.  Patient  is  stupid  and  drowsy.  5.  Patient  is  dizzy  at  times. 

Simple  Obstructive  Jaundice. 

1.  Temperature  normal. 

2.  Slight  enlargement  in  size  of  liver. 

3.  Presence  of  bile  in  the  urine. 

4.  Stupor,  coma  and  convulsions. 

5.  Headache  severe. 

Hepatogenous  Jaundice.  Ha'matogenous  Jaundice. 

1.  Occurs    with    gastro-duodenitis,    catarrh       1.  Occurs  with  fevers,  blood  diseases,  etc. 

of  bile  ducts,  etc. 

2.  Absence  of  albumin  in  urine.  2.  Presence  of  albumin  in  urine. 

3.  Presence  of  bile  coloring  matter  in  the       3.  Presence  of  bile  acids  in  the  urine. 

urine. 

4.  Jaundice  Avell  marked.  4.  Jaundice  slight. 

5.  Itching  of  skin.  5.  Small  haemorrhages  in  the  skin. 

6.  Fseces  clay-colored.  6.  Faeces  dark-colored. 


1. 

2. 

Acute  Yellow  Atrophy. 
Temperature  elevated. 
Liver  diminished  in  size. 

3. 

Presence   of   leucin   and   tyrosin   in   the 
urine. 

4. 

Mind  dull. 

5. 

Dull  frontal  headache. 

102  CATARRHAL  JAUNDICE. 

Etiology. — The  most  frequent  cause  of  such  an  inflammation  is  due  to  an 
extension  of  inflammation  in  gastro-duodenal  catarrh  into  the  common  bile 
duct.  In  this  case,  the  cause  is  attributed  to  the  use  of  improper  foods  such 
as  sweets,  eating  late  at  nights,  exposure  to  cold  and  dampness  as  a  result  of 
his  occupation.  This  disease  may  also  be  found  in  association  with  the  infec- 
tious diseases  such  as  pneumonia,  typhoid  fever  and  relapsing  fever.  Other 
causes  are  prolonged  physical  overwork  and  mental  emotions. 

Pathology. — The  liver  is  swollen  and  possesses  a  lighter  color  than  is 
normal.  The  biliary  capillaries  are  distended  with  bile.  The  mucosa  lining 
of  the  common  duct  is  swollen  and  inflamed,  and  the  catarrhal  process  may 
extend  into  the  cystic  and  in  some  cases  into  the  hepatic  duct.  Suppuration 
does  not  take  place  in  this  form  of  cholangitis.  The  gall-bladder  is  distended 
and  the  bile  is  absorbed  by  the  lymphatics  and  ultimately  reaches  the  circula- 
tion and  discolors  the  tissue. 

Treatment. — In  treating  this  case  we  will  first  relieve  his  constipation  by 
evacuating  his  bowels  daily  with  the  use  of  drugs  that  will  stimulate  both  the 
secretions  of  the  liver  and  bowels.  For  this  purpose  we  will  request  him  to 
take  one  or  two  pills  as  required,  every  evening  at  bedtime,  of  the  following 
combination : — 

IJ  Massse  hyclrargyri, 

Pulveris  jalapfe  compositi, 

Extraeti   colocynthidis  compositi,  of  each gr.   sx. 

Olei  menthge  piperitse ni^j. 

Misce.     Fiant  pilulte  No.  xx. 

The  drug  par  excellence  in  catarrhal  jaundice  to  relieve  the  inflamed  and 
swollen  condition  of  the  mucous  membrane  lining  both  the  intestines  and  the 
various  ducts  of  the  liver  is  the  fluid  extract  of  hydrastis  given  in  doses  of 
twenty  to  thirty  minims  a  half  hour  before  each  meal  and  at  bedtime.  This 
drug  will  not  only  act  upon  the  involved  mucous  membrane  but  it  will  at  the 
same  time  stimulate  the  dormant  hepatic  cells  and  liquefy  the  bile.  The  dilute 
nitrohydrochloric  acid,  which  will  also  act  as  an  intestinal  antiseptic,  and  the 
natural  salicylic  acid  obtained  from  gaultheria,  are  likewise  valuable  remedies 
in  this  disease. 

We  will  first  place  this  patient  upon  the  fluid  extract  of  hydrastis  as  pre- 
viously stated.  Also  give  him  the  high-frequency  current  over  the  hepatic 
area  for  its  stimulating  and  tonic  effect  to  the  liver  as  well  as  for  its  general 
effect  upon  the  entire  organism.  This  form  of  electricity  will  act  synergist- 
ically  with  the  hydrastis  to  relieve  the  portal  and  hepatic  congestion  and 
facilitate  the  flow  of  bile. 

The  diet  should  consist  of  foods  that  do  not  require  bile  to  facilitate  its 
digestion  or  absorption,  such  as  animal  broths,  boiled  or  poached  eggs  and 
skimmed  milk.  Starchy  foods,  vegetables  and  lean  meat  may  only  be  taken 
in  small  quantities. 

The  patient  must  be  encouraged  to  take  water  freely  in  order  to  assist 
elimination. 

Prognosis. — The  prognosis  is  always  favorable  and  this  patient  will,  I 
believe,  recover  rapidly  by  following  strictly  the  advice  and  treatment  we  have 
just  gone  over. 


SPIROCHAETE   PALLIDA.  103 


THE  SPIROCHAETE  PALLIDA. 

By  warren  C.  BATEOFF,  M.D., 

Director  of  the  Clinical  Laboratories  Medico-Chirurgical  College  and  Hospital, 

Philadelphia. 

Gentlemen: — We  will  consider  to-day  the  spirochagte  pallida,  partic- 
ularly in  its  relation  to  the  etiology,  pathology  and  diagnosis  of  syphilis.  The 
organism  is  more  correctly  termed  the  treponema  pallidum,  as  it  is,  in  all 
probahility,  a  protozoon  rather  than  a  spirochete,  the  latter  being  more  prop- 
erly classed  with  the  vegetable  kingdom.  The  original  name  of  spirochsete 
pallida  will  doubtless  have  the  more  common  usage,  hence  I  shall  refer  to  it 
by  that  name. 

As  most  of  you  are  already  aware,  it  is  a  very  thin,  pale  corkscrew-like 
organism.,  varying  in  length  from  one  to  three  times  the  diameter  of  an 
erythrocyte.  Longer  forms,  however,  occur;  that  these  exceptionally  long 
organisms  are  not  two  jointed  lengthwise,  I  think,  has  not  been  proven. 
Their  width  is  practically  never  over  three-fourths  of  a  micron.  From  six  to 
twenty  spiral  turns  are  usually  observed,  depending  upon  the  length.  These 
windings  are  absolutely  regular,  and  the  individual  turns  quite  acute.  The 
ends  are  distinctly  pointed  and  terminate  at  the  periphery  of  the  spiral,  while 
the  whole  organism  is  usually  somewhat  curved.  Flagella  have  been  demon- 
strated in  both  the  fresh  and  stained  specimen.  There  is  some  evidence  to 
warrant  the  statement  that  multiplication  is  probably  like  the  trypanosomes 
by  longitudinal  fission. 

In  the  stained  specimen  the  organism  usually  lies  free,  although  groups 
are  not  uncommonly  seen,  and  while  it  may  touch  or  lie  around  the  erythro- 
cytes, it  has  never  been  demonstrated  in  them.  It  retains  the  spiral  form 
whether  at  rest  or  in  motion,  and  when  examined  with  the  ultra-microscope, 
bodies  suggesting  nuclei  have  been  seen.  Never  having  been  successfully  cul- 
tivated outside  the  body,  its  life  history  is  unknown,  although  the  oval  and 
spindle  forms  seen  are  regarded  by  Schaudinn  as  involution  types. 

To  determine  the  presence  of  the  spirochete  pallida  in  sections  of 
tissue  is  a  task  of  considerable  complexity,  and  will  not  be  described,  as  it 
particularly  belongs  to  the  field  of  the  pathologist.  The  detection  of  the 
organism  in  the  fresh  or  stained  film  is  of  greater  interest  to  the  practitioner. 
Its  most  decided  characteristic  is  the  extreme  difficulty  with  which  it  can  be 
made  to  take  the  stain;  none  of  the  anilin  dyes  will  color  it  deeply,  and  once 
stained,  it  will  readily  fade.  While  most  readily  found  in  the  moist,  suc- 
culent lesions  (chancre,  mucus  patch  and  condylomata)  of  the  primary  and 
secondaiy  stages,  recently  it  has  been  demonstrated  in  practically  all 
syphilides.  Lymphangitis,  adenitis,  the  blood,  gumraata  and  other  tertiary 
infiltrations  have  yielded  positive  findings.  They  can  also  be  recovered  from 
practically  the  entire  body  of  congenitally  syphilitic  infants.  In  the  chancre 
it  lies  in  the  deeper  epithelial  layer,  the  lymph  spaces  and  the  walls  of  the 


104  SPIROCHAETE   PALLIDA, 

blood-vessels.  Treatment,  however,  both  constitutional  and  local,  cause  it  to 
rapidly  disappear  from  accessible  locations. 

To  examine  a  chancre  for  their  presence  it  is  necessary  to  first  cleanse 
the  lesion  with  sterile  gauze  moistened  with  normal  saline  solution  to  remove 
the  spirochffite  refringens,  epithelial  debris  and  tissue  detritus.  The  lesion 
is  then  lightly  curretted  with  a  sterile  scalpel  until  blood-stained  serum 
exudes  in  much  the  same  manner  as  in  scarification  for  vaccination.  Free 
bleeding  must  be  avoided,  as  a  large  number  of  erythrocytes  would  render 
difficult  the  detection  of  the  spirochfcte  in  the  stained  film.  A  droplet  of 
the  serum  is  then  lightly  smeared  upon  a  perfectly  clean  cover  glass  prepared 
by  cleansing  with  a  mixture  of  alcohol  and  ether  and  highly  polished. 

Fixing  by  holding  the  specimen  over  the  mouth  of  a  bottle  containing 
osmic  acid  is  said  to  give  exceptional  definition,  particularly  of  the  tapering 
extremities.  In  most  instances  fixation  is  accomplished  by  the  methyl 
alcohol  used  as  a  solvent  for  the  various  stains.  The  number  of  stains 
employed  are  almost  as  numerous  as  the  investigators  who  have  studied  the 
organism;   of  these  the  Giemsa  stain  is  probably  the  best. 

The  ordinary  Leischman  or  Wright's  blood-stain  will  answer  in  most 
instances  with  a  slight  modification  of  the  usual  technique.  After  adding 
one  or  two  drops  of  water  to  the  specimen,  previously  flooded  with  the  stain, 
either  permit  the  staining  process  to  continue  twenty-four  hours,  covering 
with  wide-mouthed  bottle  or  jar  to  prevent  evaporation.  When  time  is  an 
important  factor,  apply  heat  during  the  staining  for  forty-five  seconds.  Care 
should  be  exercised  that  the  alcohol  of  the  stain  does  not  become  ignited  or 
the  specimen  may  be  burned,  and  the  spirochsete  thus  become  unrecognizable. 

By  the  latter  method  the  organism  appears  a  deep  reddish  purple,  or 
even  black,  if  the  staining  be  prolonged ;  the  latter,  however,  is  an  aid  to  the 
beginner.  It  is  also  well  to  wash  the  specimen  thoroughly  in  a  weak  alkaline 
solution  (^0000  NaOH)  instead  of  water,  as  the  definition  is  thus  slightly 
enhanced.  The  one-twelfth  oil-immersion  lens,  with  the  brightest  illumina- 
tion possible,  is  requisite,  and  a  carefully  adjusted  focus,  owing  to  the  extreme 
thinness  of  the  organism. 

In  securing  a  specimen  from  the  eruption,  the  skin  should  first  be  pre- 
pared by  careful  cleansing  with  soap  and  water,  and  afterward  wiped  with 
sterile  normal  saline  solution.  One  method  advocated  is  to  exert  firm  lateral 
pressure  upon  the  macule  or  papule,  preferably  by  using  a  long  bladed  forcep, 
or  with  the  fingers.  This  will  finally  cause  an  exudate  of  thin  serum  con- 
taining a  few  erythrocytes,  from  which  smears  are  prepared.  The  syphilide 
may  also  be  scarified  with  a  knife  in  the  manner  above  described.  More 
satisfactory,  however,  is  the  production  of  a  small  blister,  if  there  is 
an  absence  of  the  vesicular  syphilide.  Leverditi  and  Petresco  have  demon- 
strated that  the  spirochete  passed  into  blisters  made  artificially  on  secondary 
syphilitic  lesions;  also  into  blisters  produced  on  sound  skin  in  the  vicinity 
of  secondary  cutaneous  lesions. 

The  method,  a  pledget  of  cotton  saturated  witli  the  strongest  ammonia 
water,  is  applied  over  the  cleansed  skin  and  covered  with  oiled  silk  and  a 


SPIROCHAETE   PALLIDA.  106 

strip  of  adhesive  plaster.  At  the  end  of  a  half  hour  a  blister  will  have 
formed;  then  with  a  short  piece  of  i/^-ineh  glass  tube,  drawn  to  a  capillary 
point,  previously  sterilized,  the  vesicle  is  pricked  and  the  contained  serum, 
drawn  into  the  tube  by  capillarity.  Smears  are  then  made  upon  clean  cover 
glasses. 

To  examine  the  blood  for  the  presence  of  the  organisms,  the  method  of 
Noeggerath  and  Staehelin  is  preferred;  one  cubic  centimeter  of  blood  is 
mixed  with  10  cubic  centimeters  of  a  3-per-cent.  solution  of  acetic  acid.  The 
mixture  is  then  centrifugalized,  and  smears  made  from  the  sediment. 

The  spiroehsete  pallida  is  probably  one  of  a  group  of  similar  organisms, 
hence  care  must  be  exercised  to  exclude  the  others,  particularly  the  spiro- 
cha?te  refringens,  which  is  found  in  localities  from  whence  the  spirochete 
pallida  is  sought.  Such  localities  are  the  chancre,  venereal  warts,  smegma, 
the  tonsils  and  ulcers  generally.  Its  chief  distinguishing  features  are :  larger 
size,  thicker,  quite  readily  and  deeply  stained,  and  decidedly  characteristic 
are  the  wavy  undulating  spirals  rather  than  the  corkscrew  form  of  the 
pallida.  Moreover,  the  ends  are  usually  blunt,  and  it  is  found  in  far  greater 
numbers  than  the  treponema  pallidum. 

That  diagnosis  by  finding  the  spirochfete  pallida  in  the  stained  specimen 
is  difiicult  even  for  the  expert,  was  emphasized  strongly  by  Hoffman.  It  is 
a  common  experience  to  find  but  one  or  two  in  the  entire  smear.  Finally 
the  stained  specimen  differs  from  the  living  organism,  in  that  they  are  much 
less  numerous  than  when  the  same  material  is  examined  in  the  fresh  state; 
secondly,  the  staining  caiises  the  organism  to  lose  the  typical  acute  winding 
of  the  spirals;   thirdly,  the  absence  of  motility  is  of  decided  disadvantage. 

The  most  satisfactory  method  of  demonstrating  the  organism  in  the 
living  state  is  by  means  of  the  so-called  dark  ground  illuminator.  Of  these 
the  type  manufactured  by  Eeichert  is  the  most  satisfactory,  although  Sieden- 
topf's  condenser  has  been  successfully  used. 

The  Eeichert  instrument  consists  of  a  metal  plate,  which  is  clamped  on 
the  stage  of  the  microscope.  Attached  to  the  plate  above  is  a  thick  glass 
slide  with  a  tapering  hole  through  its  center.  The  surface  of  the  conical 
aperture  is  silvered,  hence  acts  as  a  mirror  reflector.  By  means  of  a  revolv- 
ing disk,  circular  metal  plates  of  various  sizes  are  interposed  between  the 
rays  from  the  plane  mirror  of  the  microscope  below  and  the  conical  mirror 
reflector  above,  hence  only  the  marginal  rays  strike  the  conical  mirror. 
These  rays  are  in  consequence  reflected  and  converge  at  a  point  1  milli- 
meter above  the  surface  of  the  glass  slide.  Therefore,  any  opaque  body  at 
this  point  will  intercept  these  rays,  and  appear  as  a  bright  reflactile  body  on 
a  dark  background.  The  most  satisfactory  light  for  use  with  the  instru- 
ment is  either  the  sun's  rays,  the  Welsbach  or  an  arc  light. 

The  specimen  is  prepared  for  examination  by  placing  a  drop  of  the 
serum  obtained  from  the  lesion  in  the  usual  manner  upon  a  clean  cover 
glass.  This  is  laid  upon  a  clean,  well-polished  slide,  not  over  1  millimeter 
in  thickness,  and  allowed  to  spread  in  a  thin  layer  between  the  two  glass 
surfaces.     Obviously,  an  excess  of  erythrocytes  would  obscure  the  observa- 


106  SPIROCHAETE   PALLIDA. 

tion.  It  is  also  of  particular  importance  to  use  slides  free  from  scratches 
or  smokiness,  as  these  interfere  with  the  dark  ground  effect.  The  ^2  oil- 
immersion  lens  is  most  commonly  used,  although  a  Vs-inch  objective  has 
been  successfully  used  by  some.i  One  sees  in  the  field  bacteria,  erythrocytes, 
leucocytes  and  the  spirochete  actively  rotating  on  its  long  axis  in  either 
direction  without  much  change  of  position,  or  moving  steadily  about  the 
field,  or  at  times  displaying  a  spasmodic  lateral  bending  motion.  The 
motility  is  rarely  observed  for  a  period  longer  than  one  hour.  Other  varie- 
ties of  spirochgete  that  may  be  present  are  much  more  rapid  in  their  move- 
ments than  the  pallida.  Some  observers  have  claimed  to  have  seen  the 
organisms  within  the  red  and  white  blood  corpuscles;  this,  however,  is  a 
disputed  question.  As  high  as  eighty  have  been  observed  in  a  single  field; 
a  few  days'  treatment,  however,  either  constitutional  or  by  mercurial  local 
applications,  renders  it  almost  impossible  to  find  more  than  two  or  three 
organisms.  It  can  be  stated  as  a  general  law  that  the  more  succulent  the 
lesion  the  greater  the  number  of  spirochgete.  The  clinical  significance  of  the 
spirocha3te  of  Sehaudinn  and  Hoffman,  it  has  been  argued  by  most  syphilo- 
graphers  of  to-day,  is  that  the  specificity  of  the  organism  is  "a  probability 
bordering  on  certainty."  Although  cultivation  of  this  organism  has  thus  far 
been  unsuccessful,  and  hence  the  inoculation  of  it  in  pure  culture,  leaving 
Koch's  third  and  fourth  postulates  unfulfilled,  we  are,  however,  obliged  to 
accept  the  treponeraa  as  the  specific  cause  of  lues.  The  following  are  the 
facts  upon  which  the  above  assumption  is  made: — 

First. — It  has  been  fomid  in  all  stages  and  all  lesions  of  acquired  syphilis, 
and  in  the  most  contagious  lesions  as  the  chancre,  condylomata  and  mucous 
IjaLch  in  the  greatest  number.  It  occurs  in  the  blood,  exanthemata  and  vis- 
cera of  hereditary  syphilis;  also  in  the  placenta  and  umbilical  cord.  It  has 
been  a  frequent,  although  not  an  absolutely  constant  finding,  in  the  experi- 
mental syphilis  of  apes. 

Second. — It  has  never  been  found  except  in  syphilis. 

Third. — The  manner  of  grouping  of  the  spirochete  in  the  various  lesions 
accords  with  the  facts  of  the  pathology  of  the  disease. 

Fourth. — Mercury  is  uniformly  successful  in  promoting  its  rapid  disap- 
pearance from  the  lesions. 

Additionally,  the  organism  does  not  pass  through  a  Ton  filter.  A 
similar  observation  of  Metchnikoff  and  Klingenmiiller,  that  the  filter  is 
impermeable  to  syphilitic  virus,  is  striking. 

The  organism,  therefore,  apparently  bears  the  same  relation  to  syphilis 
that  the  tubercle  bacillus  does  to  tuberculosis,  or  the  gonococcus  to  gonor- 
rhoea. We  are  thus  Justified  in  accepting  a  positive  microscopic  finding  as 
furnishing  a  postive  diagnosis  of  the  disease,  and  in  instituting  treatment  at 
once.  Moreover,  as  in  the  case  of  supposed  tubercular  sputum,  a  single 
negative  result  is  not  accepted  as  final,  but  recourse  must  be  had  to  repeated 
examinations.     If  these  be  uniformly  negative,  we  can  then  state  with  confi- 

1  Harris  and  Corbus :   Journal  of  the  American  Medical  Association,  Dec.   5,   1908. 


SPIROCHAETE   PALLIDA.  107 

denee  that  the  sore  is  not  luetic.  Ravogli  and  others  have  advanced  pro- 
gressive views  on  the  pathology  of  this  affection.  It  being  claimed  that 
hardening  of  the  chancre  is  due  to  the  effort  of  the  organism  to  agglutinate 
the  spirochaete  in  order  that  they  may  remain  encapsulated  in  situ  and  finally 
be  disposed  of.  Hence,  the  greater  the  local  reaction  the  more  effective  in 
impeding  the  progress  of  the  organisms  into  the  economy. 

The  old  teaching  that  the  virus  traveled  by  the  way  of  the  various  lym- 
phatic chains  to  invade  the  organism  is  now  refuted,  for  there  are  cases  of 
malignant  syphilis  in  which  the  rapid  infection  can  be  traced  to  the  spread- 
ing of  the  virus  through  the  blood-vessels.  A  series  of  cases  have  been 
reported  in  which  chancres  of  exceptional  hardness,  accompanied  with 
adema  and  paraphimosis,  have  necessitated  circumcision,  in  consequence  of 
which  secondary  symptoms  appeared  as  late  as  two  or  three  months. 
It  appears  clearly  established  that  the  swelling  of  the  lymphatic  glands  is 
due  to  their  action  in  opposing  the  invasion  of  the  spirochiete,  hence  termed 
by  Hallopeau  le  ganglion  barriere.  It  has  been  observed  that  in  those  cases 
where  the  glands  are  little,  or  not  at  all  involved,  that  syphilis  usually  takes 
a  severe  course.  Indurated  swollen  glands,  due  to  tuberculosis  or  mixed 
infection,  often  constitute  a  complication. 

The  eruption  symptoms  of  syphilis  beginning  with  the  chancre  and  end- 
ing with  the  gumma  are  the  result  of  the  local  multiplication  of  the  organ- 
isms. The  reaction  caused  by  its  presence  in  the  various  tissues  produces 
the  skin  symptoms  observed  in  syphilitic  subjects.  Gaston  is  of  the  opinion 
that  the  difference  between  the  s}Tnptoms  of  the  primary,  secondary  and 
tertiary  stage  is  due  to  the  different  local  action  of  the  treponema  in  conse- 
quence of  modification  in  its  habits  and  growth.  Hence  the  modified 
organism  as  present  in  the  tertiary  lesions  is  capable  of  taking  on  its  original 
activity  when  inoculated  into  a  healthy  individual.  The  experiments  of 
Finger  on  the  inoculability  of  tertiary  lesions  prove  this  premise. 

It  is  also  possible  for  the  spiroehrete  to  enter  the  system  by  way  of  the 
interstices  of  the  tissues;  this  is  promoted  by  a  debilitated  state  of  the 
patient  in  which  there  is  a  lack  of  power  to  produce  antibodies,  and  thus 
impede  the  progress  of  the  invader.  It  is  the  primary  entrance  of  the  spiro- 
chjete  and  its  toxin  into  the  circulation  that  causes  the  reaction  expressed  as 
syphilitic  fever.  The  roseolar  eruption  which  follows  may  be  considered  as 
the  effort  of  the  organism  to  dispose  of  the  treponema.  After  the  first 
eruption  the  organisms  reveal  a  tendency  to  localize  themselves  in  preferred 
areas,  i.e.,  in  places  which  furnish  the  most  suitable  environment  for  their 
development.  It  is  the  action  of  other  microorganisms  with  the  spirocluiete 
which  causes  the  pustular  and  ulcerative  lesions  to  appear.  Any  locality 
subjected  to  repeated  irritation  is  favorable  for  the  invasion  and  development 
of  the  treponema  in  that  site.  The  well  known  prevalence  of  mucous  patches 
in  the  mouths  of  smokers  is  a  notable  example.  Malignant  syphilis  is  due  to 
the  lack  of  development  of  antibodies  in  an  individual  suffering  from  tuber- 
culosis, alcoholism  of  poor  hygiene,  in  consequence  of  which  tlie  opsonic 
index  is  lowered  and  the  individual  left  to  the  mercy  of  the  invading  bacteria 


108  MEDICO-LEGAL. 

and  spirochete.  It  is  not,  therefore,  the  particular  virulence  of  the  spiro- 
chfete  which  is  the  cause  of  malignancy,  hut  the  condition  of  the  system  of 
the  newly-infected  individual.  It  is  thus  justly  claimed  for  cases  presenting 
an  initial  lesion  with  marked  induration  that  the  latter  can  he  accepted  as 
evidence  of  a  strong  resisting  power  on  the  part  of  the  individual.  Namely, 
that  the  spirochsete  heing  surrounded  by  leucocytes  and  connective  tissue 
cells  in  an  effort  at  encapsulation,  the  formation  of  antibodies  is  promoted, 
and  the  individual  thus  safeguarded.  Hence,  with  suitable  local  treatment 
to  insure  the  destruction  of  the  organism  in  the  initial  lesion  and  constitu- 
tional treatment  to  destroy  the  few  spirochgetes  as  yet  at  large  in  the  system, 
the  disease  should  be  much  more  promptly  eradicated.  On  the  other  hand, 
an  unnoticed  mild  primary  sore  permits  the  treponema  to  gain  access  to  the 
circulation  with  decided  and  stubborn  secondary  symptoms  as  a  consequence. 


Original  Articles 


MEDICO-LEGAL. 

By  E.  S.  McKEE,  M.D., 
Associate  Editor  New  York  Medico-Legal  Journal. 

CINCINNATI. 

Ancient  Laws  Regulating  the  Study  oe  Medicine. 

Dr.  a.  G.  Druey,  of  Cincinnati,  in  his  interesting  book,  ''Dante — Phy- 
sician," just  out,  says:  "In  the  thirteenth  century  the  Emperor  Frederick 
II  issued  an  edict,  in  virtue  of  which  no  one  could  practice  medicine  in  the 
Kingdom  of  Naples  who  had  not  been  examined  and  created  a  master  of  the 
College  of  Salerno.  To  effect  tliis  he  must  study  logic  three  years,  and 
medicine,  including  surgery,  five  years.  The  student  was  examined  publicly 
on  the  'Therapeutics  of  Galen,'  the  first  book  of  Avicenna,  and  the  'Aphor- 
isms of  Hippocrates.'  His  diploma  was  to  be  confirmed  by  an  officer  of  the 
Senate,  and  he  was  obliged  to  continue  a  year  longer  under  an  experienced 
physician.  He  who  wished  to  practice  surgery  only  was  obliged  to  follow  the 
teachings  of  the  faculty  for  one  year  only,  but  he  must  devote  himself  to 
the  study  of  anatomy  above  all.  Aristotelian  philosophy  was,  in  Italy, 
studied  largely  as  constituting  the  scientific  basis  of  medicine.  It  is  the 
special  glory  of  the  Bologuese  Medical  School  that  it  was  the  earliest  real 
home  of  anatomical  inquiry.  Dissection  was  practiced  at  Bologna  at  least 
as  early  as  the  time  of  Thaddeus.  This  was  one  of  the  first  schools  at  which 
the  old  religious  prejudice  against  dissection  succumbed  to  the  advance  of 
scientific  progress." 


MEDICO-LEGAL.  109 


The  Criminal  Insane, 


Judge  Morschaiiser,  of  the  New  York  Supreme  Court,  is  a  young  man 
and  a  new  man  on  the  bench,  but  he  is  entitled  to  the  thanks  of  all  orderly 
and  well-disposed  citizens  in  his  recent  decision  in  the  Thaw  case.  It  would 
have  been  a  menace  to  the  public  safety  and  a  heavy  blow  to  the  best  inter- 
ests of  the  people  to  have  allowed  Thaw  his  liberty.  The  following  is  Judge 
Morshauser's  decision,  taken  from  the  New  York  Medico-Legal  Journal: — 

"In  construing  this  statute  it  should  be  born  in  mind  that  the  safety  and 
welfare  of  the  community  are  of  more  importance  than  the  freedom  of  the 
individual. 

"Bearing  in  mind  that  the  usual  punishment  for  the  act  which  led  up  to 
the  detention  of  said  Thaw  is  death  or  a  long  term  of  imprisonment,  and  that 
Thaw  escaped  the  consequence  of  such  act  solely  by  reason  of  his  existing 
mental  condition,  I  do  not  deem  it  proper  to  allow  Thaw  his  freedom,  suffer- 
ing as  he  is  from  some  form  of  insanity,  with  the  possible  recurrence  of  an 
attack  similar  to  that  which  the  jury  believe  he  was  suffering  when  he  killed 
Stanford  White. 

"In  view  of  the  existing  mental  condition  of  said  Thaw,  the  safety  of 
the  public  is  better  insured  by  his  remaining  in  custody  and  under  observance 
until  such  time  as  he  has  recovered,  or  until  it  shall  be  reasonably  certain 
that  there  is  no  danger  of  a  recurring  attack  of  the  delusion,  or  whatever 
it  may  be.^' 

Permission  to  Use  Patient's  Arm  in  Demonstrating  Testimony  Upheld. 

The  Supreme  Court  of  Montana,  in  the  personal  injury  case  of  Stevens 
vs.  Elliott,  the  physician  who  attended  the  plaintiff  at  the  time  of  his  injury 
and  for  some  time  afterwards  was  permitted  by  the  Trial  Court,  over  the 
objection  of  the  defendant,  to  make  use  of  the  plaintiff's  arm  to  demonstrate 
or  explain  his  testimony.  The  reason  given  for  the  objection  was  that  tlie 
testimony  already  given  by  the  plaintiff  was  to  the  effect  that  other  phy- 
sicians had  operated  on  the  injured  arm  after  this  one  had  ceased  to  give  it 
his  care  and  before  the  trial,  but,  conceding  this  to  be  true,  the  Court  wholly 
failed  to  see  how  it  could  affect  the  testimony  of  the  physician,  in  so  far  as 
his  conclusions  were  based  on  facts  obtained  by  him  at  the  time  of  the  injury, 
or  why  he  could  not,  by  the  use  of  the  injured  arm,  make  his  testimony  all 
the  more  easily  understood  by  the  jury.  Such  an  inspection  of  the  injured 
limb  in  the  presence  of  the  jury  is  usually  permitted.  At  least  the  applica- 
tion to  make  such  inspection  is  addressed  to  the  sound  legal  discretion  of  the 
Trial  Court,  and  its  ruling  will  not  be  disturbed,  except  for  manifest  abuse 
of  such  discretion.  The  Court  failed  to  see  wherein  the  Trial  Court  abused 
its  discretion  in  this  case. 

Damages  Occurring  During  the  Doctor's  Absence. 

In  the  light  of  recent  events  it  may  be  of  interest  to  recall  a  decision 
on  this  subject.     Judge  William  II.  Taft,  when  on  the  United  States  Circuit 


110  MEDICO-LEGAL. 

Court  for  the  Southern  District  of  Ohio,  decided  the  following  case:  A 
patient  had  been  under  the  care  of  an  oculist  who  was  treating  her  eye.  He 
made  an  operation  and  continued  his  treatment  till  he  was  called  out  of  the 
city.  He  gave  notice  of  his  intended  departure,  and  left  word  with  his 
patients  that  another  reputable  physician  would  look  after  his  patients  while 
he  was  away.  There  was  some  conflict  in  the  testimony  as  to  whether  the 
patient  went  to  this  other  physician,  but  Judge  Taft  held  that,  under  the 
circumstances,  he  having  given  notice  and  provided  for  the  necessary  treat- 
ment of  his  patients,  absolved  him  from  all  liability,  and  the  case  was  taken 
from  the  jury  and  a  judgment  entered  in  favor  of  the  physician. 

Maceeation  of  the  Fcetus  Medico-Legally  Considered. 

Pisane  (Annali  di  Obstetricia  e  Ginecologia)  tabulates  the  results  which 
he  has  attained  in  a  study  of  sixteen  foetuses  with  reference  to  the  reliable 
signs  of  maceration  and  the  length  of  time  since  death  has  occurred.  He 
states  that  the  foetus  is  very  flaccid,  all  the  serous  cavities  are  filled  with 
imbibed  fluid,  the  bones  of  the  cranium  are  loose  and  flap  about,  and  all  the 
tissues  and  organs  have  imbibed  blood  pigments.  The  endothelium  of  the 
blood-vessels  becomes  softened  and  detached,  and  the  blood  pigment  passes 
out  into  the  tissues.  He  finds  that  the  amount  of  coloration  varies  with  the 
length  of  time  since  death,  increasing  gradually.  This  pigmentation  is  of 
scientific  importance,  and  may  be  used  for  diagnosis  if  properly  limited,  but 
used  too  widely,  it  may  lead  to  mistakes. 

Pitying  the  Pitted. 

At  the  annual  dinner  of  the  Association  of  Public  Vaccinators  of  Lon- 
don, Sir  James  Chrichton-Brown  created  considerable  interest  by  relating 
the  following,  which  he  said  was  the  only  instance  in  history  known  to  him 
in  which  small-pox  did  any  real  good.  It  was  the  case  recorded  by  Oliver 
Goldsmith,  ''The  Double  Transformation": — 

No  more  presuming  on  her  sway, 
She  learns  good  nature  every  day; 
Serenely  gay  and  strict  in  duty, 
Jack  finds  his  wife  a  perfect  beauty. 

In  the  above  instance  small-pox  was  instrumental  in  restoring  matri- 
monial felicity.  Sir  James  went  on  to  relate  that  a  frivolous  coquette, 
negligent  of  her  studious  husband,  devoted  to  the  enchantment  of  her  own 
personal  charms,  aided  by  the  arts  and  artifices  of  the  toilet,  was  seized  by 
that  dire  disease  whose  ruthless  power  withers  transient  beautj^'s  charms, 
and  she  came  out  of  it  with  a  face  pitted,  and  seamed,  and  scarred,  and 
unlovely,  but  with  a  spirit  chastened  and  subdued.  A  lady  beauty  specialist 
in  London  has  recently  been  fined  500  pounds  for  serious  facial  disfigure- 
ments and  suffering,  which  attended  '^harmless  methods"  of  removing  small- 
pox pitting;   the  jury  also  found  her  guilty  of  fraud. 


BALDNESS.  Ill 

The  Law  Protecting  Children. 

Three  cases  reported  in  a  single  day  from  three  different  police  courts, 
all  appearing  in  one  paper,  the  Daily  Telegraph  of  London,  shows  the  great 
interest  taken  in  the  laws  for  the  protection  of  children  and  their  enforce- 
ment. The  amelioration  of  the  lot  of  children  in  recent  years,  through  legal 
interference,  is  very  marked.  The  use  of  children  on  the  streets  as  beggars 
to  assist  grown-up  mendicants  in  exciting  passion  and  extracting  alms  from 
passersby  is  a  practice  of  varying  degrees  of  physical  suffering,  but  always 
demoralizing.  It  is  certainly  a  crime  to  raise  up  mendicants  or  teach  chil- 
dren to  become  such. 

Damages  for  Cocaine  Poisoning  After  "Painless"  Extracting  of 

Teeth. 

The  case  has  appeared  recently  in  the  English  courts  where  an  unquali- 
fied assistant  administered  cocaine  by  hypodermic  injection  in  "painless  ex- 
tracting'^ of  teeth.  It  was  shown  by  the  testimony  that  the  solution  of  cocaine 
had  been  poured  out  into  a  glass  and  then  injected.  The  patient  soon  came 
under  the  care  of  a  medical  man  who  found  him  as  near  death  as  could  be. 
Said  medical  man  produced  tubes,  which  he  said  was  the  proper  way  to 
administer  cocaine.  Parke  Davis  &  Co.'s  London  chemist  was  called  to 
testify.  The  Judge  found  that  the  cocaine  was  negligently  administered 
and  gave  judgment  for  10  guineas.  < 

Syphilis  Communicated  by  Assault  and  Battery. 

Watson  (New  York  Medical  Journal)  reports  three  cases  of  syphilis  con- 
tracted in  this  way.  The  initial  lesion  was  situated  on  the  dorsal  surface  of 
the  hand  in  one  case,  on  the  ear  in  another,  and  on  the  scalp  in  the  third. 
The  source  of  infection  was  from  a  blow  of  the  fist  in  two  cases,  and  a  bite 
from  the  assailant  in  the  other.  Other  cases  of  like  character  are  cited  in 
the  paper.  Comparatively  little  attention  has  been  called  to  assault  and  bat- 
tery as  a  possible  cause  of  syphilis,  though  much  has  been  written  upon 
syphilis  extra-genitally  acquired.  It  would  be  interesting  to  hear  from  the 
profession  on  this  unusual  method  of  acquiring  syphilis,  as  well  as  other  inter- 
esting methods. 

BALDNESS. 
By  M.  L.  RAVITCH,  M.D., 

LOUISVILLE,   KT. 

Shakespeare,  touching  upon  the  subject  of  baldness,  does  not  give 
much  hope  to  the  bald-headed.  In  his  "Comedy  of  Errors,'*  Act  II,  Scene  2, 
you  find  the  following  discourse: — 

Dro.  S. — There's  no  time  for  a  man  to  recover  his  hair  that  grows  bald 
by  nature. 


112  BALDNESS. 

Ant.  S. — May  he  not  do  it  by  fine  or  recovery? 

Dro.  S. — Yes,  to  pay  fine  for  a  periwig,  and  recover  tlie  lost  hair 
of  another  man. 

Shakespeare  seemed  to  lay  stress  on  intellectual  development  or  too 
much  brain  work  as  the  cause  of  baldness,  when  we  read  the  following 
lines : — 

Ant.  S. — Why  is  time  such  a  niggard  of  hair  being  as  it  is  so  plentiful 
an  excrement? 

Dro.  S. — Because  it  is  a  blessing  that  he  bestows  on  beasts:  and  what 
he  has  scanted  men  in  hair  he  has  given  them  in  wit. 

Ant.  S. — Why,  but  there's  many  a  man  has  more  hair  than  wit  ? 

Dro.  S. — Kot  a  man  of  those,  but  he  has  the  wit  to  lose  his  hair. 

That  civilization  and  learning  were  the  cause  of  baldness  seems  to  be 
the  opinion  of  even  ancient  writers,  ^sculapius,  the  God  of  Medicine,  and 
Hippocrates,  the  Father  of  Medicine,  were  represented  as  bald-headed 
individuals.  So  were  the  famous  Greek  poets,  Aristophanes  and  the  noted 
sculptor,  Phidias.  This,  I  mean  baldness,  would  have  become  a  fad,  an 
'external  sign  of  intellectuality,  were  it  not  for  the  tragic  end  of  the  great 
tragedian,  ^schylus,  who,  according  to  Leonard,  in  456  B.  C,  came  to  his 
end  by  the  blundering  of  an  eagle  which  mistook  the  top  of  his  bald  head 
for  a  rock,  and  so  dashed  its  prey,  a  turtle,  upon  it,  in  order  to  break  its 
hard  concealment,  so  that  it  could  be  eaten.  It  is  needless  to  say  what  the 
result  was  to  the  man  and  the  undoubted  surprise  of  the  eagle. 

The  Hebrews  were  more  practical  and  more  scientific.  They  looked 
upon  baldness  as  a  scourge  or  parasitic  disease.  Isaiah  intimated  that  bald- 
ness was  apt  to  be  classed  with  parasitic  diseases.  Censuring  the  daughters 
of  Zion  for  their  iniquity,  he  said  that,  instead  of  well  set  hair,  baldness 
"was  to  come  upon  them  and  a  scab  upon  the  crown  of  their  heads."  (Isaiah 
iii:  16-24.) 

iPincus  has  been  looked  upon  as  the  greatest  authority  on  diseases  of  the 
hair.  According  to  Pincus,  alopecia  is  due  to  two  causes,  hereditary  and 
parasitic.  Alopecia  in  many  cases,  says  Pincus,  is  hereditary,  it  being  not 
uncommon  to  meet  with  families  in  which  the  fathers  and  sons  for  many 
generations  lose  their  hair  early  in  life.  He  even  adds  this  is  due  to  a 
markedly  stretched  condition  of  the  aponeurosis  of  the  occipito-frontalis 
muscle  which  becomes  hereditary  in  certain  families.  If  this  be  the  case, 
why  then  don't  the  daughters  become  bald-headed  as  their  brothers  do? 
Such  a  hereditary  explanation  is  not  borne  out  by  facts.  Since  authorities 
lay  stress  upon  bad  health  as  the  cause  of  baldness,  bad  health  will  undoubt- 
edly cause  diseased  hair,  but  bad  health  will  also  affect  other  organs. 

Baldness  as  the  result  of  bad  health  is  purely  due  to  a  nutritive  trouble, 
the  bulbs  being  badly  nourished,  the  hair  becoming  loose  and  falling  out. 
Neurotic  troubles  and  nervous  shocks  are  also  liable  to  cause  loss  of  hair,  or 
even  total  alopecia.  But  we  must  grant  that  in  most  cases  of  baldness  we 
meet,  the  general  health  is  usually  good.  Whether  in  church,  or  theatre,  or 
other  public  places,  look  at  the  bald-headed  sons  of  Adam,  and  you  will 


BALDNESS.  113 

usually  find  them  well-fed,  robust  and  a  jolly  lot  of  individuals.  Compara- 
tively very  few  are  in  bad  health.  To  my  mind,  Sabouraud's  theory,  in 
regard  to  baldness,  is  the  most  plausible  one.  He  maintains  that  the  essen- 
tial factor  in  all  cases  of  baldness  is  the  micro-bacillus  of  seborrhoea,  which 
he  demonstrated  in  1897. 

Lassar  and  Bishop,  several  years  ago,  have  asserted  their  opinions  on 
experiments  with  animals,  that  alopecia  prematura  (premature  baldness) 
could  be  caused  by  contagion. 

Hebra  and  Kaposi  always  maintained  that  a  chronic  seborrhoea  (dand- 
ruff) is  the  primary  condition,  and  that  alopecia  or  baldness  occurs  only 
secondarily.  It  is  a  fact  that  many  scalp  diseases,  which  have  been  attributed 
to  certain  constitutional  diseases,  have  lately  been  found  to  be  of  microbic 
origin.  Sabouraud  says  that  before  he  demonstrated  his  micro-bacillus  in 
1897,  neither  he  nor  any  one  else  "had  the  idea  that  calvities  could  be  of  a 
micro-bacillus  origin."  Prior  to  Sabouraud,  Unna  has  demonstrated  that 
in  alopecia,  due  to  seborrhoea,  he  found  an  organism — bottle-shaped — and  he 
called  it  bottle  bacillus.  In  my  own  experience  over  90  per  cent,  of  baldness 
is  due  to  dermatitis  seborrhoeicum,  in  which  the  micro-bacillus  of  Sabouraud, 
or  bottle  bacillus  of  Unna,  can  be  found.  Under  the  term  of  dermatitis 
seborrhoeicum  (inflammatory  process  of  the  skin)  we  may  include  different 
phases,  such  as  eczema,  seborrhoeicum,  pityriasis  capitis,  alopecia  pitorodes, 
seborrhcea  sicca,  going  on  to  a  distinct  seborrhoeic  baldness.  G.  Elliott,  of 
New  York,  was  the  first  American  dermatologist  who  worked  along  the  line 
of  Sabouraud  and  Unna.  In  his  paper,  read  before  the  American  Derma- 
tological  Association  in  1892,  and  published  in  the  New  York  Medical  Jour- 
nal, February,  1893,  he  pointed  out  that  out  of  234  cases  of  premature 
baldness,  216,  or  90  per  cent.,  were  due  to  purely  local  process  of  the  scalp, 
and  all  of  216  cases  presented  the  clinical  appearances  of  eczema  sebor- 
rhoeicum. He  furthermore  believes  this  to  be  an  infectious  inflammatory 
process.  Jackson,  in  a  clinical  study  of  300  private  cases,  almost  coincides 
with  Elliott.     He  gave  the  percentage  of  parasiticism  at  75. 

From  all  the  inquiries  made  by  me  in  regard  to  the  cause  of  premature 
baldness,  I  can  only  see  that  it  is  an  infectious  process  causing  several  clinical 
phenomena,  which  we  include  under  the  term  of  eczema  seborrhoeicum  of 
Unna,  or,  better  still,  dermatitis  seborrhoeicum  of  Crocker.  No  matter  how, 
whether  the  term  is  properly  used  or  not,  or  what  organism  is  the  specific 
cause,  whether  it  be  the  micro-coccus  of  Unna  or  micro-bacillus  of  Sabouraud, 
we  know  from  the  pathological  and  clinical  appearance  of  the  disease  that  it 
is  an  infectious  disease.  The  process  of  infection  and  the  subsequent  dam- 
age done  to  the  hair  by  the  micro-bacillus  of  Sabouraud  or  micro-coccus  of 
Unna,  is  differently  described  by  both  investigators;  but  I  am  inclined  to 
lean  toward  Sabouraud's  theory,  which  is  excellently  described  by  Crocker: 
"The  specific  micro-bacillus  invades  the  follicle  by  the  follicular  orifice,  it 
multiplies  and  forms  a  thin  lamina  made  up  of  microbes  which  separate  the 
hair-shaft  from  the  wall  of  the  follicle  and  descends  almost  to  the  level  of 
the  orifice  of  the  sebaceous  duct.' 


114  BALDNESS. 

"The  epithelial  irritation  excited  in  the  neighborhood  produces  homy 
layers  which  encyst  the  microbian  colony  and  form  what  Sabouraud  calls  a 
cocoon,  which  is  attached  to  one  side  of  the  hair-shaft.  The  consequences 
of  its  presence  manifest  themselves  in  sebaceous  hypersecretion,  followed  by 
glandular  h}^Dertrophy  to  three  or  four  times  the  normal  size,  and  progressive 
atrophy  of  the  hair  papilla.  Lymphocytes  and  giant  cells  in  small  quantity 
are  found  around  the  microbian  utericle,  round  the  neighboring  vessels,  in 
the  angle  of  the  arrector  pili  and  shaft,  and  round  the  base  of  the  follicle 
and  the  papilla.  The  functions  of  the  latter  are  interfered  with;  the  pig- 
ment is  no  longer  conveyed  to  the  hair-cells;  the  medullary  cells  of  the  shaft 
are  no  longer  produced;  the  diameter  of  the  shaft  is  diminished,  and  hence 
the  adult  characters  of  the  hair  are  lost,  and  the  new  hair  have  neither  pig- 
ment nor  medulla;  finally,  even  this  weak  substitute  is  not  produced,  hair 
production  ceasing  altogether  and  the  papilla  itself  disappearing."' 

From  all  the  foregoing  we  can  readily  see  that  most  cases  of  baldness 
are  of  parasitic  nature.  Taking  this  in  consideration,  we  ought  to  realize 
how  dangerous  a  comb  or  brush  would  be  when  used  even  by  several  members 
of  a  family,  but  how  much  more  so  when  used  on  the  many  in  a  barber  shop 
or  hair-dressers'  establishment.  To  carry  out  these  facts,  culture  tubes  were 
inoculated  with  the  debris  from  a  barber's  comb  and  brush,  with  the  result 
that  the  usual  organisms  found  in  the  scalp  were  alive  in  these  articles. 
Every  dermatologist  will  tell  you  that  he  has  often  cured  a  case  of  dermatitis 
seborrhoeieum,  to  have  it  relapse  after  the  patient  visits  the  barber.  I  would 
forgive  a  la}Tnan,  because  he  is  ignorant  of  such  facts,  but  I  would  hardly 
forgive  a  physician  when  he  promiscously  lets  his  barber  treat  his  scalp  with 
the  vilest  kinds  of  shampoos  or  vilest  smelling  hair  tonics. 

With  the  multiplication  of  beauty  shops  in  our  cities  and  with  the  adop- 
tion of  all  kinds  of  combs,  rats  and  switches  (the  last  two  articles  the  best 
dirt  and  germ  catchers),  and  other  contraptions  for  holding  up  their  hair,  the 
women  are  also  becoming  as  bald  as  men.  In  my  50  cases  of  premature  fall- 
ing out  of  the  hair  in  women,  38  cases  were  traced  to  infection  by  wearing 
rats  and  switches.  Only  six  of  my  female  patients  have  abandoned  wearing 
those  abominable  disease-producing  rats  and  switches.  The  improvement  in 
the  hair  was  remarkably  rapid.  The  rest  of  them  would  not  give  up  wear- 
ing rats  (will  a  woman  ever  give  up  anything  pretaining  to  fashion?),  and 
their  improvement  was  rather  slow. 

In  conclusion,  I  would  like  to  add  that  all  attempts  of  exploding  new 
theories  in  regard  to  baldness,  such  as  wearing  of  hats,  lack  of  exercise,  lack 
of  deep  breathing  by  some  persons,  thereby  producing  poisonous  air  in  the 
lungs,  all  such  theories  are  simply  a  comfort  to  those  who  explode  them. 
Though  there  is  no  doubt  that  the  majority  of  eases  of  baldness  is  due 
primarily  to  infection,  yet  we  must  not  neglect  our  health,  as  a  person  with 
bad  health,  or  "run  down"  system  (as  it  is  often  expressed),  is  easier  predis- 
posed to  infection  than  a  healthy  person.  "While  our  civilization,"  says 
Shoemaker,  "compels  us  to  be  mindful  of  the  use  of  cleanliness  for  the  hair, 
we  must  not  be  oblivious  of  its  demand  for  air  and  light.     The  hair  being  a 


ADVANTAGES  AND  DISADVANTAGES  OF  DANCING.  115 

vital  structure,  needs,  like  the  body  elsewhere,  light,  air  and  cleanliness.  It 
especially  needs  attention  to  them  in  the  midst  of  our  artifical  life  and 
civilization;  for,  in  a  state  of  nature,  the  hair  obtains  the  first  two  so  plenti- 
fiilly  that  it  can  afford  to  dispense  largely  with  the  last.^' 


Editorial 


ADVANTAGES  AND  DISADVANTAGES  OF  DANCING. 

The  pleasures  of  love,  affection,  mutual  regard,  sympathy  or  sociability, 
make  up  the  foremost  satisfaction  of  human  life,  and  £is  such  are  a  standing 
object  of  fruition,  pursuit  and  desire.  One  of  the  most  common  pleasures  at 
the  present  time  is  dancing.  It  is  indeed  a  pleasure  and  is  one  of  the  primitive 
arts.  The  rudest  savages  practiced  it  and  made  it  an  essential  element  in  every 
religious  observance  and  in  every  festival.  The  dances  seem  to  have  been 
suggested  by  mere  pleasure  and  the  desire  produced  by  it.  There  is  no  account 
of  the  origin  of  dancing,  but  combined  with  music  it  is  practiced  by  every 
nation  on  the  globe,  and  the  foundations  of  it  lie  in  the  human  constitution 
itself. 

The  Greeks,  whose  civilization  aimed  for  a  harmonious  development  of  the 
mind  and  body,  considered  dancing  as  a  necessary  part  of  education.  To  them 
a  great  dancer  was  a  great  man.  If  we  trace  dancing  back  we  find  that  it 
originated  with  the  origin  of  man.  These  dances  were  indicative  of  the  habits 
and  temperament  of  the  people. 

Sociability  seems  to  have  been  the  potent  factor  for  the  maintenance  of 
the  dances.  Whenever  the  people  assembled  dancing  naturally  took  place. 
In  the  presence  of  an  assembly  the  individuals  were  aroused,  agitated,  swayed, 
and  the  thrill  of  numbers  appears  to  be  electric  and  the  tendency  to  dance 
was  irresistible.  Dancing  may  seem  to  us  a  slight  matter  and  therefore  we 
are  less  likely  to  subject  it  to  a  close  investigation. 

It  is  an  established  fact  that  dancing  is  an  art.  It  is  a  regular  arrange- 
ment of  motion,  grace  and  music,  and  therefore  it  should  appeal  to  the  sense 
of  beauty.  However,  many  people,  in  spite  of  its  artistic  qualities,  regard  it 
simply  as  a  social  accomplishment  and  scornfully  deny  its  claims  to  be  an  art. 
If  we  analyze  this  common  pleasure  into  its  component  parts,  we  will  find  that 
it  consists  of  rhythmical  movements  of  the  body,  succeeded  by  successive  shift- 
ings  of  the  body  centre  of  gravity  in  obedience  to  the  musical  tones. 

It  is  a  well-established  fact  that  a  sound  mind  must  be  in  a  sound  body. 
^N'o  argument  is  needed  nowadays  to  prove  the  correlation  of  the  mind  and  body, 
and  if  we  interpret  it  correctly  we  find  such  is  the  case  in  all  the  pleasures  of 
which  dancing  is  a  prominent  factor.  We  find  that  the  most  trifling  amuse- 
ment is  some  indication  of  the  mental  state,  and  it  is  attributed  to  this  fact  that 
dancing  originated.  As  time  passed  on  people  have  broken  loose  from  the 
ancient  traditions.     Countless  new  avenues  have  opened  out  before  us,  and  a 


116  ADVANTAGES  AND  DISADVANTAGES  OF  DANCING. 

host  of  dormant  energies  which  have  sprung  up  into  life  have  brought  with 
them  new  tastes  and  new  desires.  Progress,  in  fact,  has  assumed  the  propor- 
tions of  a  revolution  and  its  effects  have  been  profound  and  far-reaching. 

Very  little  progress,  however,  has  been  made  in  dancing,  and  it  seems  to 
be  the  most  extensive  and  least  involved  of  all  emotional  influences  at  work  in 
education  and  development.  As  the  writer  has  stated  above,  that  dancing 
necessitates  a  feeling  of  rhythm,  it  would  naturally  and  instinctively  induce 
one  to  regulate  his  footsteps  to  a  certain  order  and  in  this  manner  cultivate  a 
stronger  instinct  for  rhythm  and  harmonious  activity  of  the  body.  Ehythm 
is  the  fundamental  principle  of  life  and  every  organ  in  our  body  works 
rhytlmiically — such  as  is  seen  in  the  contractions  and  dilatations  of  the  heart, 
the  balance  of  equilibrium  in  metabolism,  etc. 

The  ancient  Greeks  understood  the  significance  of  these  things  better,  and 
in  their  estimation  the  body  and  mind  were  imity,  and  therefore  it  was  necessary 
that  they  be  developed  as  one. 

To  condemn  dancing,  we  must  show  that  it  is  ill-adapted  to  view  and  that 
it  indirectly  interferes  with  a  reasonable  scheme  of  intercourse.  As  every 
story  has  two  sides — a  good  and  a  bad — so  is  the  case  with  dancing.  If  we 
look  at  the  beneficial  effects  of  dancing  we  find  that  it  is  a  very  valuable  aid 
for  many  people,  since  it  enables  them  to  acquire  muscular  control  and  dex- 
terity. It  enables  them  to  take  exercise,  which  for  different  reasons  they  are 
unable  to  engage  elsewhere.  If  it  were  not  for  the  pleasure  that  they  experience 
they  would  never  take  this  form  of  exercise;  for  the  ordinary  conditions 
of  their  life  do  not  permit  daily  exercise.  After  the  dance  is  overy  they  feel 
more  invigorated,  the  bodily  functions  are  stimulated.  The  people  come  out 
happier,  because  of  the  healthful-blooded  rhythm  that  still  pulsates  through 
their  bodies,  for  it  means  that  they  have  a  new  feeling  about  life.  Dancing 
furnishes  to  them  an  outlet  for  their  pent-up  feelings  and  impulses  in  rhythm 
of  artistic  grace.  It  furnishes  amusement  and  pleasure  which  is  a  part  of  our 
life  and  is  one  of  the  things  worth  living  for. 

It  is  claimed  by  many  that  dancing  restores  motor  elements  of  expression 
and  in  this  manner  develops  the  muscles  and  motor  communications  which  are 
prone  to  atrophy  from  disuse  and  inactivity.  It  also  enables  the  participant 
of  the  dances  to  gain  control  over  his  strength  and  grace  of  his  body.  This 
kind  of  culture  is  the  most  educative  of  all,  because  it  places  the  control  of  the 
muscles  under  the  will,  and  the  exercises  involved  are  those  which  tend  to  estab- 
lish and  improve  the  enduring  powers.  It  appears  very  strange  to  pronounce 
so  common  an  amusement  as  dancing,  unnatural  and  harmful,  but  upon  closer 
inspection  we  can  see  its  defects. 

Looking  at  dancing  as  an  exercise,  the  late  hours,  the  heated  rooms, 
exhausted  atmosphere,  place  it  most  unfavorably  in  comparison  with  almost 
every  out-door  pastime.  Dancing  is  very  harmful  to  individuals  with  diseased 
hearts  on  account  of  the  overexertion  and  the  increased  amount  of  work  on  the 
already  over-strained  heart.  Another  great  objection  is  the  sexual  feeling 
which  it  encourages  by  stimulating  the  desire  already  under  insufficient  control, 
and  thus  probably  destroys  the  balance  of  character.  J.  0.  Davis. 


ALCOHOL. 


ARTERIAL  SCLEROSIS. 


117 


yiatcria  /yicdica  and  Therapeutics 


ALCOHOL  IN   THE   TREATMENT   OF 
NEURALGL/^. 

Dr.  Alexander  recommends  the  great 
benefits  to  be  derived  from  injections  of 
alcohol  in  the  treatment  of  neuralgia. 
He  urges  its  use  on  all  cases  before  resort- 
ing to  operative  measures.  He  states  the 
injections  of  alcohol  will  relieve  the 
patient's  pain  even  where  it  is  impossible 
to  remove  the  constitutional  cause,  such 
as  in  case  of  brain  tumor,  while  waiting 
for  the  exact  diagnosis.  He  thinks  that 
it  is  important  to  practice  on  the 
anatomic  studies  and  on  the  cadaver 
before  attempting  to  apply  this  teclmic. 
A  patient  is  reported  to  have  been 
relieved  of  pain  for  a  year  until  the  intra- 
cranial cause  was  located.  Great  caution 
is  required  with  this  technic,  he  warns, 
for  nerves  with  a  motor  element.  (Ber- 
liner klinische  Wochenschrift,  November 
3,  1908.)  

AMMONIUM  CARBONATE  IN  THE  TREAT- 
MENT OP  CORYZA. 

Dr.  Bevery  Eobinson  recommends  very 
highly  this  drug  in  acute  coryza.  He 
gives  a  grain  to  the  dessertspoonful,  with 
some  flavoring  agent,  and  repeats  this 
dose  every  hour  for  twelve  doses.  For 
the  next  twelve  or  twenty-four  hours  he 
gives  the  remedy  every  two  or  three 
hours.  It  is  unnecessary  to  continue 
this  treatment  if  the  attack  is  not 
aborted  in  forty-eight  hours.  Care  must 
be  exercised  in  not  administering  too 
much  ammonium  carbonate  and  too 
frequently,  since  it  occasions  unpleasant 
symptoms  of  cardiac  disability  of  a 
temporary  nature  and  also  becomes  a 
notable  depressant  of  the  circulation. 
Sometimes  the  author  uses  the  aromatic 
spirits  of  ammonia  instead  of  the  ammo- 
nium   carbonate,   in   twenty-drop    doses 


every  two  hours,  diluted  with  water,  but 
it  is  not  so  efficacious  as  the  former. 

When  the  ammonium  carbonate  is 
used  soon  enough  and  in  suitable  doses, 
good  results  have  been  reaped.  In  those 
cases  in  which  it  has  failed,  it  is  due  to 
its  not  being  used  early  enough  and  in 
accordance  with  the  precise  manner 
indicated.  (Medical  Fortnightly,  Jan- 
uary 11,  1909). 


ARTERIAL  SCLEROSIS,  TREATMENT  OF. 
Dr.  Gouget  reports  favorable  results  on 
his  views  of  treating  calcareous  arteries. 
Since  increased  tension  is  the  chief  cause 
of  this  affection,  the  usual  aim  is  to  do 
away  with  this  underlying  cause.  The 
author  recommends  the  iodides  as  the 
most  valuable  drugs  to  combat  this  dis- 
ease. He  prefers  potassium  iodide  better 
than  sodium  iodide,  since  the  former  is 
more  resolvent  than  the  latter.  Of 
course,  no  method  of  treatment  can 
restore  arteries  which  have  become  cal- 
careous; but  in  the  initial  stage  the 
process  may  be  arrested  by  potassium 
iodide,  and  the  solvent  action  of  potas- 
sium may  be  combined  with  the  tension- 
lowering  effect  of  sodium,  by  giving  both 
salts  simultaneously  or  alternately;  3  to 
7  grains  of  potassium  iodide  and  50  to 
20  grains  of  sodium  iodide  may  be  given 
in  twenty-four  hours.  They  should  be 
administered  during  meals,  two  or  three 
times  a  day,  freely  diluted  with  water 
and  combined  with  some  alkali,  on 
account  of  the  tendency  of  acid  drinks  to 
liberate  iodine,  and  so  cause  gastric  dis- 
turbance. If  the  drugs  are  badly  borne, 
opium  or  belladonna  may  be  combined 
with  them.  S}'mptomatic  treatment 
must  be  directed  against  cardiac,  renal 
and  cerebral  complications,  and,  above 
all,  against  pain. 


118 


BIER'S  METHOD. 


BURNS. 


For  alleviation  of  the  pain,  the  author 
recommends  morphine  and  atropine. 

The  patients  should  be  allowed  a  mixed 
diet,  except  shell-fish,  'liigh"  game, 
smoked  or  salted  fish  and  meat,  pork  and 
such  foods  which  contain  toxins  which 
cause  vascular  constriction  and  in  this 
manner  produce  a  high  tension.  The 
evening  meal  should  be  light  and  the 
patient  is  permitted  to  eat  fresh  meats, 
fish,  eggs,  milk,  vegetables,  ripe  and 
cooked  fruits.  He  should  partake  spar- 
ingly of  food  and  should  not  ingest  con- 
siderable fluids,  in  order  that  he  may  not 
overload  his  vascular  system.  Another 
important  point  is  that  the  patient  should 
avoid  excesses  of  all  kinds,  even  intellec- 
tual and  moral  exertions  and  high  living 
of  every  description,  tobacco,  alcohol  and 
lead  poisoning  being  especially  injurious 
to  them.  (British  Medical  Journal, 
October  17,  1908). 


With  the  patient  in  bed,  the  apparatus 
is  applied  for  30  minutes,  in  two  sittings. 
The  pain  soon  passes  away,  secretion 
becomes  normal,  infiltration  disappears, 
and  healing  results.  (Therapeutic  Ga- 
zette, December  15,  1908). 


BIER'S  HYPEIl.ffiMIA  METHOD  IN  THE 
TREATMENT  OF  INFLAMMATION  OF 
THE  GLANDS  OF  BARTHOLIN. 
Dr.  Plass  notes  that  inflammation  of 
the  glands  of  Bartholin  is  generally  of 
gonorrhoeal  origin  and  finally  terminates 
in  abscess  of  the  gland,  followed  by 
infiltration  of  the  surrounding  tissues. 
Since  the  general,  conservative  treatment 
of  such  inflammation  has  been  unsuc- 
cessful, the  author  has  modified  the 
vacmun  glass  of  Bier,  so  that  the  rubber 
tube  and  ball  cannot  be  infected  with  the 
discharge.  His  method  is  as  follows : 
The  assistant  holds  the  labium  majus  and 
the  glass  is  put  in  place,  one  to  one  and 
a  half  centimeters  in  front  of  the  pos- 
terior commissure,  so  that  the  outlet  of 
the  inflammed  gland  lies  in  the  middle 
of  the  opening  of  the  glass.  Too  great 
suction  with  the  ball  is  to  be  depracated, 
since  the  tissues  are  drawn  deeply  into 
the  opening  and  resorption  and  circula- 
tion are  thus  prevented. 


BURNS,  TREATMENT  OF. 

Dr.  Eenner  recommends  a  powder  and 
the  advisability  of  applying  it  in  the 
treatment  of  burns  of  all  degrees.  This 
powder  is  made  up  by  one  part  of  sub- 
nitrate  of  bismuth  to  two  parts  of  kaolin. 
A  thick  layer  of  this  powder  is  placed 
over  the  burnt  surface  after  it  has  been 
thoroughly  cleansed.  Over  this  he  band- 
ages a  layer  of  sterilized  gauze,  the  whole 
being  finally  covered  by  thick  layers  of 
wadding.  This  dressing  is  changed 
every  day  so  long  as  there  is  much  dis- 
charge, the  injured  area  being  sub- 
merged in  a  partial  or  complete  bath, 
according  to  the  extent  and  situation  of 
the  burn.  This  powder,  the  author 
claims,  speedily  takes  up  the  fluid  from 
the  burnt  tissue  and  converts  it  into  a 
black  and  desiccated  eschar.  This  prop- 
erty is  due  to  its  very  active  absorbing 
power.  In  burns  of  a  mild  degree,  the 
area,  after  the  use  of  the  powder,  is 
covered  by  a  thick  crust,  which  serves  as 
an  excellent  protection  during  the 
growth  of  the  new  epidermis.  By  this 
treatment,  for  which  are  claimed  the 
advantages  of  simplicity  and  cheapness, 
together  with  the  capacity  of  arresting 
free  secretion  and  preventing  septic 
infection,  pain,  it  is  asserted,  is  relieved 
and  the  temperature  is  kept  down.  In 
some  few  cases,  there  has  been  an  urti- 
carial rash  with  much  itching  around  the 
burn,  but  this,  the  author  states,  soon 
disappears  after  a  temporary  suspension 
of  the  use  of  the  powder.  (British 
Medical  Journal,  January  2,  1909). 


CORYFIN. 


GELATIN. 


119 


CORYFIN,  ITS  USE  IN  COLDS. 

Dr.  Baunigarten  states  that  coryfin  is 
a  new  menthol  ester  which  can  be  used 
to  relieve  the  unpleasant  symptoms  of 
cold.  It  can  be  applied  to  the  nose  by 
means  of  a  swab,  or  else  a  pledget  of  wool 
on  which  some  coryfin  has  been  powdered 
can  be  laid  within  the  nose. 

Cor3^fin  does  not  lose  its  effect  after 
prolonged  use.  Along  with  ansesthesin, 
the  author  has  found  it  of  value  in  the 
treatment  of  tuberculosis  of  the  larynx. 
(Klin.  Therap.  Woch.,  No.  51,  1907). 


FRACTURE  OF  THE  PATELLA,  TREAT- 
MENT OF  OLD. 

Dr.  J.  Eolter  describes  a  very  advan- 
tageous method  in  operating  upon  a 
fractured  patella.  His  patient  was  a 
woman  aged  37  years,  who  had  fractured 
her  right  patella  eight  years  previously. 
Satisfactory  union  took  place,  but  some 
eleven  weeks  after  the  accident  she  met 
with  a  second  slight  accident,  and  sepa- 
rated the  newly-united  fragments.  Al- 
though no  union  took  place  after  the 
second  accident,  she  was  able  to  walk 
fairly  well.  A  year  ago  she  fell  and 
fractured  her  left  patella.  The  right 
patella  on  examination  was  found  to  be 
broken  in  two  at  the  junction  of  the 
upper  quarter  and  lower  three  quarters. 
There  was  an  interval  of  two  inches 
between  the  fragments.  The  leg  could 
not  be  fully  extended.  The  fragments  of 
the  left  patella  lay  some  2%  inches  apart, 
and  the  upper  fraginent  only  measured 
34  inch.  The  function  of  the  left  leg 
was  less  good  than  that  of  the  right. 
She  could  only  extend  the  leg  to  half  a 
right  angle.  She  could  walk  with  a 
stick,  but  could  not  walk  upstairs. 

Dr.  Eolter  first  extended  the  quadriceps 
by  means  of  a  strip  of  strapping  and 
weight.  On  removing  it  for  the  opera- 
tion, he  found  that  the  extension  pro- 


duced by  the  strapping  had  again  dis- 
appeared, and  that  it  was  impossible  to 
bring  the  fragments  of  the  left  patella 
together.  He,  therefore,  excised  the  scar 
tissue  and  applied  a  silver-wire  suture  to 
the  patella,  and  found  that  there  was  still 
about  one  inch  of  separation.  He  then 
dissected  a  strip  of  the  aponeurosis  of 
the  muscle,  measuring  about  1%  inches, 
by  nearly  3  inches,  leaving  an  attach- 
ment below  at  the  upper  fragment. 
Muscle  fibres  were  intentionally  left  on 
the  under  surface  of  the  aponeurosis  strip. 
This  was  turned  downward  in  such  a 
way  that  the  muscular  surface  lay  over 
the  patella  fragments  and  it  was  sutured 
by  nimierous  catgut  sutures  to  the  frag- 
ments. (Calcutta  Medical  Journal, 
December,  1908). 


GELATIN  AS  AN  AN.ffiSTHETIC  AND  AS  A 
HAEMOSTATIC. 

Dr.  L.  J.  Facio  advises  the  use  of 
daily  subcutaneous  injections  of  gelatin — 
not  more  than  25  c.c.  of  a  one-per-cent. 
solution  of  gelatin — for  the  arrest  of 
pain.  The  pain  was  constantly  attenu- 
ated by  the  first  injection  and  disappeared 
completely  after  the  second  or  third. 
With  an  aneurysm  the  effect  is  more 
marked  than  that  of  morphine.  How- 
ever, the  effect  was  less  pronounced  than 
that  of  morphine  in  pleurisy,  articular 
pains,  progressive  paralysis,  etc.,  but  the 
effect  lasted  longer.  There  are  no  by- 
effects  of  any  consequence  observed  in  his 
experience,  and  the  local  pain  is  slight 
when  these  small  amounts  are  injected. 
The  anaesthetic  action  occurs  promptly 
and  lasts  for  twenty-four  hours  at  least, 
and  sometimes  for  three  days,  or  even 
longer. 

Dr.  Chaput  highly  advocates  the  use  of 
gelatin  as  a  ha3mostatic.  Instead  of 
opening  the  wound  again  in  case  of 
severe  secondary  haemorrhage,  he  raises 


120 


TABES  DORSALIS. 


GYNECOLOGY. 


the  part,  raising  the  foot  of  the  bed  30 
cm.,  after  a  hiparotomy,  covers  the 
region  with  an  ice  bag,  injects  physiologic 
saline  solution  under  the  skin  or  into  a 
vein,  and  then  injects  into  the  thigh  500 
grammes  of  a  one-per-cent.  solution  of 
gelatin.  If  the  haemorrhage  recurs,  the 
wound  must  be  opened,  the  clots  removed, 
and  the  oozing  vessels  ligated,  after  the 
hasmorrhage  has  been  arrested  by  repeat- 
ing the  above  measures.  The  author 
relates  a  number  of  examples  to  show  the 
remarkable  benefit  from  this  method. 
(Journal  of  the  American  Medical  Asso- 
ciation, January  9,  1909). 


HIGH-FREaUENCY   CURRENTS   IN  TABES 
DORSALIS. 

Dr.  ISTagelschmidt  reports  the  good 
results  obtained  from  the  treatment  of 
tabes  dorsalis  by  electricity.  He  gives 
the  details  of  twenty-four  cases  in  which 
the  patients  were  treated  by  application 
of  the  high-frequency  current,  with  im- 
provement in  the  subjective  symptoms, 
although  the  objective  were  not  materially 
modified.  He  is  convinced  that  these 
results  can  not  be  attrilnited  to  sugges- 
tion, as  the  pains  in  tabes  are  usually 
influenced  by  suggestion,  even  in  hypno- 
sis. Some  of  the  patients  had  been 
addicted  to  morphine.  The  ataxia  was 
improved  only  in  cases  in  which  the 
electricity  was  used  as  an  adjuvant  to  the 
Frenkel  exercise  therapy.  Under  these 
conditions  tlie  improvement  far  surpassed 
anything  observed  witliout  it.  Incon- 
tinence was  cured  in  the  five  cases  in 
which  it  existed  and  the  sexual  func- 
tion restored  in  nearly  every  instance. 
(Miinchener  med.  Woch.,  December  8, 
1908).  

HOT    lODIN    LAVAGE    OF    THE    INFECTED 
PUERPERAL  UTERUS. 
Dr.    Oi"tali   discusses   this   method   of 
treatment  and  highly  commends  it.     The 


vagina  is  disinfected,  dilated  and  the 
uterus  lightly  curetted  to  remove  all 
retained  clots,  after  which  the  uterus  is 
flushed  with  from  100  to  500  gm.  of  a 
mixture  of  equal  parts  of  tincture  of 
iodine  and  hot  water,  allowing  free 
escape  to  the  fluid.  After  a  few  minutes, 
or  at  the  first  complaint  by  the  patient, 
the  uterus  is  rinsed  out  with  plain  boiled 
water  to  remove  any  excess  of  iodin.  It 
is  not  necessary  to  tampoon  the  uterus  or 
the  vagina.  The  author  has  applied  this 
process  in  three  cases  (Mergari's  method 
of  treating  puerperal  infection)  and  he  is 
highly  satisfied  with  his  results.  He 
states  that  the  normal  conditions  are 
restored  in  the  uterus  in  a  very  short 
time.  (Gazetta  degli  Ospedali  e  della 
Cliniche,  Milan,  November  23). 


HYPER.ffiMIA  TREATMENT  IN 
GYNECOLOGY. 

Dr.  A.  Stein,  New  York,  discusses  the 
treatment  of  gynecologic  and  obstetric 
conditions  by  the  artificial  induction  of 
local  hypera?mia.  He  states  the  good 
results  obtained  from  the  use  of  the  hot- 
air  method.  It  is  applicable  in  chronic 
inflamed  adnexa,  pelvic  exudates,  chronic 
parametritis  and  perimetritis,  contracted 
painful  scars,  and  fixed  malpositions  of 
the  uterus  and  adnexa  when  resulting 
from  inflammatory  processes.  It  is  con- 
traindicated  when  there  is  fever,  in  preg- 
nancy, in  hasmorrhage  not  of  ovarian 
origin,  in  menstruation  and  hemorrhagic 
endometritis,  and  in  advanced  pulmonary 
and  cardiac  diseases.  The  hot  air 
method  is  very  valuable  in  diagnosing 
pus  foci,  since  the  presence  of  pus  foci 
causes  a  rise  in  the  temperature  after  the 
first  hot  air  treatment.  It  is  then  advis- 
able to  discontinue  the  treatment  and 
bring  about  the  absorption  of  the  pus  by 
other  means  before  continuing  it  again. 
For  practical  purposes,  the  easiest  way  to 


PROSTATE. 


SCIATICA. 


121 


give  hot  air  treatment  in  private  practice 
is  by  means  of  the  ordinary  semicirciilar 
cradle,  made  air-tight  by  covering  it  with 
blankets,  and  carrying  the  hot  air  to  it 
by  a  small  funnel-shaped,  sheet-iron 
chimney,  or  colored  electric  light  bulbs 
may  be  used  inside  the  cradle.  The  hot 
air  treatment  causes  an  active  local 
hypersemia  and  stimulates  metabolism, 
relieving  pain  and  causing  absorption  or 
breaking  down  of  exudates.  Perspira- 
tion is  caused,  cooling  the  skin  and 
allowing  high  temperatures  to  be  em- 
ployed. The  treatment  begins,  in  fact, 
only  when  the  temperature  has  reached 
80  or  100°  C.  (176  to  212°  F.).  The 
first  treatment  should  not  be  over  25  or 
30  minutes;  later,  if  the  patient's  con- 
dition favors  it,  it  may  last  60  minutes. 
It  must  be  remembered  that  advanced 
pulmonary  or  heart  disease  contra- 
indicates  its  use.  The  author  also  speaks 
of  the  weighting  treatment  in  combina- 
tion with  the  hot-air  treatment,  and 
recommends  it  highly  to  the  general 
practitioner,  since  it  does  not  require  any 
complicated  appliances.  He  has  also 
found  that  dry  cupping  increases  the  flow 
of  milk  and  is  very  useful  in  the  treat- 
ment of  puerperal  mastitis,  since  it  allays 
pain  and  inflammatory  symptoms  at 
once.  The  incisions  need  only  be  small 
ones  if  pus  has  formed,  and  the  shape 
and  function  of  the  breast  can  be  pre- 
served. In  conclusion,  he  speaks  of  the 
importance  of  attention  to  the  general 
condition  of  the  patient  as  an  essential  in 
any  use  of  the  treatment  by  artificial 
hyperaemia.  (Journal  of  the  American 
Medical  Association,  January  23.) 


He  thinks  that  the  hypertrophy  is  a 
tumor  growth  and,  therefore,  the  causes 
which  promote  the  enlargement  should  be 
avoided.  The  patient  should  not  ingest 
large  quantities  of  water  or  drink  any 
alcoholic  beverage,  and  he  should  avoid 
chills  and  long  journeys.  However,  the 
patient  should  take  light  food,  mild  exer- 
cise, warm  baths  and  rubs  as  often  as  he 
can  and  he  should  keep  his  abdomen  con- 
stantly warm.  The  patient  should 
urinate  at  the  least  desire,  walking  about 
a  little  if  urination  is  difficult.  Hot  sitz 
baths  will  frequently  bring  the  urine 
when  all  other  means  have  failed.  He 
regards  regular  aseptic  catheterization  as 
the  normal  method  of  treating  hyper- 
trophy of  the  prostate,  operating  only 
when  this  proves  impracticable,  and  then 
removing  the  entire  gland.  If  the 
patient  is  unable  to  stand  this,  he  does  a 
cystotomy.  (Thera.  Monatshefte,  Ber- 
lin, December  22,  No.  12,  pp.  605,  678). 


HYPERTROPHIED  PROSTATE,  TREAT- 
MENT  OF. 
Dr.  Hilderbrandt  maintains  that  en- 
largement of  the  prostate  is  amenable  to 
simple  hygienic  and   dietetic  measures. 


INJECTIONS   OF   SALT   SOLUTION   IN 
SCIATICA. 

Dr.  D'Orsay  Hecht  reports  the  sur- 
prisingly good  results  in  controlling  pain 
by  the  use  of  injections  of  salt  solution  in 
sciatica.  After  reviewing  the  literature 
of  alcoholic  injections  in  these  cases,  he 
concludes  that  they  are  unsuited  and 
shows  the  advantages  and  results  of  his 
method.  He  injects  a  considerable 
quantity  of  salt  solution  into  the  sciatic 
nerve  at  one  or  more  points  in  its  course, 
after  it  leaves  the  great  sacro-sciatic 
foramen.  He  has  not  met  with  any 
accidents,  and  in  conclusion  he  comments 
as  follows:  "(1)  The  deep  infiltrating 
perineural  injections  palliate  the  pain  of 
sciatica.  (2)  The  acute,  subacute  and 
chronic  types  of  sciatica  lend  themselves 
to  this  treatment,  and,  whereas,  the  num- 
ber of  injections  required  varies,  im- 
mediate notable  relief  is  afforded  by  the 


122 


SCIATICA. 


KELOIDS. 


first  injection  in  nearly  all  eases.  (3) 
The  treatment  is  most  indicated  and 
effective  in  the  non-symptomatic  cases, 
but  is  also  of  value  in  the  symptomatic 
variety.  (4)  Normal  salt  solution  of 
varying  temperature  and  quantity,  or  the 
betaeucain  solution  of  Lange,  is  to  be 
preferred  to  other  anaesthetic  or  mordant 
solutions.  Alcohol  is  harmful  and  con- 
traindicated.  (5)  The  sciatic  nerve  may 
be  reached  deep  in  the  ischiotrochanteric 
hollow  (its  peroneal  branch  lower  down 
at  the  capitellum  fibulae),  but  it  is  more 
surely  and  safely  reached, directly  after 
its  emergence  from  the  notch.  (6)  The 
point  for  puncture  and  penetration  to  the 
nerve  is  best  determined  by  drawing  a 
line  between  the  postero-external  border 
of  the  great  trochanter  and  the  sacro- 
coccygeal joint  at  the  junction  of  the 
inner  third  and  outer  two-thirds  of  this 
line  is  the  spine  of  the  ischium.  A 
thmnb's  breadth  to  the  outer  side  of  this 
spine  lies  the  sciatic  nerve.  Cadaver 
experiment  and  clinical  experience  lead 
me  to  endorse  this  landmark  above  all 
others.  (7)  The  method  requires  a 
syringe  (preferably  metal)  with  a  capac- 
ity for  from  30  to  60  c.c.  or  more,  a 
needle  of  desirable  length  (8  to  13  cm.) 
directly  attachable  to  the  syringe.  (8) 
Accidents  of  any  consequence  almost 
never  occur.  Unpleasant  effects  and 
complications  are  few  and  insignificant. 
(9)  The  prognosis  in  the  sense  of  a  cure 
is  good  if  the  facts  suffice — namely,  that 
in  the  large  number  of  cases  observed  for 
from  one  to  four  years  many  patients 
have  been  entirely  free  from  pain  during 
that  long  interval.  Improvement  is 
common.  Eecurrences  are  not  the  rule, 
and  failures  are  the  exceptions."  (Jour- 
nal of  the  American  Medical  Association, 
February,  6,  1909.) 


KELOIDS,     INJECTIONS    OF    FIBROLYSIN 
IN  THE  TREATMENT  OF. 

Dr.  E.  E.  Brennan  reports  a  case  in 
which  a  keloid  developed  in  a  patient  as 
the  result  of  a  bum.  The  patient,  aged 
sixteen,  while  masquerading,  was  terribly 
burned  about  the  face.  He  was  taken  to 
the  Flower  Hospital  for  treatment,  and 
was  dismissed  cured,  two  months  later. 
Later  he  was  brought  to  Dr.  Bodine's 
clinic  for  the  removal  of  the  tissue  that 
had  formed  from  the  burn.  A  diag- 
nosis of  keloid  was  made,  and  injections 
of  fibrolysin  recommended. 

The  injection  is  made  into  the  tumor 
itself  with  an  ordinary  Pravaz  syringe. 
The  injections  can  be  made  as  often  as 
necessary.  In  this  ease  one  was  niade 
each  week  until  twenty-four  had  been 
given,  with  the  following  result:  The 
keloid  tissue  sloughed,  broke  down  and 
ulcerated,  and  what  remained  was  ab- 
sorbed. The  injections  given  in  this 
case  were  quite  painful. 

The  author  heartily  recommends  fibro- 
lysin for  the  removal  of  cicatrical  tissue. 

European  confreres  have  also  reported 
brilliant  results  from  its  use  in  traumatic 
stricture  of  the  oesophagus  when  the 
injection  is  made  subcutaneously.  (New 
York  Polyclinic  Journal,  November, 
1908).  

ISOPRAL   IN   CARDIAC   AFFECTIONS. 

Dr.  Peters  states  that  this  drug  is  of 
great  value  in  patients  suffering  from  the 
various  forms  of  cardiac  disease.  In 
referring  to  the  literature  on  the  subject, 
he  finds  that  certain  clinicians  have  ex- 
pressed the  opinion  that  isopral  is 
endowed  with  a  toxic  effect  on  the  heart. 
This  he  denies.  Actual  reports  of  cases 
in  which  isopral  is  supposed  to  have 
undesirable  actions  on  the  circulatory 
system  are  few,  and  most  of  these,  he 
thinks,  can  be  explained  without  diffi- 


DIAERHCEA. 


TETANUS. 


123 


culty.  The  symptoms  complained  of 
were  in  all  cases  S3Tnptoms  which  could 
readily  arise  in  the  course  of  the  disease 
which  was  being  treated,  and  he  there- 
fore objects  to  assigning  the  cause  to  the 
drug  which  was  given.  He  has  given 
isopral  in  a  number  of  cardiac  patients, 
and  has  not  met  with  any  toxic  effects 
either  on  the  cardiac  nerves,  or  on  the 
vascular  system,  or  on  the  blood  pressure. 
The  heart  itself  is  not  attacked  by  this 
drug,  nor  have  any  deleterious  effects 
been  noticed  in  any  of  his  patients  during 
the  exhibition  of  the  drug.  In  cases  in 
which  salicylate  of  sodium  was  not  well 
tolerated,  he  obtained  a  good  pain-reliev- 
ing action  from  isopral.  He  therefore 
recommends  isopral  as  a  safe  hypnotic, 
which  can  be  given  even  in  advanced 
heart  disease.  (Deut.  med.  Woch.,  Octo- 
ber 29,  1908). 


LlftUOR  HYDRARGYRI  PERCHIORIDI  IN 
TREATMENT  OF  DIARRHCEA. 

Dr.  Faichnie  speaks  very  highly  of  the 
use  of  liquor  hydrargyri  perchloridi  in 
diarrhoea.  He  states  that  this  drug  was 
found  an  exceedingly  valuable  medicine 
during  the  South  African  War,  when 
diarrhoea  was  a  very  common  complaint. 

Liquor  hydrargyri  perchloridi  is  de- 
scribed as  an  intestinal  disinfectant,  and 
combined  with  chlorod}Tie  seems  to 
remove  the  cause  as  well  as  the  symptoms 
of  diarrhoea. 

Its  use  is  well  known,  and  his  reason 
for  bringing  it  forward  now  is  that  when 
in  charge  of  two  sections  of  a  British 
Field  Hospital,  during  the  late  Mohmand 
expedition  he  was  unable  to  administer 
it  for  a  time,  when  diarrhoea  was  preva- 
lent, as  it  is  not  provided  in  the  panniers. 
As  a  substitute,  however,  he  used  the 
following,  which  acted  equally  well,  viz., 
one  tablet  of  the  perchloride  of  mercury 
supplied  as  an  antiseptic,  containing  8.75 


grains  of  hydrargyri  perchloridum,  dis- 
solved in  17%  ounces  of  water,  which 
gave  a  mixture  containing  Y^g  grain  in 
one  fluid  drachm,  the  same  strength  as 
the  B.  P.  preparation.  The  blue  color  of 
the  tablet,  due  to  an  aniline  dye,  is  quite 
hannless.  (Journal  of  the  Eoyal  Army 
Medical  Corps,  October,  1908). 


MAGNESIUM    SULPHATE   IN   TETANUS. 

Dr.  Miller  briefly  abstracts  the  re- 
ported cases  up  to  date  with  a  detailed 
account  of  a  boy  seven  years  old.  Of  the 
14  cases  on  record  treated  with  mag- 
nesium sulphate,  11  severe  and  usually 
fatal  cases  received  subarachnoid  injec- 
tions, but  of  this  number  5  recovered, 
making  a  mortality  of  55  per  cent.  The 
three  remaining  cases  were  of  a  milder 
type  and  all  recovered  with  infusions  of 
magnesium  sulphate. 

The  brief  resume  of  the  case  which  he 
reported  is  as  follows:  Diagnosis. — 
Tetanus.  Incubation,  seven  days.  Ad- 
mitted to  the  wards  of  the  Johns  Hop- 
kins Hospital  on  the  tenth  day.  Eleven 
lumbar  punctures  were  made  within 
thirteen  days,  approximately  25  c.c.  of  a 
twenty-five-per-cent.  solution  of  mag- 
nesium sulphate  injected  into  the 
meninges  at  each  puncture.  Extensive 
paralysis  followed  each  injection  and 
involved  usually  all  the  muscles,  except 
those  of  the  head,  neck,  and  diaphragm, 
and  lasted  approximately  18  to  29  hours. 
The  injections  were  followed  several 
times  by  respiratory  collapse,  lasting 
eleven  to  fourteen  hours,  and  the  pulse 
dropped,  though  not  to  a  dangerous  level. 
Antitoxin,  daily  for  fourteen  days,  in 
doses  varying  from  1500  to  7000  units, 
copious  saline  ena3mas  and  infusions,  and 
sedatives  for  a  short  time,  were  also  used 
in  the  treatment.  Discharged  as  cured 
five  weeks  after  admission  to  hospital. 
Miller  says  that  it  may  be  affirmed  that 


124 


OXYGEN. 


PHYSOSTIGINIIN. 


by  the  use  of  magnesium  sulphate  it  is 
possible  to  achieve  complete  muscular 
relaxation  in  almost  all  cases  of  tetanus; 
from  the  report  of  results  there  seems  to 
be  a  distinct  benefit  to  the  patient  in  this 
condition,  inasmuch  as  it  prevents  the 
rajjid  exhaustion  due  to  convulsions  and 
in  most  instances  has  made  it  possible 
for  the  patient  to  take  nourishment.  It 
is  very  lilcely  that  when  the  technique  is 
worked  out  completely,  a  great  many  lives 
will  be  saved.  (American  Journal  of  the 
Medical  Sciences,  December,  1908). 


OXYGEN  INSUFFLATION  FOE,  REVIVAL  OF 
NEW  BORN. 

Dr.  Cavazza  discusses  a  method  for  the 
restoration  of  respiration  after  the  ordi- 
nary methods  have  failed.  His  method 
consists  in  taking  a  breath  of  oxygen  and 
then  one  of  air  and  then  by  mouth  to 
mouth  insufflation,  breathes  the  oxygen 
into  the  child's  lungs,  stimulating  breath- 
ing by  the  reflexes  from  time  to  time. 
He  has  been  successful  in  three  very 
severe  cases.  In  one  case  of  long  and 
difficult  labor,  asphyxia  was  marked,  but 
the  heart  was  faintly  l)eating.  After 
half  an  hour  of  the  oxygen  insufflation 
the  temperature  rose  to  normal  and  the 
heart  gained  ground  a  little,  but  there 
was  not  a  trace  of  respiration.  He  kept 
up  the  insufflations  for  two  hours  and 
three-quarters,  when  signs  of  restoration 
of  breathing  were  perceived  and  the 
child  soon  revived.  In  one  case  he  kept 
up  the  insufflation  for  an  hour  before  the 
oxygen  arrived,  the  heart  action  slightly 
improving  under  it.  Signs  of  respira- 
tion became  evident  in  twenty  minutes 
after  the  oxygen  was  used.  The  author 
believes  that  the  advantages  of  this 
measure,  as  a  last  resort,  counterbalance 
all  the  possible  drawbacks.  (Journal  of 
the  American  Medical  Association,  Jan- 
uary 9,  1909). 


PANCREAS  DIABETES,  TREATMENT  OF. 
Dr.  Bruck  remarks  that  the  Joint 
action  of  the  adrenalin  and  pancreatic 
secretions  under  normal  conditions  pre- 
vent glycosuria,  but  if  the  pancreatic 
secretion  is  lacking,  the  adrenalin  gets 
the  upper  hand  and  glycosuria  follows. 
He,  therefore,  suggests  that  the  antagon- 
istic action  of  adrenalin  might  be  utilized 
in  the  treatment  of  diabetes.  No  glyco- 
suria is  produced  in  dogs  after  the  pan- 
creas is  removed  and  the  adrenalin 
secretion  is  inhibited  or  if  an  active 
pancreas  preparation  is  injected  into  the 
veins.  The  pancreas  diabetes  is,  there- 
fore, rather  a  negative  pancreas  and  a 
positive  supra-renal  diabetes,  as  the  over- 
production of  adrenal  is  responsible  for 
the  glycosuria.  He  suggests  that  the 
same  principal  might  be  applied  in 
pancreas  diabetes,  which  is  the  base  for 
the  treatment  of  exophthalmic  goiter  with 
the  serum  or  milk  of  thyroidectomized 
animals.  By  excluding  the  adrenalin 
from  the  circulation,  the  milk  or  serum 
of  animals  thus  treated  might  prove  an 
effectual  means  of  supplying  the  diabetic 
with  the  missing  neutralizing  pancreatic 
secretion.  (Medizinische  klinic,  Berlin, 
November  15,  1908.) 


PHYSOSTIGMIN   IN  POSTOPERATIVE 
ILEUS. 

Dr.  Goth  gives  new  views  on  the  treat- 
ment of  postoperative  ileus.  He  reports 
three  cases  of  severe  ileus  from  paralysis 
of  the  bowels  after  major  operations. 
The  symptoms  indicated  a  septic  infec- 
tion except  that  the  tongue  was  healthy 
looking;  %4  of  a  grain  (0.001  gm.)  of 
physostigmin  salicylate  was  injected  and 
immediately  vigorous  peristalsis  was 
induced.  Twenty  minutes  after  the  last 
dose,  there  was  no  more  flatus.  In  one 
case  a  third  injection  was  administered, 
while  in  another  case  ^/32  gr.  (0.003  gm.) 


SODIUM  CINNAMATE. 


STRYCHNINE. 


125 


accomplished  the  desired  results  in  less 
than  half  an  hour.-  The  author  attri- 
butes the  cause  of  the  postoperative 
paralysis  as  due  to  the  lack  of  an  omen- 
tum as  a  covering  for  the  intestines. 
(Zentralblatt  fiir  Gyuakologie,  Leipsig, 
December  19,  1908). 


SODIUM   CINNAMATE  IN  TUBERCULOSIS. 

Drs.  Eeynier  and  Bluson  state  that 
they  think  that  sodium  cinnamate  has 
beneficial  results  in  tuberculosis.  They 
report  twenty-one  cases  of  pulmonary  and 
external  tuberculosis  in  which  this  drug 
has  been  given  a  thorough  trial.  In  ten 
cases  the  bacilli  vanished  from  the 
sputum  and  the  stethoscope  showed 
approximately  normal  conditions  out  of 
the  nineteen  patients  who  showed  the 
most  benefit.  Their  experience  seems  to 
suggest  that  this  drug  combines  with  the 
toxins  engendered  by  the  bacilli,  trans- 
forming them  into  non-toxic  compounds. 
Favorable  voices  have  been  raised  here 
and  there  since  Landerer  first  proclaimed 
the  efficiency  of  sodium  cinnamate,  and  it 
has  been  successfully  used  in  Spain,  but 
Eeynier  asserts  that  it  has  not  been 
given  generally  the  attention  it  deserves. 
He  prefers  to  give  this  drug  in  subcu- 
taneous or  intramuscular  injections,  up 
to  the  maximum  of  0.3  or  0.4  gm.  (from 
4.5  to  6  gr.)  in  two  days.  His  patients 
were  mostly  adults.  (Bull,  de  P Acad- 
emic de  Medecine,  Paris,  November  24, 
1908). 

STRYCHNINE  IN  PARALYZED  LIMBS. 

Dr.  W.  Steele,  of  Mongaup  Valley, 
N.  Y.,  states  that  the  hypodermic  use  of 
strychnine  sulphate  has  a  good  local 
effect  and  is  of  temporary  benefit  in 
paralyzed  muscles;  that  some  patients 
require  five  to  ten  times  the  usual  dose; 


and  that  %  grain  is  about  the  proper 
amount  where  paralysis  is  complete. 

Two  cases  are  detailed :  The  first  case 
was  one  of  acute  transverse  myelitis,  in 
a  man  fifty-seven  years  of  age.  Paralysis 
of  one  leg  from  hip  down;  nearly  com- 
plete. He  received  ^o  grain  strychnine 
sulphate  injected  in  the  paralyzed  mus- 
cles of  the  hip  or  leg  daily,  except  Sun- 
days, for  twenty-six  days.  There  was 
some  improvement  and  little  atrophy. 
The  dose  was  then  doubled  to  Yiq  grain, 
and  these  injections  were  continued  for 
twenty-seven  days  more.  This  was 
changed  to  silver  nitrate,  but  since  there 
was  less  effect  and  improvement,  it  was 
abandoned  after  having  been  used  for 
sixty-nine  days.  Then  four  tablets  of 
the  strychnine  sulphate,  Y20  grain  each, 
once  a  day  were  used,  which  was  finally 
increased  to  six,  and  even  to  seven  tab- 
lets. Injections  were  made  at  two  or 
three  places  of  the  paralyzed  leg  at  one 
time.  After  being  treated  for  114  days, 
the  treatment  was  discontinued.  The  pa- 
tient was  in  excellent  health,  and  was 
able  to  walk.  Six  years  later  he  had  an- 
other and  less  severe  attack  in  the  other 

Ipcr 

The  second  case  was  one  of  apoplexy, 
followed  by  hsemiplegia  of  the  left  side. 
Fourteen  days  after  the  stroke  com- 
menced hypodermic  injections  of  strych- 
nine sulphate  were  given,  using  34o-gi'ain 
tablets  twice  a  day,  and  running  the  dose 
up  to  Yio  grain  on  the  third  day,  finally 
giving  him  four  tablets  twice  a  day,  or 
%o  grain  per  day,  which  treatment  was 
continued  for  eight  days.  Patient  gained 
rapidly  in  every  way  except  use  of  his 
fingers.  Four  weeks  after  the  attack  he 
went  home,  and  eight  weeks  after  the  at- 
tack he  was  walking  with  a  cane,  though 
he  could  not  move  fingers.  (New  York 
State  Journal  of  Medicine,  October, 
1908.) 


126 


SWEATING  FEET. 


X-RAYS. 


SWEATING  FEET,  TREATMENT  OF. 

It  is  stated  (in  the  Medical  World, 
November,  1908)  that  good  results  have 
been  obtained  from  the  following  treat- 
ment. Make  a  solution  of  potassium 
permanganate  so  that  it  will  be  of  a 
deep  red  color.  Soak  the  feet  in  it  for 
fifteen  minutes  before  retiring.  The 
next  night  make  a  solution  of  formalde- 
hyde, a  dram  to  a  pint  of  water,  and 
soak  the  feet  in  this  for  fifteen  minutes. 
Continue  these  alternate  treatments  until 
the  excessive  perspiration  stops.  If  the 
skin  is  already  abraded,  use  a  weaker 
solution  of  formaldehyde  to  start  with,  as 
it  will  cause  intense  smarting  on  an 
abraded  surface;  one  can  speedily 
increase  the  strength  of  the  solution  as 
tolerance  is  established  and  as  the  skin 
becomes  toughened. 

Make  up  a  powder  composed  of  a  dram 
of  salicylic  acid  and  a  dram  of  tannic 
acid,  with  an  ounce  of  boric  acid.  Dust 
the  feet  with  this  in  the  morning  and 
sprinkle  the  inside  of  the  socks  Avith  it 
before  putting  them  on.  It  may  be 
necessary,  at  intervals  of  a  few  months, 
to  resume  treatment  for  a  few  nights 
only;  yet  some  cases,  once  cured,  never 
again  cause  trouble.  (Merck's  Archives, 
December,  1908). 


THE  X-RAYS  IN  EPITHELIOMA. 

G,  E.  Pfahler,  Philadelphia,  divides 
the  epitheliomas,  as  regards  their  treat- 
ment by  the  Eontgen-rays,  into  five 
classes:  (1)  Superficial  epitheliomata 
of  the  exposed  surfaces  of  the  hands  and 
face,  which  should  yield  practically  100 
per  cent,  of  cures.  They  are  usually 
small  in  area,  of  slow  growth  and  com- 
paratively painless.  They  will  usually 
require  ten  or  twelve  treatments  and 
from  two  to  three  months  for  a  cure ;  the 
results  are  more  likely  to  be  permanent 


than  with  any  other  treatment.  If  un- 
treated there  is  a  possibility  of  this  form 
passing  into  the  deep  ulcerating  type. 
(2)  Superficial  epitheliomata  associated 
with  senile  keratosis  also  yield  to  the 
Eontgen-rays  very  similarly  to  those  of 
Class  1,  but  recurrences  are  much  more 
probable.  These  patients  also  seem  to 
have  exposures  at  short  intervals  on  ac- 
coimt  of  the  risk  of  dermatitis.  (3) 
Pearly  epitheliomata.  These  include  a 
smaU  group  of  cases  in  which  there  is  a 
circle  of  pearl-like  elevations  forming  a 
ridge  and  surrounding  a  central  area 
much  resembling  healthy  skin.  The 
ridge  spreads,  often  irregularly,  while  the 
center  heals.  They  are  of  slow  growth 
and  not  very  malignant,  but  they  yield  to 
treatment  less  readily  than  the  other 
superficial  forms.  Best  results  will  prob- 
ably be  obtained  by  protecting  the  soft 
center  and  treating  the  border  strongly 
with  a  very  soft  tube.  (4)  Under  the 
class  of  deep  ulcerating  epitheliomata, 
Pfahler  groups  those  cases  that  involve 
the  deeper  tissues  and  present  large  ulcer- 
ating surfaces  with  indurated  edges  and 
often  with  an  indurated  base.  They  may 
involve  any  part  of  the  body,  and  are  at 
times  associated  with  enlargement  of 
neighboring  lymphatic  glands.  They 
often  consist  of  recurrence  of  superficial 
epitheliomata  of  Class  1  after  treatment 
with  caustics,  curettement  or  excision. 
These  cases  do  not  yield  readily  to  the 
rays,  and  should  be  excised  when  possible. 
(5)  Epitheliomata  on  mucous  surfaces, 
including  those  on  the  lips  and  inner 
surface  of  the  cheeks,  the  vagina  and  the 
penis.  In  these  cases  no  time  should  be 
lost  by  X-ray  treatment,  but  the  growth 
should  be  excised  at  once,  and  this  fol- 
lowed by  a  thorough  course  of  treatment 
with  the  rays  over  the  glandular  area. 
(Journal  of  the  American  Medical  Asso- 
ciation, November  21.) 


BOOK  REVIEWS.  127 

GREATER  NEW  YORK  NUMBER. 

An  unusual  feature  of  medical  journalism  will  be  presented  in  the  March  issue  of  the 
American  Journal  of  Surgery.  The  entire  original  subject-matter  in  this  issue  will  be 
contributed  by  New  York  City  surgeons  of  note,  and  a  number  of  new  operations  will  be  first 
presented  therein.  Among  the  contributions  to  appear  are:  "A  New  and  Simple  Method 
of  Intestinal  Anastomosis"  (illustrated),  by  Howard  Lilienthal,  M.D.,  Attending  Surgeon, 
Mt.  Sinai  Hospital.  "Sigmoiditis  and  Perisigmoiditis,"  by  James  P.  Tuttle,  M.D.,  Professor 
of  Rectal  Suj-gery,  New  York  Polyclinic,  New  York.  "Sacral  Suspension  of  the  Uterus — ^A 
New  Technic"  (illustrated),  by  James  Van  Doren  Young,  M.D.,  Surgeon,  St.  Elizabeth  Hos- 
pital, New  York.  "Cancer  of  the  Breast,"  by  Willy  Meyer,  M.D.,  Professor  of  Surgery,  Post- 
Graduate  Medical  School;  Attending  Surgeon  of  German  Hospital.  New  York.  "A  Modified 
Operation  for  Inguinal  Hernia"  (illustrated),  by  Albert  E.  Sellenings,  M.D.,  New  York. 
"The  Localization  and  Removal  of  Foreign  Bodies  with  Especial  Reference  to  Those  in  the 
Skeletal  Tissues"  (illustrated),  by  Dr.  Walter  M.  Brickner,  Assistant  Adjunct  Surgeon,  Mt. 
Sinai  Hospital ;  Editor-in-Chief,  American  Journal  of  Surgery,  New  York.  "An  Operation 
for  Direct  Blood  Transfusion  with  a  Description  of  a  Simple  Method,"  by  John  A.  Hartwell, 
M.D.,  Attending  Surgeon  to  Bellevue  Hospital,  New  York.  "Plastic  Mastoid  Operation — A 
New  Method  of  Operating  in  Acute  Mastoiditis,"  by  T.  F.  Hopkins,  M.D.,  Assistant  Surgeon 
Oral.,  New  York  Eye  and  Ear  Infirmary,  New  York.  "Dislocation  of  the  Cervical  Vertebrae" 
(illustrated),  by  James  P.  Warbasse,  M.D.,  Special  Editor,  American  Journal  of  Surgery; 
Attending  Surgeon  to  Seney  and  German  Hospital,  Brooklyn.  "Surgery  of  the  Pericardium 
and  Heart,"  by  H.  Beeckman  De  Latour,  M.D.,  Attending  Surgeon  to  St.  John  and  Norwegian 
Hospitals;  Professor  of  Clinical  Surgery,  Long  Island  Medical  College.  "Fibrosis  Uteri  and 
Its  Surgical  Treatment"  (illustrated),  by  S.  W.  Bandler,  M.D.,  Adjunct  Professor  of  Gyne- 
cology, New  York  Post-Graduate  Medical  School.  "Laryngeal  Stenosis  in  the  Adult,  Suc- 
cessfully Treated  by  Intubation,"  by  William  K.  Simpson,  M.D.,  Professor  Laryngology, 
College  of  Physicians  and  Surgeons,  New  York. 


THE  AMERICAN  SOCIETY  FOR  THE  STUDY  OF  ALCOHOL  AND 
OTHER  NARCOTICS. 

The  American  Society  for  the  Study  of  Alcohol  and  Other  Narcotics  will  hold  a  meeting 
at  Washington,  D.  C,  March  17th,  18th  and  19th,  in  the  afternoons  and  evenings,  for  the 
presentation  and  discussion  of  papers  on  the  various  phases  of  the  alcoholic  problem. 

This  Society  was  organized  in  1870,  and  w^as  the  first  medical  association  to  take  up 
the  study  of  alcohol  and  the  diseases  following  from  its  use.  The  present  meeting  is  a 
response  to  an  invitation  from  leading  men  at  the  Capitol  to  present  to  the  profession  and 
public  some  scientific  and  authoritative  conclusions  concerning  the  alcoholic  problem,  based 
on  facts  of  laboratory  and  clinical  research,  and  entirely  from  a  scientific  point  of  view. 

Over  thirty  papers  on  different  phases  of  the  subject  have  been  promised,  and  many  of 
them  from  the  great  leaders  of  the  medical  profession.  Physicians  and  all  interested  are 
very  cordially  invited  to  be  present.  For  programs  and  particulars,  address  Dr.  T.  D. 
Crothers,  Secretary,  Hartford,  Conn. 


5ool<  Reviews 


1 


Diseases  of  the  Genito-Urinary  Organs  and  the  Kidney.  By  Robert  Holmes  Greene, 
A.M.,  M.D.,  Professor  of  Genito-Urinary  Surgery,  Medical  Department  of  Fordham  Uni- 
versity; Genito-Urinary  Surgeon  to  tlie  City  and  to  the  French  Hospital,  New  York 
City,  and  Harlow  Brooks,  M.D.,  Assistant  Professor  of  Clinical  Medicine,  University  and 
Bellevue  Hospital  Medical  School;    Visiting  Physician  to  the  City  Hospital,  New  York 


128  BOOK  REVIEWS. 

City.     Second  Edition,  Revised  and  Enlarged,  with  323  Illustrations.     Philadelphia  and 
London:     W.  B.  Saunders  Company,  1908. 

The  aim  of  this  volume  is  to  present  a  discussion  of  the  more  important  diseased  condi- 
tions of  the  uro-genital  tract,  taken  from  the  standpoint  of  the  general  practitioner  and 
surgeon.  This  volume  consists  of  thirty  chapters,  and  three  hundred  and  twenty-three  illus- 
trations. The  chapter  on  "The  Surgery  of  the  Kidney"  deserves  especial  mention,  and  the 
description  of  the  various  surgical  procedures  makes  it  one  of  the  most  important  features 
of  this  handsome  volume.  The  author  describes  very  vividly  the  method  as  to  the  permanent 
retention  of  the  kidney  after  fixation,  as  advised  by  Dr.  J.  M.  Edebohls. 

This  edition  is  a  thorough  review  of  the  previous  one,  and  together  with  the  numerous 
changes  and  additional  subjects,  has  been  brought  up  to  the  requirements  of  to-day. 

In  the  chapter  devoted  to  the  consideration  of  the  tumors  of  the  kidney  the  authors 
state  that  the  hypernephroma  is  the  most  frequent  tiunor  that  occurs  as  a  primary  growth. 
"These  tumors  are  said  to  spring  from  the  fetal  tissue  originally  intended  to  develop  into 
adrenal  bodies,  but  which  become  detached  and  incorporated  in  the  anlage  of  the  kidney." 

The  general  arrangement  of  the  book  is  extremely  pleasing,  and  the  consideration  of  the 
different  instruments  cannot  be  surpassed. 

The  author  concludes  his  work  with  an  interesting  chapter  on  "Sexual  Neuroses." 

Principles  and  Practice  of  Physical  Diagnosis.  By  John  C.  DaCosta,  Jr.,  M.D.,  Asso- 
ciate in  Clinical  Medicine,  Jefferson  Medical  College;  Chief  of  Medical  Clinic  and 
Assistant  Visiting  Physician,  Jefferson  Hospital;  Hematologist,  German  Hospital; 
Fellow  of  the  College  of  Physicians  of  Philadelphia;  Associate  Member  of  the  Associa- 
tion of  American  Physicians;  Member  of  the  American  Climatologieal  Association. 
With  212  Original  Illustrations.  Philadelphia  and  London:  W.  B.  Saunders  Company, 
1908. 

In  compiling  this  work  on  the  "Principles  and  Practice  of  Physical  Diagnosis,"  Professor 
DaCosta  has  undertaken  a  piece  of  w^ork  that  is  well  worth  doing,  and  has  performed  the 
task  exceedingly  well.  He  has  taken  up  the  subject  from  all  its  aspects,  and  in  order  to 
guide  those  far  advanced  in  the  study  and  practice  of  medicine,  the  subjects  of  pathology 
and  diagnosis  are  accorded  commensurate  prominence. 

The  text  is  eminently  practical;  theory  is  dispensed  with  as  much  as  possible,  or  where 
mentioned,  is  dealt  with  briefly  and  fairly.  An  interesting  and  valuable  consideration  is 
given  to  the  various  types  and  abnormalities  of  the  chest,  embodying  many  of  the  author's 
own  observations  on  the  subjects,  as  well  as  the  more  recent  methods  of  investigation. 

The  book  is  divided  into  eight  sections,  namely:  "Methods  and  Technic  of  Physical 
Examination;"  "Examination  of  the  Thorax;"  "Examination  of  the  Bronchopulmonary 
System;"  "Diseases  of  the  Bronchopulmonary  System  and  Mediastinum;"  "Examination 
of  the  Cardiovascular  System;"  "Diseases  of  the  Cardiovascular  System;"  "Examination  of 
the  Abdomen  and  Abdominal  Viscera." 

Thoracometry,  cyrtometry,  sphygmomanometry,  sphygmography  and  cardiography  are  dis- 
cussed at  length. 

The  various  affections  of  the  heart  are  considered,  and  stress  is  laid  on  the  leading  points 
to  be  found  during  the  physical  examination,  and  the  erroneous  and  exaggerated  statements 
often  made  in  this  connection  are  pointed  out.  He  also  states  the  clinical  anatomy  and 
pathology,  and  their  importance  in  health  and  disease,  and  it  enables  one  to  interpret  intelli- 
gently and  correctly  the  results  which  are  obtained  by  the  various  modes  of  examination. 
The  text  is  lucid  and  clear,  is  admirably  matched  and  illuminated  by  numerous  and  adequate 
illustrations,  photographs  and  diagrams.  The  feature  of  this  work  is  its  fullness  in  detail 
and  the  numerous  points  in  technic. 

The  subject  matter  is  conveniently  arranged,  with  a  capital  table  of  contents  at  the 
beginning,  and  an  admirable  index  at  the  end. 

A  Reference  Handbook  of  Gynecology  for  Nurses.  By  Catharine  McFarlane,  M.D., 
Gynecologist  to  the  Woman's  Hospital  of  Philadelphia.  Illustrated.  Philadelphia  and 
London:    W.  B.  Saunders  Company,  1908. 

This  is  truly  the  nurses'  desideratum  as  to  a  reference  hand-book  of  gynecology.  This 
is  a  small  book,  handsomely  bound,  and  contains  the  essential  facts  concerning  gynecologic 
examinations,  positions,  diseases,  minor  and  major  gynecologic  operations. 

Every  chapter  contains  just  what  the  nurse  wants  in  the  performance  of  her  duties.  All 
the  details  of  asepsis  and  antisepsis  during  other  operative  cases  are  well  stated.  The 
thoroughly  practical  caste  of  the  book  is  A\hat  recommends  it  to  the  nurse.  Everything  is 
arranged  systematically,  and  will  no  doubt  serve  as  a  valuable  guide. 


Monthly   Cyclopaedia 

AND 

Medical  Bulletin 


(Published  thb  Last  op  Each  Month) 


Monthly  Cyclopaedia  Section 


Vol.  II.  PHILADELPHIA,  MARCH,  1909.  No.  3. 


Original  Articles 


Department  in  charge  of  J.  MADISON  TAYLOR,  A.M.,  M.D. 


THE  TREATMENT  OF  TYPHOID  FEVER  WITH  SOLUTION  OF  CALCIUM 

CREOSOTE. 

Analysis  of  118  Cases— Practical  Remarks  on  the  Disease/ 

By  LOUIS  KOLIPINSKI,  M.D., 

WASHINGTON,   D.   O. 

(Concluded  from  the  February  issue.) 

Pigmentation  of  the  palms  and  soles  was  not  encountered. 

Glossitis,  stomatitis,  tonsillitis,  parotitis,  lesions  of  oesophagus,  disturb- 
ance of  the  stomach,  except  flatulence  and  vomiting,  not  seen. 

Diarrhoea  in  the  beginning  is  frequent  from  food  or  purgatives.  This 
rights  itself.  Dian-hoea  during  the  course  is  due  to  infected  milk,  which  should 
alwa3^s  be  changed  at  once  as  previously  described.     Medication  is  superfluous. 

Meteorism  is  found  in  all  toxsemic  patients.  No  instance  of  it  required 
particular  attention,  its  degree  being  moderate  or  indicated  only. 

Dysentery  not  met  with. 

Abdominal  pain  not  uncommon  in  hypogastrium,  right  or  left  flank  or 
groin.  That  it  bears  absolute  relation  to  grave  intestinal  complications  is  not 
certain  although  pain  and  tenderness  appear  in  them.  Abdominal  pain  is 
commonly  due  to  intestinal  flatulence  or  constipation. 

1  The  treatises  on  typhoid  fever  by  Curachmann,  in  Nothnagel's  "Encyclopedia  of 
Practical  Medicine,"  edited  by  Wm.  Osier,  and  of  McCrae  in  "Modern  Medicine,"  edited 
by  the  came,  were  used  as  guides  to  the  text  of  this  essay. 

3  (129) 


130  THE  TREATMENT  OF  TYPHOID  FEVER. 

Abdominal  tenderness  was  not  found,  it  is  without  doubt  of  more  import 
than  pain. 

Hcemorrliage  and  perforation  of  the  intestine. — It  is  a  doubtful  fact  that 
haemorrhage  or  perforation  can  occur  in  typhoid  fever  unless  the  intestinal 
ulceration  is  in  a  septic  and  necrotic  state.  Haemorrhage  and  perforation  are 
accidents  when  the  ulcers  are  partly  gangrenous  and  in  the  act  of  casting  off 
the  slough. 

There  are  in  this  series  none  of  perforation  and  of  haemorrhage  but  two; 
which  latter  are  not  to  be  counted  in  a  comparative  study  of  results  of  treat- 
ment, as  one  case  was  first  seen  after  the  occurrence  of  three  severe  bleedings 
and  the  other  had  been  sick  with  the  fever  three  weeks  before  treatment  was 
begun.  Both  of  these  serious  complications  are  therefore  practically  very 
much  less  frequent,  or  as  in  this  collection,  absent.  Haemorrhage  and 
perforation  being  lesions  of  the  same  site,  and  only  different  in  depth  or 
direction,  may  therefore  happen  either  separately  or  combined. 

There  is  one  great  exciting  cause,  which  will  be  found  if  sought  for  in 
almost  all  of  these  events,  namely,  the  patient  sitting  up  or  getting  out  of 
bed.  By  either  of  which  acts  the  intestinal  movement  or  motion  is  increased, 
much  more  so  in  urination  and  defsecation.  The  intra-abdominal  pressure 
and  compression  increases,  all  of  which  start  the  injury  of  rupture  or  a  tear. 

From  this  reasoning  it  is  apparent  that,  in  the  flat  supine  posture  of  the 
body  in  typhoid  fever,  the  intestinal  ulceration  is  guarded  from  mechanical 
harm  in  the  highest  possible  degree.  No  case  can  be  considered  properly 
cared  for  and  treated  in  which  the  bed  is  left  before  convalescence  is  well 
established.  Haemorrhage  and  perforation  appear  to  be  more  common  in  the 
German  than  in  other  nations  of  mankind,  comparing  only  the  Caucasian 
race. 

Rectal  diseases. — There  was  no  case  of  complicating  dysentery,  none  of 
ulceration  of  the  rectum,  none  of  fissure  of  the  anus. 

Hoemorrhoids,  old  or  recent,  may  play  an  important  role  in  bleeding  from 
the  rectum.  There  were  three  instances  of  this.  In  one  it  caused  the  soimding 
of  an  alarm  from  fear  of  intestinal  haemorrhage.  Another  was  a  robust  man, 
with  the  ambulatory  form  of  the  disease,  in  whom  hemorrhoidal  bleeding  was 
so  prolonged  and  abundant  that  he  was  highly  exsanguinated  before  treatment 
was  begun.  He  had  not  recovered  from  his  anaemia  at  the  end  of  six  months. 
The  third  was  a  woman  who  had  had  a  mild,  short,  primary  fever.  Fscal 
impaction  brought  on  a  relapse.  Futile  efforts  at  defaecation  caused  repeated 
and  copious  bleeding  from  haemorrhoids.  She  had  attacks  of  vertigo,  faintness, 
looked  bloodless  and  the  legs  became  oedematous.  The  fever  of  the  relapse  ran 
a  low  course  to  recovery. 

Splenic  enlargement  never  grew  to  clinical  interest  or  importance  and  was 
not  sought  for  with  the  object  of  diagnosis. 

Diseases  of  gall  bladder. — Gall  stone,  cholecystitis,  empyema,  not  observed. 

Pancreatic  diseases. — ISTo  pancreatic  disturbance  or  disease  found. 

Epistaxis. — Happened  in  several  instances  in  children.  The  amount  of 
bleeding  was  so  small  and  short  that  no  local  treatment  was  needed.     For  the 


THE  TREATMENT  OF  TYPHOID  FEVER.  131 

bleeding  from  the  nose  in  typhoid  fever,  insufflation  of  precipitated  sulphur  is 
relied  upon ;  all  forms  of  plugging  are  eschewed. 

Larynx. — No  form  of  laryngeal  involvement  encountered.  Eespiratory 
act.  This  varied  from  24  to  28.  Was  not  irregular  or  suffered  any  inter- 
ference. 

Bronchitis. — In  one  case  a  heavy,  acute  purulent  broncliitis. 

Cough. — There  was  in  many  a  laryngo-bronchial  cough,  accompanying 
the  rise  of  the  fever  and  disappearing  with  its  decline.  The  cough  apparently 
aggravated  by  the  supine  position  and  being  in  its  sound,  short  and  sharp.  No 
medication  was  given  and  its  frequency  was  very  probably  intensified  by  the 
stimulating  action  of  the  calcium  creosote  on  the  respiratory  mucous  membrane. 

Labor  pneumonia,  pneumotyphoid,  bronchopneumonia,  and  pleurisy. 
None  of  these  diseases  present.  Likewise  no  case  of  lung  infarction  or  abscess. 
No  instance  of  hsemophthisis. 

The  Pulse  ranged  from  80  to  90  beats  per  miaute.  The  rapid  pulse  of  a 
weakening  state  and  the  apparent  debility  of  the  third-week  period,  a  pulse  of 
120  to  130  was  counteracted  by  increase  of  milk.  The  decrotic  pulse  not  often 
felt  and  only  of  a  few  days'  existence.  The  slow  pulse  of  the  decline  of  fever 
with  normal  or  subnormal  morning  temperature  disappeared  with  convalescence 
and  the  taking  of  mixed  food. 

Endocarditis,  pericarditis,  heart  weakness,  and  myocarditis  not  observed. 

Collapse. — This  dangerous  complication  was  not  met  with.  It  is  the 
outcome  of  high  fever,  much  sepsis  and  insufficient  food.  To  combat  it  when 
it  has  been  allowed  to  break  in  is  mostly  hopeless.  The  various  cardiac 
stimulants  that  are  sanctioned  are  like  a  sword  of  lead. 

Diseases  of  the  arteries. — None  found. 

Diseases  of  the  veins. — One  case  of  left  femoral  thrombosis.  On  the 
eleventh  day  of  a  twenty-day  fever,  moderate  pain,  no  increase  of  fever. 
Swelling  of  limb  gone  a  month  later. 

Headache. — The  headache  of  the  first  few  days  is  fairly  frequent;  never 
severe;   invariably  disappears  spontaneously;   no  medication. 

Insomnia  was  occasionally  so  intense  that  an  opiate  was  given  at  night. 
The  sleeplessness  is  of  short  duration  and  never  persists  as  the  fever  grows 
less. 

Stupor  occasionally  encountered,  oftener  in  children,  lasts  only  a  few 
days. 

Delirium  marked,  but  not  violent,  in  three  cases  of  the  whole  number. 

Dreams  were  not  frequent,  not  vivid  or  causing  fear  the  next  day.  In 
some  the  dreams  were  of  food  and  of  eating,  the  recollection  of  them  pleasant. 

Memory. — The  memory  in  some  slightly  defective,  but  not  of  such  extent 
or  degree  of  impairment  as  to  be  objectively  striking.  The  recollection  of  the 
experience  of  the  disease  not  unpleasant. 

Psychoses. — One  case  of  alternating  melancholia  and  mania  in  a  middle 
aged  female.  Type  of  fever  low.  The  mental  derangement  began  with  the 
inception  of  the  disease  and  disappeared  with  the  fever. 


132  THE  TREATMENT  OF  TYPHOID  FEVER. 

Tremor. — Noted  in  a  number  of  cases  at  the  height.  No  case  of  trismus 
or  tetany. 

Hysteria. — A  number  of  times  in  women.  A  dangerous  complication  if 
not  correctly  estimated,  as  it  makes  the  diagnosis  more  difficult.  The  hysterical 
outburst  grows  worse  with  the  primary  disease  and  should  in  every  instance 
be  disregarded,  the  mind  intent  alone  on  the  treatment  of  the  typhoid  fever. 

Meningitis. — No  case  of  serous  or  purulent  meningitis — one  case  of 
typhoid  fever  in  a  child  exactly  simulating  epidemic,  cerebrospinal  menin- 
gitis; the  headache,  the  sudden  onset,  the  vomiting,  the  herpes,  and  Kemig's 
sign. 

Convulsions. — One  case  of  a  lad  of  16  years  with  a  solitary  initial  con- 
vidsion  on  getting  out  of  bed. 

Neuritis  not  found.  The  condition  described  as  "tender  toes,"  which 
seems  to  be  a  neuritis  or  neuralgia  of  the  feet  likewise  not  encountered. 

Polyuria. — This  is  normal  to  this  as  to  other  treatments  where  much 
liquid  is  ingested.  Diabetes  insipidus,  a  dangerous  associated  disease  not  met 
with. 

Nephrotyphus,  hsematuria,  pyuria,  albuminuria,  not  found. 

Typhoid  hacilluria  in  a  niunber  of  the  cases. 

Retention  of  urine  did  not  happen.  The  use  of  a  catheter  in  typhoid 
fever  may  bring  to  the  patient  great  misfortune. 

Menstruation. — In  some  it  continued;  in  others,  younger  subjects,  it  dis- 
appeared one  or  two  months. 

Pregnancy. — One  case,  fifth  pregnancy  of  a  woman  of  34  years.  Time 
6^  months.  Duration  of  fever  seventeen  days.  Child  at  term  large  and 
robust,  requiring  for  the  mother  obstetric  forceps  for  the  first  time. 

Mastitis,  orchitis,  thyroiditis,  enlargement  of  subcutaneous  lymphatic 
glands;    none  of  these  found. 

Periostitis,  myelitis,  osteomyelitis,  not  found. 

Arthritis  deformans. — One  example  in  a  young  woman  of  twenty-four. 
Acute  exquisite  enlargement  of  knuckles  of  both  hands,  the  shoulder  joints  and 
one  wrist,  pain  and  crepitus  present;  spontaneous  disappearance  within  10  to 
14  days. 

Muscles  not  found  involved  or  injured. 

Abscess. — One  subcutaneous  abscess  due  to  saline  axillary  transfusion. 

Alveolar  ahscess  not  found. 

The  following  were  associated  diseases: — 

1.  Pulmonary  tuberculosis. — In  one  case  the  typhoid  fever  was  the 
complicating  disease,  duration  37  days.  In  two  other  patients  acute  pulmonary 
tuberculosis  appeared  in  2  or  3  months  after  recovery  from  the  typhoid  fever. 

2.  Epidemic  influenza. — One  case  in  a  child. 

3.  Migraine. — One  case  in  a  girl. 

4.  Diabetes  mellitus. — One  case  in  a  male  of  22.  It  had  been  of  severe 
form  for  six  months.  The  accompanying  chart  shows  the  fever  and  the  rela- 
tion to  it  of  the  daily  composition  of  the  urine.  The  glycosuria  reappeared 
in  the  decline  and  convalescence. 


THE  TREA'OIENT  OF  TYPHOID  FEVER. 


133 


Dla^noals 


134  THE  TREATMENT  OF  TYPHOID  FEVER. 

Abscess  of  ear. — Two  cases  in  children  of  double  otitis  media  purulenta. 
The  one  a  female  infant  of  two  years,  the  otitis  on  the  seventh  day;  the  other 
a  girl  of  five  years  likewise  with  epidemic  influenza,  the  otitis  on  the  fourth  day. 
The  Diagnosis. — The  diagnosis  of  typhoid  fever  for  rapidity  and  accuracy 
depends  on  the  experience  and  skill  of  the  practitioner.  The  symptoms  which 
lead  to  its  detection  are  the  history  of  the  beginning,  the  fact  of  no  former 
genuine  attack,  the  appearance  and  manner  of  the  subject,  the  nature  of  his 
complaints,  the  temperature  and  its  behavior  for  one  or  two  days,  and  the 
frequency  of  the  pulse. 

As  it  is  a  matter  of  great  rarity  that  the  patient  suspects  or  declares  the 
name  of  his  disease,  and  as  the  beginning  of  the  febrile  infection  acts  as  an 
intoxicant  to  the  brain,  so  does  the  altered  speech,  manner,  behavior  and  ideas 
vary  with  the  individual,  and  has  led  some  to  say  that  the  symptoms  are  of  a 
protean  character. 

However  strange,  new  or  fallacious  the  case  may  attempt  to  be,  it  is  rare 
that  a  correct  diagnosis  cannot  be  made  within  twenty- four  hours  and  seldom 
that  deliberate  study  and  reflection  is  deceived  by  an  incorrect  opinion. 

It  is  in  all  cases  absolutely  necessary  to  review  the  various  visceral  and 
systemic  diseases  that  present  any  species  of  similarity  and  to  exclude  the 
same.  Of  these  diseases  one  must  always  remember  tuberculosis,  pulmonary, 
miliary,  intestinal  and  meningeal;  cerebrospinal  meningitis,  the  septieasmias, 
ulcerative  endocarditis,  osteomyelitis,  epidemic  influenza,  the  malarias,  the 
exanthemata,  particularly  small-pox;  the  pneumonias  and  pleurisies;  food 
stuff  intoxication,  ptomaine  poisoning,  typhus  and  relapsing  fever  where 
found;  anthrax  and  acute  glanders;  secondary  syphilis  and  more  often  the 
fever  of  the  tertiary  stage;   trichinosis,  acute  nephritis  and  appendicitis. 

The  whole  nature  of  a  rapid  diagnosis  is  a  mental  inspection  of  the 
patient  based  on  practice  and  very  much  like  the  recognition  of  diphtheria  at 
a  glance  by  one  familiar  with  its  gross  appearance.  The  proof  of  a 
bacteriologic  culture  is  hardly  needed  to  a  practiced  worker. 

The  tests  and  several  symptoms  of  typhoid  fever  much  in  vogue  are  highly 
useful  to  prove  the  existence  of  the  disease,  but  none  are  equal  in  quickness 
founded  on  experience.  The  rose  spot  eruption,  the  enlarged  spleen,  the 
typhoid  stools;  the  typhoid  bacilli  in  blood,  fasces  and  urine.  The  Gruber- 
Widal  reaction;  the  Diazo  reaction  of  Ehrlich  are  the  symptoms  and  tests 
that  are  meant.  The  Widal  reaction  was  made  use  of  in  fevers  of  short  dura- 
tion— of  ten  days  or  less.  Such  are  often  a  matter  of  dispute  or  suspicion. 
The  initial  fever  is  high,  with  a  rapid  decline.  The  convalescence  lasts  longer 
than  the  disease.  The  Widal  reaction  is  of  great  value  to  confirm  the  correct 
diagnosis. 

Prognosis. — As  in  this  series  of  118  consecutive  cases  there  was  no  mortal 
one,  the  prognosis  in  typhoid  fever  with  this  treatment  can  be  claimed  to  be 
good.  Typhoid  fever  is  always  a  serious  disease  of  great  and  universal 
prevalence.  The  subjects  of  it  deserve  none  other  than  careful  and  constant 
medical  attendance.  When  we  consider  the  manifold  dangers  within  the 
stricken  individual,  the  many  fatal  accidents  he  may  encounter  from  without. 


THE  TREATMENT  OF  TYPHOID  FEVER.  135 

the  imperfections  of  human  aid  in  the  nursing,  the  liability  of  error  in 
directions  or  execution;  these  possibilities  will  perhaps  always,  with  the  best 
of  treatments,  give  a  mortality  of  2  to  3  per  centum. 

The  Nurse. — Each  case  deserves  a  single  nurse.  The  best  nurse  is  one 
with  training  in  her  work,  and  of  these  the  one  who  knows  the  method  of  treat- 
ment and  its  capabilities.  A  "trained"  nurse,  a  synonym  of  expense  and  worry, 
imfortunately  to  some  of  the  laity,  is  not  a  necessity.  In  the  case  of  a  child, 
the  best  nurse,  if  her  health  allow,  is  its  mother,  the  wife  of  a  husband,  a  sister 
of  some  one  of  her  family.  An  adult  male  or  female  of  moderate  intelligence, 
some  aptitude  and  fair  perseverence  does  very  well,  if  the  medical  attendant 
give  the  proper  instructions  and  is  sure  to  supervise  the  execution  thereof. 

The  maxim  for  all  concerned  in  the  treatment  is  the  Ciceronian  proverb : 
Uno  opere,  eandem  incudem  noctem  diemque  tundere. 

Hospital  or  home  treatment. — The  home  treatment  is  superior  to  the 
hospital  treatment  in  most  particulars.  The  most  powerful  argimient  and  the 
final  one  is  the  greater  mortality  in  institutions.  At  home  the  subject  has  no 
sense  of  isolation  or  neglect.  No  longing  for  his  family,  more  constant  nursing, 
ready  redress  for  complaints.  No  dangers  from  the  transportation  of  his  sick 
body.  He  feels  security  and  protection,  a  greater  hope  of  recovery.  He 
responds  more  quickly  to  treatment.  In  fine,  he  receives  at  home  the  earliest 
diagnosis  and  its  proper  application. 

Remarks  on  other  treatment  and  medicines  in  typhoid  fever. 

The  Care  of  the  mouth. — Cleanliness  practiced  on  the  buccal  cavity  and 
various  mild  antiseptics  in  use  are  unnecessary.  The  state  of  the  coating  of  the 
tongue,  the  salivary  secretion  and  moisture  are  useful  in  being  clinical  marks 
of  the  extent  and  degree  of  intestinal  ulceration  and  of  the  general  infection. 
A  moist  cavity  and  a  receding  coating  are  early  signs  of  healing  lesions.  The 
frequent  washing  and  mopping  of  the  mouth  are  apt  to  irritate  or  inflame  it. 

Alcohol. — All  the  various  forms  of  alcoholic  drink  are  unnecessary  and  of 
no  therapeutic  value  at  all.  The  belief  in  alcohol  as  a  "stimulant"  is  a 
primitive,  popular  fallacy,  not  proven  by  clinical  or  experimental  medicine. 

Diet. — There  is  no  other  diet  for  typhoid  fever  but  milk,  and  if  such  is 
ever  found  it  will  not  be  able  to  compare  with  what  we  possess,  in  price, 
abundance,  labor  of  manufacture,  or  collection. 

Cardiac  and  circulatory  stimulants. — These  are  not  used  and  their 
exhibition  is  always  an  act  engendered  by  alarm  or  apprehension.  The 
rational  cardiac  stimulant  is  the  quantity  of  fluid  required  to  replenish  the 
blood  as  reduced  and  drained  by  the  disease. 

Cold  and  hydrotherapy. — It  is  a  well  known  fact  that  the  subject  of  this 
fever  is  exhausted  by  great  summer  heat  and  that  an  ideal  temperature  in  the 
cold  months  is  found  in  a  room,  without  fire,  where  the  thermometer  is  from 
45  to  60°  F.  Cold  thus  used  is  agreeable  to  the  sick.  Cold  water  in  sponging 
the  body,  the  wet  pack  and  the  bath,  whilst  of  great  value,  are  entirely  dis- 
carded for  weighty  reasons.  An  ice  cap  to  the  head,  an  ice  bag  or  coil  to 
abdomen  or  other  part  of  the  body  should  not  be  applied.  The  wet  pack  was 
used  twice,  on  two  occasions  on  the  same  day,  in  the  case  of  a  small  boy, 


136  MEDICAL  TREATMENT  OF  ACUTE  APPENDICITIS. 

stuporous  and  rebellious  to  nursing  when  awakened.  He  resented  any  dis- 
turbance of  his  repose.  Here  the  cold  wet  pack  acted  well,  not  to  benefit  the 
disease  but  to  make  the  sick  one  rational  and  tractable.  Daily  ablutions  are 
left  to  be  practiced  as  the  nurse  thinks  proper  or  the  patient  desires;  the  only 
important  act  being  the  bathing  or  sponging  of  the  dorsal  region  of  the  trunk 
to  detect  the  appearance  of  any  spot  of  beginning  decubitus.  No  systematic 
sponging  of  the  body  is  advised;  no  use  of  the  wet  pack;  no  immersion  in  a 
cold  or  tepid  bath. 

The  bath  treatment  of  typlioid  fever  has  saved  many  lives  and  is  a  useful 
and  powerful  aid  in  the  cure.  All  said  in  its  favor  by  those  who  have  had 
extensive  experience  with  it  is  true  and  no  one  should  venture  to  condemn  it  on 
any  hearsay  or  theoretical  reason  alone. 

The  opponents  of  the  bath,  however,  are  not  found  amongst  clinicians, 
and  such  indeed  could  not  deny  its  salutai-y  effects,  but,  paradoxically  enough, 
its  real  opponents  are  the  typhoid  fever  patients  the  bath  has  cured.  Asking 
those  who  have  had  the  bath  treatment,  months  and  years  afterwards,  their 
impressions  of  it,  awaken  a  sense  of  dislike,  fear  or  dread.  It  will  be  difficult 
to  find  the  words  of  one  expressing  pleasure  or  praise;  it  will  be  very  easy  to 
elicit  an  "0,  never  again !" 

In  the  home  treatment  with  baths,  there  is  the  doubly  painful  scene  to  be 
witnessed,  the  cries,  pleading  and  struggles  of  the  sick  and  the  alarm  and 
weeping  of  the  family.  Hard  is  the  lot  of  the  practitioner  who  uses  the  bath 
treatment  as  his  great  weapon.  Where  it  cures,  aversion  as  a  part  reward; 
where  it  fails  or  where  death  ends  the  disease, .  The  reader  may  com- 
plete the  sentence.  The  bath  treatment  can  therefore  be  discarded  where  a 
better  treatment  is  found,  and  that  is  a  better  treatment,  where  the  bath  is  not 
used;  which  the  patient  welcomes  and  does  not  oppose;  where  complications 
are  lessened,  where  the  disease  is  shortened;  where  the  mortality  is  reduced  to 
a  minimum  number. 


MEDICAL  TREATMENT  OF  ACUTE  APPENDICITIS. 

By  THOMAS  G.  GREEN,  M.D., 

SHELBYVILLE,    IND. 

While  surgery  has  been  shown  a  decided  favor  in  the  treatment  of  all 
forms  of  this  disease,  the  conscientious  surgeon  will  not  close  the  door  against 
future  possibilities  in  any  form  oJ'  treatment  of  acute  appendicitis  promising 
the  mitigation  of  human  suffering  and  the  saving  of  human  life,  since  the 
consensus  of  professional  opinion  is  never  stationary,  but  ever  advancing,  ever 
accepting  facts  and  methods  of  practical  utility  gleaned  by  the  general  prac- 
titioner from  the  field  of  general  practice.  General  medicine  is  not  retrograd- 
ing. The  general  practitioner  of  medicine  is  to-day  better  qualified  and  better 
equipped  to  fulfill  the  mission  of  his  high  calling  than  ever  before  in  the  world's 
history.     He  is  quietly  going  about  his  work,  frequently  introducing  new  and 


MEDICAL  TREATMENT  OF  ACUTE  APPENDICITIS.  137 

original  ideas  in  the  application  of  remedies  to  disease,  securing  results  that 
were  not  dreamed  of  twenty  years  ago,  when  appendicitis  began  to  attract 
general  attention. 

A  physician  to-day  may  be  a  fair  operator,  yet  deficient  in  his  knowledge  of 
therapy,  while  at  the  same  time  a  general  practitioner  may  be  deficient  in  his 
knowledge  of  anatomy  and  physiology  to  the  extent  of  blinding  him  to  many 
surgical  and  therapeutic  possibilities,  which  are  made  comprehensive  in  the 
light  of  anatomical  and  physiological  knowledge. 

"We  have  been  prompted  to  attempt  this  article  because  of  so  much  attention 
having  been  given  to  the  removal  of  the  appendix,  both  in  its  diseased  condition 
and  its  normal  state,  while  so  little  interest  has  been  manifested  in  the  means 
and  agencies  that  may  be  invoked  for  the  removal  of  the  cause  of  disease  within 
the  organ.  The  purpose,  therefore,  of  this  paper  will  have  been  accomplished 
if  no  other  point  be  gained  than  to  stimulate  a  more  thorough  investigation  of 
the  subject  from  a  medico-surgical  point  of  view. 

Eeviewing  the  medical  treatment  devised  for  acute  appendicitis,  one  is 
impressed  with  its  briefness,  absence  of  specified  dosage,  and  the  want  of 
confidence  shown  in  medical  agents.  No  prescribed  course  of  treatment  has 
come  under  my  observation  for  the  process  itself,  which  can  inspire  the  prac- 
titioner with  any  reasonable  hope  of  ultimate  success  in  the  use  of  medical 
agents,  or  place  the  patient  in  a  condition  the  most  favorable  for  surgical  treat- 
ment. We  are  told  to  "give  opium  in  sufficient  amounts  for  the  relief  of  pain 
only,"  to  "evacuate  the  bowels  with  salts  or  oil,"  and  to  "apply  the  ice-bag  to 
the  abdominal  wall." 

As  a  result  the  iuflammation  progresses,  the  patient  is  given  over  in  most 
cases  to  the  surgeon  for  treatment,  or,  as  sometimes  happens,  surgical  treatment 
is  not  accepted  by  the  patient  or  his  friends,  and  death  ensues,  or,  conservative 
nature,  making  the  best  of  a  bad  bargain,  restores  the  patient  to  partial  recovery 
and  elects  him  to  "future  attacks."  Opium,  having  the  well  known  physio- 
logical property  to  check  or  modify  all  secretions  of  the  body,  save,  perhaps,  that 
of  the  skin,  the  use  of  it  places  the  intestinal  mucous  membrane  in  no  functional 
condition  to  favor  the  process  of  osmosis.  Salines  are  supposed  to  stimulate 
osmosis,  but  when  used  in  connection  with  opium,  this  process  is  so  far  modified 
that  the  secretion  of  serum  is  insufficient  to  soften  the  mass  of  faecal  matter,  or 
increase  the  volume  of  intestinal  fluids  necessary  to  promote  elimination. 

In  most  cases  of  acute  appendicitis,  we  find  gastric  irritation  present.  The 
use  of  opium  does  not  tend  to  relieve  this  irritation  when  given  in  amounts 
sufficient  for  the  relief  of  pain  only,  and  when  so  given  peristalsis  is  enfeebled, 
and  the  result  is,  the  stomach  is  left  in  no  condition  to  retain  either  salines  or 
other  purgatives. 

Considering  the  length  of  the  intestinal  tract,  and  its  usual  constipated 
condition  at  the  onset  of  engorgement,  it  is  not  imreasonable  to  ask :  When  do  we 
know,  even  under  the  most  favorable  conditions,  that  it  has  been  cleared  of  fgecal 
matter?  We  certainly  can  not  hope  to  accomplish  this  result  by  the  adminis- 
tration of  antagonistic  remedies  at  a  time  when  there  is  more  or  less  rigidity 
present,  constricting  the  lumen  of  the  bowel  and  counteracting  the  laxative  effect 


138  MEDICAL  TREATMENT  OF  ACUTE  APPENDICITIS. 

of  any  remedy  that  may  be  used.  This  method  of  treatment  will  invariably 
accentuate  the  symptoms,  by  bringing  about  the  exact  results  we  desire  to 
obviate,  viz. :  peristalsis,  griping  and  spasm  of  the  gut,  and  it  is  by  no  means 
a  rational  course  to  pursue  preparatory  to  surgical  treatment.  So  far  as  relates 
to  the  application  of  the  ice-bag  to  the  abdominal  wall,  we  recognize  its  use  as 
a  valuable  adjunct  to  other  remedies. 

Viewing  the  literature  on  the  vermiform  appendix  from  the  medical  stand- 
point one  is  brought  to  face  an  open  field  for  investigation,  wherein  mystery 
and  uncertainty  are  the  prime  factors  presented. 

The  organ,  having  no  known  function,  frequently  taking  on  inflammation 
with  misleading  symptoms,  such  as  pain  in  parts  remote  from  the  seat  of 
engorgement,  accompanied  by  vomiting,  and  other  symptoms  common  to  gastric, 
hepatic  and  intestinal  disorders,  has  given  rise  to  uncertain,  expectant  and 
palliative  plans  of  treatment  with  delay  in  one  way  or  another  until  the  proper 
time  has  passed  for  medical  agents  to  correct  the  difficulty,  this  state  of 
affairs  having  been  brought  about  by  no  other  cause  than  the  absence  of  rationally 
and  radically  prescribed  treatment.  Since  appendicitis  has,  I  believe,  been 
given  more  prominence  during  the  past  twenty  years  than  any  other  intestinal 
disorder,  it  is  phenomenal  that  so  little  medical  treatment  has,  up  to  the  present 
time,  been  devised  for  its  prevention,  treatment  and  cure. 

The  profession  is  yet  divided  upon  theories  and  plans  of  treatment,  some 
claiming  there  is  no  medical  treatment  for  this  malady.  While  one  has  said, 
"the  near  future  will  demonstrate  that  the  treatment  of  appendicitis  belongs 
to  medicine  and  not  to  surgery,"  the  other  urges  that  "the  result  of  purely 
medical  treatment  is  not  sufficiently  bad,  and  of  surgical  treatment  not 
sufficiently  satisfactory  to  justify  operative  intervention  in  all  cases."  As  a 
ru]e,  at  the  beginning  of  treatment  of  acute  appendicitis,  the  surgeon  is  no  more 
certain  of  existing  conditions  nor  of  the  results  he  is  able  to  secure  prior  to 
operating  than  is  the  general  practitioner,  prior  to  treatment.  Mistaken 
diagnoses  are  frequent;  a  healthy  appendix  is  often  found  and  removed;  so 
proficient  has  the  surgeon  become  in  some  localities,  that  operations  are  per- 
formed upon  all  cases  of  painful  abdomen  due  to  uncertain  origin. 

W^hile  surgery  is  to  be  complimented  for  giving  relief  in  cases  adapted  to 
this  line  of  treatment,  and  due  homage  granted  for  bearing  responsibilities 
in  appendicitis  for  years  past,  the  time  seems  propitious  when  the  medical  branch 
of  the  profession  should  awaken  to  its  responsibility,  and  share  alike  with  the 
surgeon  the  treatment  of  this  disease. 

When  the  general  practitioner  of  medicine  shall  have  come  to  realize  the 
efficiency  of  medical  treatment  of  acute  appendicitis  and  shall  have  become 
capable,  through  differential  diagnosis  by  means  of  its  clinical  history,  physical 
signs  and  subject  s_ymptoms  to  distinguish  the  character  and  stage  of  inflam- 
mation in  the  individual  case,  and  when  he  shall  appreciate  the  efficacy  of  a 
harmless  th.ough  radical  primary  treatment,  there  will  result  tlie  abortion  of 
many  incipient  cases;  the  cure  of  many  found  in  the  first  stage  of  inflammation; 
the  frequent  evacuation  of  the  appendicular  abscess  through  its  normal  exit 
into  the  bowel  to  be  followed  by  spontaneous  cure,  while  surgical  cases  will  be 


MEDICAL  TREATMENT  OF  ACUTE  APPENDICITIS.  I39 

speedily  placed  in  the  most  favorable  condition  preparatory  to  surgical  treat- 
ment. Then  there  will  result  a  marked  diminution  of  sub-acute  and  chronic 
cases  commonly  known  as  "recurrent  attacks." 

Acute  inflammation  of  the  vermiform  appendix  should  be  classed  among 
the  visceral  diseases  coming  primarily  within  the  domain  of  the  general  prac- 
titioner, who  should  be  able  to  treat  it  with  the  same  degree  of  confidence  of 
ultimate  success  one  assumes  in  the  treatment  of  any  other  abnormal  inflamma- 
tion. It  is  not  our  purpose  here  to  dwell  upon  the  anatomy  of  the  appendix; 
it  is  sufficient  to  say  it  is  composed  of  the  same  structures  entering  into  the 
formation  of  the  intestinal  tract  and  endowed  with  muscular  fiber  sufficient  to 
demonstrate  its  power  of  resistance,  and  circulation  sufficient  to  establish  con- 
servative healing  when  associated  parts  are  in  their  normal  state  and  function. 
Were  it  not  so  constructed,  no  one  would  be  free  from  inflammation  of  this 
organ,  situated  as  it  is,  where,  from  gravity,  the  mass  of  fgecal  matter  must 
continually  pass  over  its  cul-de-sac  formation. 

That  it  has  resistive  power  has  been  frequently  demonstrated  in  cases 
where  there  had  been  cohesion  of  its  mucous  membrane  with  atrophy  of  the 
part  giving  evidence  of  previous  inflammation  in  subjects  having  undergone  no 
treatment  for  the  disease,  discoveries  being  made  of  this  condition  during 
autopsies,  following  death  from  other  causes.  Too  much  attention  is  being 
paid  the  theory  that  the  appendix  in  its  insignificance  is  prone  to  become 
inflamed  through  its  want  of  resistive  power  from  its  cramped  position  and 
feeble  circulation.  While  in  the  main  this  point  is  not  to  be  ignored,  yet  this 
condition  should  be  classed  as  sub-acute  or  chronic  engorgement.  Attention 
should  rather  be  directed  to  the  immediate  cause  underlying  these  conditions 
in  the  strictly  acute  form  of  the  disease,  since  constipation  and  impaction 
exert  a  pressure  many  times  greater  than  the  inherent  power  of  the  appendix 
to  resist  in  acute  inflammation. 

Be  it  understood  the  terms  "constipation"  and  "impaction"  in  this  paper 
are  used  figuratively  to  make  comprehensive  the  local  source  of  irritation  and 
are  not  meant  to  imply  that  the  entire  bowel  must  necessarily  be  involved  in 
constipation  and  impaction  to  produce  the  irritation,  the  presence  of  effete 
matter  within  the  appendix,  of  either  solid  or  fluid  nature,  for  any  great  length 
of  time  being  sufficient  to  justify  the  use  of  these  terms. 

Constipation  and  impaction  being  prime  factors  in  the  causation  of  acute 
appendicitis,  we  are  not  surprised  at  the  fatal  issue  from  early  surgical  inter- 
vention in  many  cases.  When  we  consider  the  septic  condition  present  from 
constipation  and  impaction,  and  when  we  also  consider  that  tumefaction  conies 
in  to  lend  a  hand  in  pressure  of  the  parts,  all  conspiring  to  eliminate  the  one 
essential  condition  favorable  to  resolution,  viz. :  imobstructed  blood  and 
l}'niphatic  vessels.  The  faecal  matter  found  within  the  engorged  cjKCum  and 
appendix  does  not  consist  alone  of  deposits  of  debris  following  digestion  and 
absorption  of  food,  but  also  of  deposits  of  nerve-waste  and  other  tissue  waste 
matter  eliminated  by  glandular  organs.  This  effete  matter  being  held  in  con- 
tact with  the  mucous  membrane  enters  largely  into  the  source  of  irritation 


140  MEDICAL  TREATMEISTT  OF  ACUTE  APPENDICITIS. 

producing  the  catarrhal  and  ulcerative  forms  of  the  disease,  obstruction  of 
the  appendicular  orifice  being  not  the  only  source  of  irritation. 

Therefore,  looking  into  one  of  the  immediate  causes  of  the  disease  we 
believe  the  appendix  able  to  resist  engorgement,  congestion  and  inflammation, 
when  given  the  opportunity  at  the  onset  of  the  attack  by  prompt  and  energetic 
treatment  in  the  evacuation  and  cleansing  of  the  adjacent  parts,  viz.:  the 
larger  and  smaller  bowel,  and  with  proper  treatment  may  terminate  in  resolu- 
tion. Although  cohesion  of  its  mucosa  frequently  results  with  atrophy  of  the 
appendix,  the  patient  sufi^ers  no  further  inconvenience  from  disease  of  the  organ. 

Trcaiment. — Since  about  eighty-five  per  cent,  of  cases  suffering  from  acute 
pain  in  the  abdominal  cavity,  settling  within  twenty-four  hours  in  the  right 
iliac  region  with  rigidity  of  right  rectus  muscle,  develop  into  the  class  of  cases 
generally  diagnosed  as  appendicitis,  and  in  view  of  the  fact  that  these  cases 
are  frequently  given  surgical  treatment  including  exploratory  incisions  made 
in  anticipation  of  appendicitis,  the  appendix  in  most  cases  being  removed 
whether  or  not  found  in  a  diseased  condition,  it  behooves  the  general  practi- 
tioner to  likewise  take  heroic  though  rational  measures  to  abort  or  modify  the 
disease.  The  urgent  necessity  for  immediate  and  well-directed  treatment  to 
stay  the  progress  of  inflammation  and,  at  the  same  time  to  pursue  a  line  of 
treatment  by  which  one  can  reasonably  hope  to  "remove  the  cause,"  calls  for 
no  mincing  of  remedies  nor  procrastination  in  any  way  whatever.  Especially 
is  the  general  practitioner  justified  in  this  effort  when  the  given  line  of  treat- 
ment prepares  the  patient  for  surgical  treatment  which  may  intervene  at  any 
time  deemed  necessary  throughout  its  course. 

There  are  four  primary  points  to  be  gained  at  the  beginning  of 
treatment : — 

First,  the  immediate  relief  from  pain  and  vomiting  if  present.  Second, 
the  arresting  of  peristalsis  of  the  entire  intestinal  tract.  Third,  muscular 
relaxation  of  the  entire  alimentary  canal.  Fourth,  painless  evacuation  of  the 
entire  contents  of  larger  and  smaller  bowel. 

There  must  follow  the  administration  of  cleansing  and  antiseptic  agents, 
in  conjunction  with  substantial  rectal  feeding  when  needed. 

Several  years  ago  Alonzo  Clark  taught  the  method  of  treating  peritonitis 
by  giving  opium  to  the  point  of  toleration,  the  use  of  which  in  the  hands  of 
the  discreet  physician  has  been  a  boon  to  humanity,  the  general  practitioner 
frequently  meeting  with  cases  of  visceral  inflammation  beyond  his  power  to 
control  were  it  not  for  the  use  of  opium  in  one  form  or  another  during  critical 
periods  in  conjunction  with  other  means  and  agents  that  can  only  be  applied 
while  the  patient  is  under  the  physiological  effects  of  the  drug.  We  are 
cognizant  of  the  fact  that  much  has  been  said  for  and  against  the  use  of  opium 
in  acute  appendicitis.  The  extreme  degree  of  action  in  either  case  is  always 
to  be  avoided,  since  it  is  wiser  to  take  a  neutral  stand,  making  use  of  any  means 
experience  has  proven  valuable  in  securing  results. 

The  great  difficulty,  it  seems,  in  the  treatment  of  acute  appendicitis,  has 
been  to  relieve  the  patient's  suffering  and  at  the  same  time  clear  the  affected 


MEDICAL  TREATMENT  OF  ACUTE  APPENDICITIS.  141 

parts  of  offending  matter.  As  has  been  shown,  salts  and  other  laxatives  given 
in  the  routine  way  have  not  proven  satisfactory. 

The  pivot  upon  which  the  following  plan  of  treatment  turns  those  amenable 
cases  of  acute  appendicitis  roimd  to  resolution  within  three  to  fourteen  days 
will  be  shown  to  rest  upon  the  fact  that  thorough  evacuation  of  faecal  matter 
can  be  secured,  aseptic  cleanliness  of  the  alimentary  canal  established,  and 
beneficial  results  obtained  from  internal  antiseptics  (to  all  intents  and  pur- 
poses) independent  of  intestinal  peristalsis. 

I  have  found  plain  morphia-sulphate  given  hypodermically  in  dose  ranging 
from  one-half  to  one  grain  in  adults,  at  iutervals  from  six  to  twelve  hours,  at 
the  discretion  of  the  attending  physician,  to  arrest  peristalsis  and  to  give  relief 
from  all  pain  and  vomiting  within  the  hour  of  its  administration,  and  to 
produce  a  degree  of  relaxation  of  the  alimentary  canal,  second  only  to  general 
anesthesia.  Thus  the  first  three  primary  points  in  the  beginning  of  treatment 
are  gained  in  the  most  convenient  manner  to  both  patient  and  physician. 

In  addition  to  this,  plain  morphia-sulphate  to  the  point  of  tolerance  lays  a 
retarding  hand  upon  congestion  and  inflammation  at  the  seat  of  disease,  and 
since  rupture  into  the  peritoneal  cavity  from  the  inflamed  parts  is  so  strenuously 
feared  throughout  the  course  of  inflammation,  we  have  in  plain  morphia- 
sulphate  the  remedy  par  excellence  with  which  to  control  the  degree  of  inflam- 
mation conducive  to  this  complication,  and  one  which  we  reasonably  believe 
exerts  no  little  influence  in  aiding  to  build  a  protective  wall  about  the  inflamed 
area.  Indeed,  Deaver  says,  "I  have  seen  too  great  a  number  of  cases  of 
appendicitis  sent  into  the  hospital  for  operation  in  which  there  was  little  room 
for  doubt  that  the  excessive  peristalsis  caused  by  the  persistent  administration 
of  salines  had  only  more  widely  diffused  the  septic  matter  in  the  abdominal 
cavity,  and  was  in  large  measure  directly  responsible  for  the  presence  of  diffuse 
peritonitis.  The  mortality  of  cases  which  have  reached  this  stage  is  only  too 
well  known.  On  the  other  hand,  patients  who  have  had  opium  administered 
to  them  usually  are  brought  to  the  hospitals  with  localized  inflammation  or 
abscess,  and  the  mortality  of  such  cases  is  decidedly  less  than  that  of  those 
attended  by  general  peritonitis." 

While  the  disease  in  its  acute  form  rapidly  reduces  the  vital  powers  of 
the  patient,  in  plain  morphia-sulphate  we  have  one  of  the  best  known  agents  to 
meet  this  contingency  by  sustaining  the  heart's  action  and  relieving  irritability 
of  the  nervous  system.  The  remarkable  degree  of  tolerance  for  plain  morphia- 
sulphate  manifested  by  patients  suffering  from  inflammation  of  abdominal 
viscera  is,  in  many  cases,  phenomenal,  inasmuch  as  many  waking  hours  are 
enjoyed  in  comfort  while  little  profound  hypnotic  effect  of  the  drug  is  present; 
while  its  effect  upon  the  stomach  abating  the  desire  for  food  is  to  be  desired, 
until  such  time  arrives  when  food  can  be  taken  with  impunity.  Aside  from 
all  these  advantages,  the  sense  of  taste  is  obtunded,  both  the  tongiie  and  stomach 
are  placed  in  a  condition  resembling  local  anoesthesia,  which  is  in  fact,  one  of 
the  most  valuable,  if  not  the  most  valuable  point  gained,  since  it  places  these 
organs  under  the  control  of  the  physician,  rendering  him  able  to  administer 
in  sufficient  amounts  the  only  remedy  known  to  the  writer  that  can  be  relied 


142  MEDICAL  treatmp:nt  of  acute  appendicitis. 

on  under  plain  morphia-sulphate  to  point  of  toleration,  to  gain  the  fourth  point 
in  the  beginning  of  treatment,  viz. :  painless  evacuation  of  the  contents  of  both 
larger  and  smaller  bowel. 

During  the  first  hour  following  the  hypodermic  dose  of  morphia,  the 
lower  bowel  should  be  flushed  with  soap  suds  enema,  care  being  taken  to  secure 
the  reasonable  evacuation  of  the  contents  of  the  colon  before  the  patient  is 
permitted  to  pass  fully  under  the  influence  of  morphine.  It  is  well  to  allow 
one  hour  to  intervene  from  the  hypodermic  injection  of  morphine,  before 
attempting  to  give  remedies  by  the  stomach,  at  which  time  the  patient  will  be 
placed  in  the  condition  most  favorable  to  the  swallowing  and  retaining  castor 
oil  in  amounts  sufficient  to  guarantee  its  traversing  the  entire  length  of  the 
passive  and  relaxed  bowel,  gravitating  throughout  the  intestinal  canal  by  virtue 
of  its  own  weight  independent  of  peristalsis,  emulsifying  the  intestinal  contents 
and  increasing  the  volume  of  intestinal  fluids  to  a  degree  necessary  to  stimulate 
evacuation.  Castor  oil  given  as  warm  as  the  patient  can  swallow,  in  three- 
ounce  doses  in  adults,  can  be  relied  on  to  pass  throughout  the  intestinal  tract 
producing  no  irritation  nor  peristalsis  discernible  to  the  patient,  and  after  an 
interval  of  from  four  to  six  hours,  free  and  comfortable  evacuation  will  occur. 
Should  emesis  follow  and  the  oil  be  rejected,  it  will  be  due  either  to  the  insuffi- 
cient amount  of  morphia  being  given  or  to  the  dose  of  oil  being  given  too  soon 
after  giving  the  hypodermic  of  morphia,  in  which  case  an  additional 
amount  of  morphia  must  be  given,  or  sufficient  time  be  permitted  to  elapse  to 
assure  the  physiological  efilects  of  the  drug  before  repeating  the  dose  of  oil. 
Following  the  hypodermic  dose  of  morphine,  castor  oil  should,  at  all  times,  be 
given  entirely  alone,  the  stomach  being  in  no  physiological  condition  to  digest 
foods  of  either  solid  or  fluid  consistency.  Digestion  for  the  time  is  arrested, 
while  the  mucous  membranes  of  the  stomach  and  intestines  are  rendered  dry. 
This  is  to  be  remembered  for  its  inestimable  points  of  importance  which  will 
follow ;  therefore,  all  foods  and  fluids,  including  water,  are  to  be  withheld  after 
giving  the  oil,  and  the  patient  should  be  permitted  to  rest  in  comfort.  Plain 
morphia-sulphate  given  h3^podermically  in  full  doses  renders  the  intestines 
incapable  of  responding  with  peristaltic  action  to  the  dose  of  oil,  which  gravitates 
throughout  the  passive  and  relaxed  bowel,  exerting  a  soothing  influence  by 
reason  of  its  ability  through  its  density  to  resist  the  enfeebled  absorptive  powers 
of  the  raucous  membrane  of  the  small  intestines. 

At  the  same  time  general  secretion  of  the  intestinal  organs  is  checked 
or  so  far  modified  by  plain  morphia-sulphate  that  no  reduction  of  the  patient's 
vitality  is  produced  by  depletion  from  the  throwing  ofi:  of  mucous  to  any  great 
extent.  The  oil,  as  it  were,  acting  independent  of  osmosis,  peristalsis  and 
absorption  is  sufficient  guarantee  to  recommend  its  use,  instead  of  salines  in 
these  cases,  where  the  saving  of  the  patient's  vital  powers  is  of  paramount 
importance. 

Complete  rest  and  quietude  should  be  enjoyed  throughout  the  course  of 
treatment.  The  dose  of  morphine  should  not  be  repeated  before  copious  evacua- 
tions have  been  secured,  unless  pain  should  be  present.  No  apprehension  need 
be  aroused  should  results  not  be  secured  for  six  or  eight  hours  following  the 


MEDICAL  TREAITVIENT  OF  ACUTE  APPENDICITIS.  143 

administration  of  the  oil;  it  is  to  be  remembered  that  the  oil  is  gravitating 
through  the  relaxed  small  intestines,  emulsifying  its  contents,  passing  the  same 
through  the  ileo-caecal  valve  into  the  colon,  while  the  opiate  is  counteracting 
any  toxic  effects  from  castor  oil  by  checking  absorption  of  the  small  intestine. 
Should  it  be  found  expedient  to  repeat  the  dose  of  morphia  before  securing 
evacuation,  tlie  colon  should  be  flushed  with  normal  salt  solution  to  promote 
elimination  of  any  oil  there  present. 

Two  or  more  routine  treatments,  including  flushing  of  the  colon  and  the 
full  hypodermic  of  morphia  to  be  followed  at  the  expiration  of  an  hour  with 
the  full  three-ounce  dose  of  castor  oil,  should  be  given  to  patients  seen  early 
in  the  course  of  acute  appendicitis  to  secure  the  thorough  cleansing  of  the 
large  and  small  bowel,  and  to  secure  also  a  constant  flow  of  non-irritating  oil 
into  the  caecum,  where  it  can  be  relied  on  to  gravitate  to  and  penetrate  into  the 
appendix  during  the  slightest  intervals  of  relaxation  of  the  organ.  We  can 
reasonably  expect  the  oil  to  reach  the  interior  of  the  appendix,  since  relaxation 
is  secured,  and  also  since  congestion  and  inflammation  are,  for  the  time  being, 
retarded  by  the  use  of  morphia  hypodermically.  While  the  density  of  castor 
oil  renders  it  capable  of  acting  as  a  vehicle  for  the  expulsion  and  elimination  of 
mucous  and  other  products  of  inflammation  contained  within  the  appendix, 
the  slight  movement  of  the  colon  during  the  process  of  defecation  and  rectal 
flushing  is  conducive  to  this  result. 

While  it  is  impossible  to  outline  the  exact  intervals  of  treatment  in  all 
eases,  suffice  to  say  from  eight  to  ten  ounces  of  castor  oil  should  be  given  in 
pronounced  acute  cases  in  adults,  with  sufficient  morphia  to  secure  painless 
evacuation  during  the  first  three  or  four  days  of  treatment;  care  being  taken 
to  flush  the  colon  at  six-  or  eight-hour  intervals  following  the  administration 
of  oil  to  prevent  the  absorption  of  toxic  principals. 

After  each  season  of  evacuations  the  colon  should  be  flushed  with  normal 
salt  solution  or  soap  suds,  to  secure  thorough  cleansing.  Near  the  close  of  the 
hour  following  the  repetition  of  morphia,  one  pint  of  normal  salt  solution  may 
be  slowly  injected  into  the  colon  and  retained.  This  salt  solution  may  be 
repeated  and  retained  at  two-  or  three-hour  intervals,  while  the  patient  is 
under  the  influence  of  morphia,  if  desired,  to  relieve  the  patient's  thirst  and 
sustain  renal  action.  The  mucosa  of  the  colon  being  rendered  clean  from  flush- 
ing, and  dry  from  morphia,  presents  a  broad  plane  for  rapid  absorption  of  foods 
and  normal  salt  solutions.  Under  this  method  of  treatment  I  have  seen  no 
case  of  retention  of  urine  necessitating  the  use  of  the  catheter,  while  its  effect 
in  sustaining  the  patient  is  all  that  can  be  desired. 

Within  an  interval  of  four  to  twelve  hours,  during  which  one  or  two  treat- 
ments are  given,  there  results  the  evacuation  of  copious  stools  of  foul  faecal 
matter  of  a  semi-solid  consistency,  showing  a  thorough  mixing  of  oil.  In  many 
cases  the  vast  amount  of  faecal  matter  eliminated  is  out  of  all  proportion  to 
the  expectation  of  the  physician,  and  rapidly  assumes  a  characteristic  yellow 
color. 

At  no  time  should  the  morphia  be  withheld  during  the  first  two  or  three 
days  of  treatment  when  pain  is  present,  in  view  of  hastening  evacuation.     Five 


144  MEDICAL  TREATMENT  OF  ACUTE  APPENDICITIS. 

or  six  hours'  time  should  be  given  the  oil  to  travel  throughout  the  small  intes- 
tine ;  then  should  the  physician  fear  retention  of  ffecal  matter,  distention  of  the 
gut,  or  absorption  of  toxic  principals  by  the  colon,  an  enema  of  strong  salt 
solution  may  be  used  to  hasten  results. 

In  all  acute  cases  the  dose  of  morphia  should  be  repeated  within  twenty- 
four  hours,  and  in  most  cases  at  a  shorter  interval  of  time,  to  secure  its  constant 
action  upon  the  inflamed  parts  and  to  prepare  the  patient  for  the  dose  of  oil 
to  follow. 

This  plan  of  treatment  must  be  continued  until  confident  all  faecal  matter 
has  been  eliminated — a  course  of  four  or  five  days'  duration  being  required  in 
many  cases — while  the  doses  of  morphia  and  oil  must  be  continued  in 
diminished  amounts  for  several  days  longer  to  secure  beneficial  effects  of  both 
remedies  upon  the  inflamed  parts.  The  treatment  can  be  withheld  at  any 
time  to  remove  the  so  called  "masking"  (?)  of  the  symptoms,  or  in  anticipation 
of  surgical  intervention. 

In  all  cases,  save  those  seen  in  the  incipient  stage  of  engorgement  where 
the  first  treatment  aborts  the  malady,  there  will  develop  the  characteristic  tumor 
in  the  right  iliac  region.  The  development  of  this  tumor  is  by  no  means 
indicative  that  surgical  treatment  must  at  once  follow,  since  in  many  cases  it 
tenninates  in  resolution  within  a  few  days  when  the  physical  signs  of  the 
patient  do  not  point  to  sepsis.  Or,  it  is  so  far  diminished  and  freed  from  acute 
inflammation  to  guarantee  better  and  safer  surgical  treatment,  while  in  many 
cases  slight  tenderness  remains  for  several  weeks  to  gradually  disappear,  to  be 
followed  by  no  "future  attacks."  The  stools  should  be  carefully  watched  at  all 
times  for  the  characteristic  discharge  of  pus  from  the  appendicular  abscess. 

Rectal  Feeding. — Food  should  not  be  given  per  rectum  during  the  first 
five  or  six  days  of  treatment.  ISTo  class  of  patients,  however,  are  more  adapted 
to  this  plan  of  nourishment  than  those  suffering  from  acute  appendicitis. 

Taking  advantage  of  time  following  the  hypodennic  dose  of  morphia, 
fluid  foods  in  amounts  not  exceeding  six  ounces  can  be  passed  through  the 
fountain  syringe  into  the  rectum,  causing  no  peristaltic  action  of  the  gut  or 
forcing  of  its  contents  backward  into  the  ctecmn. 

Prior  to  rectal  feeding,  the  colon  should  be  flushed  with  soap-suds  or  a 
noiTOal  salt  solution,  then  panopepton,  coffee,  milk,  meat  broths  and  whiskey  or 
brandy  may  be  used  in  any  combination  or  proportion  desired. 

Subnormal  Conditions. — While  subnormal  temperature  and  subnormal 
pulse,  alternating  with  freakish  flights  of  temperature  and  excessive  diaphoresis 
are  indicative  of  pus  formation  and  absorption,  this  trend  of  symptoms  has  not 
appeared  in  cases  put  upon  treatment  early  in  the  course  of  the  disease.  Yet 
subnormal  temperature  and  pulse  prior  to  rapid  rise  of  temperature  have 
been  frequently  seen  to  be  followed  by  normal  temperature  and  normal  per- 
spiration during  resolution  in  well  developed  cases.  I  consider  subnormal 
pulse  and  temperature,  in  the  absence  of  freakish  flights  of  temperature  and 
excessive  sweating,  as  characteristic  of  acute  appendicitis  as  it  is  of  some 
forms  of  hepatic  troubles.  It  is  fair  to  presume  that  the  dryness  of  the 
intestines  facilitating  the  absorption  of  cholesterin  and  bile  salts  deposited 


MEDICAL  TREATMENT  OF  ACUTE  APPENDICITIS.  145 

within  the  gut,  responsible  for  this  subnormal  state  just  as  subnormal  tempera- 
ture and  subnormal  pulse  are  frequently  found  in  cases  recovering  from  enteric 
fever,  independent  of  liEemorrhage  or  perforation,  when  an  abundance  of  nerve 
waste  matter — cholesterin — is  thrown  off  with  bile  salts,  the  whole  being 
incorporated  with  faecal  matter  during  a  constipated  period. 

Subnormal  pulse  and  temperature  are  not  pathognomonic  of  pus  formation 
in  acute  appendicitis.  Under  this  treatment  when  subnormal  conditions  prevail 
it  is  well  to  withhold  the  oil  and  morphia,  or  give  them  in  diminished  amounts, 
allowing  the  patient  beef  broth  and  other  liquid  nourishment  with  careful 
rectal  feeding. 

Strychnine  sulphate,  ^o  grain  with  digitalin  and  nitroglycerin  can  be 
given  hypodermically,  or  combined  with  caffeine  citrate,  Yg  grain,  and  given  by 
the  stomach,  the  patient  getting  these  remedies  every  three  or  four  hours  until 
reaction  is  established.  Strychnine  sulphate  %o  grain,  given  either  hypo- 
dermically or  encapsuled  at  three-  or  four-hour  intervals  is  a  valuable  tonic 
during  the  latter  part  of  the  course  of  treatment. 

The  salicylate  of  soda,  given  either  by  the  stomach  or  per  rectum,  is  contra- 
indicated  with  this  line  of  treatment,  owing  to  rapid  absorption.  Great  dis- 
comfort follows  its  use  when  given  in  antiseptic  doses.  Calomel,  as  a  rule, 
is  not  indicated,  except,  perhaps,  under  special  conditions  that  may  develop  in 
the  individual  case. 

The  carbonate  of  guaiacol  (duotal),  I  have  found  to  be  of  inestimable  value 
as  an  intestinal  antiseptic  in  acute  appendicitis.  It  may  be  given  in  three- 
or  four-grain  doses  every  three  or  four  hours  at  any  and  all  times,  throughout 
the  course  of  treatment. 

Turpentine  in  three-  or  four-drop  doses,  upon  the  tongue,  will  be  found 
useful  in  many  cases,  where  dryness  of  the  tongue  predominates. 

The  ice-bag  should  rest  upon  a  fold  of  either  flannel  or  cotton  cloth  when 
applied  to  the  abdominal  wall,  and  not  be  permitted  to  come  in  contact  with  the 
patient,  unless  it  is  protected  by  some  sort  of  thin  covering  in  addition  to  its 
rubber  surface. 

Too  much  care  and  attention  cannot  be  taken  in  returning  to  stomach 
feeding,  beef  broth,  panopepton  and  other  meat  broths  being  first  permissible. 
Milk  should  be  classed  as  solid  food  here,  as  it  is  liable  to  form  curd.  Since 
rectal  feeding  is  so  admirably  adapted  to  these  cases,  there  is  scarcely  any 
excuse  for  giving  solid  foods  too  early  during  convalescence. 

Morphia  should  be  discontinued  upon  the  return  to  stomach  feeding. 
Tincture  opium  and  castor  oil  should  be  given  at  this  time  at  least  once  daily, 
if  pain  be  present,  in  amounts  to  secure  evacuation  and  cleansing  of  tlie 
bowels,  with  enemata  to  facilitate  results,  and  oil  should  be  continued  at 
gradually  lengthened  intervals  until  all  tenderness  of  the  parts  have  disappeared. 
Pastry  foods  of  all  sorts  should  be  avoided  until  complete  recovery  has  been 
established. 

In  brief  recapitulation,  I  would  say,  the  colon  should  be  cleansed  with  soap- 
suds or  normal  salt  solution  after  each  evacuation,  and  prior  to  repeating  the 
4 


146  CONCEPTS  CONCERNING  HYSTERIA. 

hypodermic  dose  of  morphia.  The  patient  may  then  be  permitted  to  enjoy  a 
short  season  of  rest,  or  the  morphia  repeated  as  the  exigency  of  the  case  demands. 
Near  the  close  of  the  hour  following  morphia  hypodermically,  food  may 
be  passed  into  the  rectimi,  through  a  small  bulb  attached  to  an  ordinary  fountain 
syringe.  Shortly  following  the  rectal  feeding,  the  dose  of  oil  may  be  given, 
after  which  the  patient  should  be  encouraged  to  rest  until  aroused  by  the  desire 
to  defecate.  While  I  have  found  it  necessary  in  some  cases  to  withhold  water 
from  the  stomach  until  the  symptoms  point  to  resolution,  yet  hot  water  may 
be  given  in  selected  cases,  at  intervals  when  it  is  least  calculated  to  cause  emesis, 
and  given  freely  in  the  later  stages  of  the  disease  and  during  convalescence  with 
decided  advantage,  relieving  pain  and  tenderness  of  the  stomach  and  affected 
parts. 

THE  CLARIFICATION  OF  OUR  CONCEPTS  CONCERNING  HYSTERIA. 

Bt  TOM  A.  WILLIAJVIS,  M.B.,  CM.  (Edin.), 

WASHINGTON,   D.    C. 

The  recent  discussion  at  the  Paris  Xeurologieal  Society^  has  done  much 
to  give  precision  to  the  vague  conception  so  unfortunately  attached  to  the 
word  hysteria.  It  was  in  1901  that  the  Society,  after  hearing  the  astonishing 
definition  of  Babinski,^  began  the  enquiry  which  has  fructified  in  the  con- 
clusions which  now  emerge  after  the  elimination  of  poorly  observed  cases, 
clouded  reasoning  and  ill-digested  theories. 

The  suggastions  at  the  root  of  those  symptoms  of  hysteria  formerly  believed 
to  be  autochthonous  and  durable,  and  termed  stigmata,  are  generally,  though 
not  always,  of  medical  origin.  It  is  very  significant  that  Bernheim^  for  fifteen 
and  Babinski^  for  ten  years  have  never  seen  hemiansesthesia,  contracted  visual 
fields,  dyscromatopsia  or  monocular  poliopia,  except  in  patients  previously 
examined  medically.  The  mode  of  genesis  of  these  symptoms  was  first 
indicated  by  Bernheim^ ;  and  the  writer  has  recently  presented  the  theme  in  a 
translation  of  his  communication  before  the  Congress  of  French  Neurologists, 
at  Lille^.  Medico-legal  examples  in  the  making  have  recently  been  adduced 
by  Brissaud,"^  as,  for  instance,  that  where  Dupinet,  who  had  found  no 
hemianaesthcsia  in  a  workman  after  an  accident,  saw  it  produced  by  the 
examination  of  another  expert.  It  is  impossible,  however,  to  prove  a  universal 
negative;  and  to  that  extent  Dejerine  and  Ea3Tnond  are  justified  in  believing 
that  undoubted  hysterical  sjonptoms  may  arise  independently  of  immediate  sug- 
gestion. But  it  must  be  remembered  that  hemiplegia  of  organic  origin  is  a 
familiar  Sight,  and  that  to  the  lay  mind  palsy  connotes  insensibility.  Hence  it  is 
not  astonishing  that  a  man  who  believes  a  limb  incapacitated,  believes  it  also 
insensitive;  this,  however,  is  a  suggestion.  The  discovery  of  basal  suggestions 
in  hysteria  is  proportional  to  skill  in  psycho-analysis  in  genuine  cases,  and  to 
detective  shrewdness  in  cases  arising  from  mythomania.^ 

Many  so-called  hystericals  are,  in  reality,  merely  mystifiers,  more  or  less 


CONCEPTS  CONCERNING  HYSTERIA.  147 

conscious  of  their  deviation  from  straightforward  action.     The  following  cases 
are  examples: — 

A  young  girl^  announced  that  on  a  certain  day  and  hour  she  would  die. 
When  the  time  came  she  feigned  death,  resisting  with  astonishing  fortitude  all 
the  stimuli  used  to  awaken  her  from  her  apparent  state  of  catalepsy  or  coma. 
This  comedy  lasted  three  days;  then  she  arose  and  dressed  herself,  pretending 
to  come  out  of  a  dream,  and  amused  herself  with  the  stupefaction  of  her  family 
and  friends.  When  interrogated  by  her  doctor,  she  confessed  her  trick  and 
said  that  she  had  never  been  so  happy  as  she  was  while  watching  the  efforts, 
threats  and  prayers  of  those  around  her.  In  spite  of  the  confession  the  same 
scene,  more  or  less  varied,  occurred  on  ten  other  occasions,  although  she  appeared 
to  be  a  young  woman  of  good  heart  and  intelligence. 

A  second  case  is  that  of  a  man  in  a  hospital  who  confessed  to  concealing 
a  h}'podermic  syringe  in  his  rectum ;  and  this  was  not  all,  for  in  a  moment  of 
exasperation,  an  evacuation  revealed  two.^^ 

Sucli  cases  have  contributed  largely  to  the  confusion  of  our  conception  of 
hysteria.  They  must  be  eliminated  from  a  discussion  of  its  nature.  So  also 
must  be  excluded  abnormalities  of  the  tendon,  skin  and  pupil  reflexes,  which 
are  not  modifiable  by  suggestion. 

Urticaria,  dermatographia,  eruptions,  oedema,  haemorrhages,  ulcers,  gan- 
grene, and  other  circulatory  or  trophic  perturbationsi^  arise  from  chemical  or 
structural  abnormalities,  whether  in  suggestible  individuals  or  not,  and  have 
nothing  to  do  with  hysteria;  nor  is  the  temperature  modifiable  by  suggestion; 
and  the  urinary,  sudoriferous,  and  salivary  secretions^^  are  so  only  slightly  rarely 
and  only  insofar  as  the  emotional  attitude  may  be  perturbed  by  a  suggestion.^^ 

The  foregoing  assertions  must  not  be  misinterpreted;  for  it  must  be 
remembered  that  the  tendon  reflexes  may  be  suppressed  by  voluntary  muscular 
contraction,  and  the  cutaneous  reflexes,  such  as  that  to  tickling,  may  be  inhibited 
by  a  strong  effort  of  the  will. 

It  must  not  be  forgotten  that  many  intoxicated  states  which  paralyze  the 
neurones  which  govern  the  reflexes  also  necessarily  interfere  with  the  psyche, 
and  give  rise  among  other  sjmiptoms  to  many  of  hysterical  type.  This  by  no 
means  means  the  modification  of  reflexes  by  the  hysterical  s}Tnptoms ;  both  are 
effects  of  a  common  cause  and  either  may  occur  independently  in  accordance 
with  the  preponderance  of  the  intoxication  upon  one  or  other  part  of  the  nervous 
system. 

Many  maintain  that  psychoneuroses  other  than  hysteria  are  amenable  to 
suggestion,  Dejerine,  for  example,  citing  the  false  gastropaths,  whom  he  calls 
neurasthenics.  The  writer  has  elsewhere^^  endeavored  to  elucidate  this  source 
of  error,  and  to  show  how  a  false  belief  in  one's  inability  to  digest,  whether 
implanted  by  medical  suggestion  or  otherwise  (i.e.,  a  hysterical  fixed  idea), 
produces  asthenia  by  slow  starvation  on  account  of  the  malassimilation  caused  by 
worry  that  food  which  has  been  eaten  may  disagree.  The  state  induced  is  a 
secondary  neurasthesia,  and,  of  course,  demands  the  Wier  Mitchell  treatment; 
but  the  initial  cause,  the  false  idea,  must  be  removed  by  phychotherapy,  and 
unless  80  removed  may  again  cause  failure  of  nutrition. 


148  CONCEPTS  CONCERNING  HYSTERIA. 

Patients  suffering  from  mental  debility,  dream-like  states,  hebephrenia 
and  other  forms  of  dementia  prgecox,  mental  confusion,  states^^  of  emotional 
perversion,  etc.,  insofar  as  they  are  suggestible,  are  hystericals;  but  the  whole 
syndrome  cannot  be  removed  by  suggestion,  as  it  can  in  cases  of  uncomplicated 
hysteria.  For  the  differential  characters  of  such  states,  I  must  again  refer  the 
reader  elsewhere. ^^  The  victims  of  what  has  variously  been  called  cerebral 
neurasthenia,  idio-obsessive  psychosis,  maladie  de  double,  delire  de  toucher  and 
latterly,  psychasthenia  are  the  antitheses  of  the  hysterical,  though  many  of 
their  sjinptoms  may  be  imitated  by  suggestion,  and  so  removed.  The  essential 
psychasthenic  characters,  however,  do  not  accompany  a  symptom  simulated  in 
this  way.  I  cannot  better  contrast  these  characters  than  in  the  following 
extract  from  International  Clinics  i^"^ 

"The  very  important  diagnosis  between  hysteria  and  psychasthenia  depends 
upon  the  following:  First,  as  to  fixed  ideas,  their  duration  in  hysteria  tends 
to  be  long;  for,  though  they  are  easily  buried  and  forgotten,  they  are  resus- 
citated with  great  ease  and  infallibility,  whereas  in  the  psychasthenic  the  fixed 
ideas  are  very  mobile,  but  keep  recurring  voluntarily,  and  indeed  become 
cherished  parts  of  the  individual,  and  are  far  more  difficult  to  eradicate  than 
those  of  the  hysteric.  Second,  hysterical  ideas  are  evoked  by  well-defined  and 
not  numerous  associations,  'suggestions';  in  the  psychasthenic,  they  are  often 
evoked  by  apparently  irrelevant  associations,  which  are  searched  for  by  the 
patient :  thus  the  'points  de  repere'  are  very  numerous,  cannot  be  predicted 
with  certainty,  and  are  often  mere  excuses  for  crises  of  rumination  or  tics. 
Third,  in  the  hysteric,  the  ideas  tend  to  become  kinetic;  whereas  the  psychas- 
thenic's  constant  state  of  uncertainty  causes  him  to  oscillate  between  'I  would' 
and  'I  would  not.'  Inhibition  is  too  strong  to  allow  an  act,  but  not  strong 
enough  to  dismiss  the  obsession, 

"The  anorexia  in  hysterics  is  derived  from  a  simple  idea  not  to  eat,  sug- 
gested by  imitation,  extraneously  or  in  a  dream.  Cases  of  true  loss  of  the 
feeling  of  hunger  are  not  hysterical,  but  accord  with  the  'anorexia  mentale'  of 
Lesegue,!^  in  whose  days  hysteria  was  poorly  differentiated.  The  anorexia  of 
the  psychasthenic  is  secondary  to  an  obsession,  usually  of  shame  of  body,  of  being 
fat,  or  of  the  act  qf  eating,  and  is  accompanied  by  numerous  stigmata  of  the 
psychasthenic  state."^^ 

It  must,  however,  be  remembered  that  the  neurasthenic  state  favors  sug- 
gestibility, though  it  is  not  of  the  d}Tiamic  kind,  which  the  hysterical  manifests, 
but  is  of  a  passive,  aboulic  character. 

From  the  foregoing  considerations  it  follows:  (1)  that  from  hysteria  must 
be  eliminated  cases  of  trickery,  simulation  and  mythomania;  (2)  that  to  the 
syndrome  of  hysteria  do  not  belong  modifications  of  reflectivity;  (3)  that  the 
vasomotor  and  trophic  neuroses  have  nothing  to  do  with  hysteria  and  (4)  that 
other  psychoneurotic  states  such  as  psychasthenia,  neurasthenia,  cenesthopathia, 
mental  debility,  and  confusion,  the  early  phases  of  dementia  proscox,  dream-like 
states,  and  emotional  perversions  must  not  be  confounded  with  hysteria. 

Having  eliminated  these  negative  characters,  there  remain  the  very  definite 
conclusions  which  I  quote  again  from  International  Clinics  :^^ 


CONCEPTS  CONCERNING  HYSTERIA.  149 

"1.  That  all  the  symptoms  which  may  legitimately  be  included  under 
hysteria  are  imposed  by  suggestion. 

"2.  That  the  state  of  suggestibility  derives  from  (a)  faulty  education, 
tending  to  perpetuate  and  fortify  the  natural  suggestibility  of  the  child;  (b) 
cerebral  modifications  due  to  organic  causes,  the  action  of  which  necessarily 
varies  among  individuals  in  accordance  with  (c)  the  hereditary  constitution." 

For  clarification  of  the  issue  we  are  indebted  to  Babinski  and  the  dis- 
cussions which  his  pertinacity  has  inspired  in  the  Paris  Neurological  Society; 
and  for  a  full  account  of  the  data,  the  reader  is  referred  to  the  reports  of  these.^i 

Space  forbids  even  a  statement  of  the  therapeutics  and  medico-legal  corol- 
laries of  these  conclusions.  The  latter  were  alluded  to  in  the  Monthly 
Cyclopedia  of  November  last.22  The  former  should  clarify  our  understand- 
ing of  much  of  the  pseudo-scientific  psychotherapy  now  becoming  so  rampant. 

A  clear  conception  of  the  psychological  mechanism  of  hysteria  will  add 
enormously  to  the  power  of  medical  men  in  controlling  the  psychoneurotic 
element  present  in  so  many  diseased  conditions. 

The  hit-or-miss  psychotherapy-of-encouragement  in  many  cases  does  more 
harm  than  good.  It  is  as  dangerous  therapeutically  as  digitalis  or  the  knife 
in  hands  ignorant  of  pathology.  The  delicate  judgments  upon  which  the 
treatment  depends  certainly  cannot  be  entrusted  to  the  untrained.  However 
supple-witted  may  be  a  pedagogue,  priest  or  mental  healer,  he  lacks  the  broad 
training  in  the  fundamentals  of  clinical  medicine  in  which,  unfortunately, 
some  men  who  specialize  too  early  in  their  career  are  also  deficient.  Accord- 
ingly, the  therapy  of  hysteria  as  well  as  of  the  other  psychoneuroses  can  be 
intrusted  with  safety  only  to  the  physician,  and  he  in  turn  must  rise  to  the 
occasion  by  studying  the  pathogenesis  of  these  as  he  now  does  that  of  arterio- 
sclerosis or  glandular  insuiSciency.  In  the  meanwhile,  he  must  have  recourse 
for  advice,  and  sometimes  for  direction,  to  the  few  men  who  have  already 
devoted  themselves  to  this  study. 

References. 

1  La  Discussion  sur  I'Hysterie;     Socigl6  de  Neurologle  de  Paris,  Rertie  Neiirologiqiie, 

1908.  Williams:     Status  of  Hysteria;    New  York  Med.  Joum.,  Jan.  9,   1909. 

2  Babinski:  La  Definition  de  I'Hystdrie;  Revue  Neurologique,  1901. 
3BEBNHEiii:     Comment  je  Comprends  le  mot  Hysterio;    Bui.  Med.,  1907. 
4BAGINSKI:  Ma  Conception  de  I'Hysterie;    Paris,   1906. 
sBeknheim:     Suggestion,  Hypnotisme,  et  Hyst^rie;    Paris,  1903. 

6  Williams:     Le  R5le  du  Medecin   en   cr(5ant  ou  en   maintenant   par   des   Suggestions 
maladroites  les  Maladies  produites  par  I'lmagination;    Congres  de  Lille,  190G. 
Trans.  Amer.  Med.,  Aug.,  1908. 
tBbissaud:     ReAiie  Neurologique,  1908. 
8Dupe:6:     La  Mythomanie,  Paris,  1905. 
0  Dallet  :     Cited  by  Dupr?.  loc.  cit. 

ioMeige:     Les  (Edoraes  Trophiques;    Nouvol.  Icon,  de  la  Salpetriere,   1899. 
iiSouQUES:     Ngvrose  Secretoire;    R6vue  Neurologique.  1908. 

12  Cited  in  the  discussion  upon  Hysteria;    Revue  Neurologique,  1908. 

13  Discussion  sur  I'Hysterie;    loc.  cit. 

14  Williams:     The  Most  Common  Cause  of  Nervous  Indigestion;    Joum.  of  Abnormal 

Psycholog\%  Boston.  Feb.,  1909. 

15  Pascal:     Forme  Prodromale  Neurastheni que   de   la   Demence   PrCcoce;     Les   Ictus   dans 

la  D^mence  Preeoce;    Congres  de  Lille,  L'Encfphale,  1906. 
lOWlLLlAArs:     Differential  Diagnosis  of  Neurasthenia  from  (Jther  AflFections  often  mis- 
taken for  it;    Archives  of  Diagnosis,  Jan.,  1909. 


150  PRACTICAL  APPLICATIONS  OF  DR.  SAJOUS'S  PRINCIPLES. 

17  WilxiAMS:     Consideration  as  to  the  Nature  of  Hysteria  with  Application  to  a  Case; 

International  Clinics,  Oct.,  1908.    The  Trend  of  the  Clinicians  Concept,  of  H. ; 
Bost.  Med.  and  Surg.  Journ.,  1909.     Psychol.  Review,  Feb.,  1909. 

18  DuPRfi :     Les  Cenesthopaths,  L'Enc6phale,  1907. 

19  Raysiond  et  Janet:     Les  Obsessions  et  la  Psychasthfenie,  Paris,  1903. 

20  Loc.  cit. 

21  Loc.  cit. 

22  Williams  :     Recent    Advances    in    Hysteria    in    Relation    to    Traumatic    Neuroses, 

Monthly  Cycl.  and  Med.  Bull.,  Nov.,  1908. 


A  FEW  PRACTICAL  APPLICATIONS  OP  THE  NEWEST  PRINCIPLES 
INTRODUCED  BY  DR.  SAJOUS.' 

By  J.  MADISON  TAYLOR,  B.A.,  M.D., 

PHILADELPHIA. 

The  work  to  which  Dr.  Sajous  has  given  his  attention  for  over  twenty 
years  may  be  characterized  briefly  as  a  new  interpretation  of  the  scientific 
factors  in  all  branches  of  medicine,  direct  and  contributory,  calculated  to 
place  the  clinician  on  a  basis  of  precision  and  confidence.  He,  in  common  with 
all  other  alert  thinkers,  is  painfully  aware  that  there  is  not  only  much  confusion 
and  apparent  contradiction  in  existing  teachings,  but  also  that  we  have  by  no 
means  yet  learned  a  large  number  of  truths  most  essential  to  the  solution  of 
daily  recurring  problems. 

To  be  aware  of  what  we  do  not  know  and  to  estimate  our  own  shortcomings 
with  a  due  sense  of  proportion,  to  state  these  omissions  with  logic  and  candor, 
is  in  any  stage  of  scientific  evolution  as  important  as  isolated  discoveries.  Not 
only  so,  but  those  discoveries  are  of  greatest  utility  which  make  for  the  achieve- 
ment of  a  consistent  conception  of  the  many  brilliant  findings  of  others,  which 
may,  however,  stand  so  far  apart,  may  be  so  involved  in  less  essential  details, 
that  they  fail  to  fuse  into  the  scheme  of  logically  related  facts.  The  greatest 
possible  of  discoveries,  then,  are  those  which  put  into  our  hands  unerring  laws 
of  action,  or  conduct,  or  thought,  and  the  foundations  of  which  are  solidly 
established  scientific  facts. 

The  first  thing  demanded  of  any  clinician  is  not  alone  whether  the  patient 
presents  a  well-defined  picture  of  functional  derangement,  of  infection  or 
malignant  disease,  but  also  to  determine  to  what  extent  our  drugs  are  able  to 
antagonize  morbific  agencies.  Every  wise  practitioner  unconsciously  formulates 
such  laws  in  his  mind  as  he  has  evolved  from  his  own  experience.  He  uses  the 
classic  or  current  rules  for  general  diagnosis  and  the  action  of  remedies,  but 
none  is  more  vividly  conscious  than  he,  nowadays,  that  his  cherished  rules 
frequently  conflict  with  his  own  observations  and  do  not  appeal  to  logical 
reasoning. 

He  is  confronted  by  two  sources  of  confusion :  1,  the  misleading  influence 
of  those  who,  working  within  the  narrow  field  of  laboratory  work,  make  dog- 


1  Read  by  request  before  the  North  Branch  of  the  Philadelphia  County  Medical 
Society,  February  18,  1909. 


PRACTICAL  APPLICATIONS  OF  DR.   SAJOUS'S  PRINCIPLES.  151 

matic  statements  which  threaten  the  integrity  of  well-established  beliefs,  leaving 
him  high  and  dry  on  the  shores  of  doubt ;  and  2,  the  exploitation  of  profoundly 
abstruse  and  complex  diagnostic  methods  and  forms  of  treatment  of  such 
extreme  specialization  in  technique  that  he,  the  practitioner,  can  make  little 
use  of  them. 

It  is  precisely  in  this  connection  that  Sajous's  labors  will  prove  invaluable 
to  the  profession.  He  urges  that  the  prevailing  confusion  and  the  growing 
complexity  in  every  branch  is  the  inevitable  result  of  the  absence  of  precise 
knowledge  concerning  certain  most  important  organs  in  all  the  conjectures  of 
investigators,  clinicians,  etc.  Investigators  and  clinicians  find  themselves 
blocked  at  every  step,  and  obliged  to  account  theoretically  for  a  multitude  of 
phenomena  which  these  organs  awaken.  He  has  shown,  in  his  work  on  the 
"Internal  Secretions,"  that  as  soon  as  the  functions  he  has  ascribed,  after 
painstaking  research,  to  the  adrenals,  the  thyroid,  the  pancreas,  etc.,  are  taken 
into  account,  all  confusion  disappears  and  solidly  established  facts  fall  into  line, 
so  to  say,  of  their  own  accord.  And  more,  he  has  furnished  not  only  the  key 
to  the  stronghold  of  our  defenses  against  disease  by  showing  that  those  identical 
organs,  whose  functions  he  has  brought  to  light,  are  those  which,  through  the 
entire  animal  scale,  protect  the  body  against  poisons,  but  he  has  also  shown  that 
the  physician  can  control  this  mechanism  at  will,  with  the  commonplace  reme- 
dies in  daily  use.  Confusion,  hesitation  and  empiricism  is  thus  replaced  by 
precision,  timely  intervention  and  scientific  accuracy. 

The  results,  though  Dr.  Sajous's  labors  may  be  said  to  be  still  in  their 
infanc)',  do  not  belie  the  expectations  that  such  contributions  to  our  knowledge 
should  fulfil.  It  is  of  almost  daily  occurrence  now  to  hear  of  some  ease  in 
which  his  views,  accepted  as  a  last  resort,  have  yielded  unexpected  results  in 
diseases  of  various  kinds.  It  is  my  purpose,  in  this  communication,  to  show 
how  his  conceptions  work  out  in  practice,  by  citing  a  few  cases  of  epilepsy  in 
childhood.  These  are  simply  three  of  the  many  which  my  case-books  furnish 
in  which  the  results  have  coincided  with  his  expectations. 

No  derangement  or  disease  which  afflicts  humanity  has  called  out  a  greater 
multiplicity  of  effort  than  epilepsy,  especially  when  occurring  in  childhood. 
Without  attempting  to  review  the  current  beliefs  or  to  estimate  the  enormous 
importance  of  recorded  observations,  let  us  bear  in  mind  that  Sajous  has  done 
his  uttermost  to  utilize  all  available  knowledge.  He  arrives  at  personal  con- 
clusions, however,  which  make  it  possible  to  see  much  deeper  into  causal  agencies 
and  to  show  how  they  may  be  overcome  and,  in  most  instances,  a  cure  effected. 
"Literature  shows  plainly,"  he  writes,  "that  the  dominant  feature  in  the 
pathogenesis  of  convulsions  is  tho  impairment  of  metabolism,  and  that  the 
spasmogenic  agent  is  some  toxic  agent  in  the  blood-stream.  Pathologic  varia- 
tions of  vasomotor  action,  due  more  or  less  to  a  morbid  condition  of  the 
blood,  have  also  asserted  themselves  so  strikingly  in  the  production  of  fits  that 
some  observers  have  been  inclined  to  regard  them  as  the  foundation  of  the 
whole  symptom-complex.  Again,  the  destruction  of  the  spasmogenic  agent  has 
been  urged  by  some  as  the  only  reasonable  principle  of  cure  in  opposition  to  the 


152  PRACTICAL  APPLICATIONS  OF  DR.  SAJOUS'S  PRINCIPLES. 

use  of  bromides  and  chloral,  which  tend  to  increase  its  formation   in  the 
blood-stream." 

A  common  feature  in  all  cases  of  epilepsy  is  (as  Spitzka  pointed  out  in 
1881)  "explosive  activity  of  an  unduly  irritable  vasomotor  center,"  and  most 
neurologists  regard  epilepsy  as  a  "functional  vasomotor  disease."  Sajous 
reaches  the  fundamental  conclusion,  therefore,  that  we  have  as  "the  cause  of 
convulsions  a  toxic  in  the  blood  capable  of  producing  a  high  vascular  tension 
and  thereby  excessive  hypera3mia  of  the  cortex.  This  hyperEemia  is  a  recog- 
nized cause  of  the  epileptic  seizures ;  the  exciting  factor  is  a  poison  formed  in 
the  tissues,  and  our  chief  aim,  therefore,  should  be  to  destroy  that  poison  and 
to  prevent  its  further  formation.  Not  only  do  bromides  not  assist  in  this 
essential  process,  they  hinder  it;  they  act  chiefly  as  depressants  to  the  circula- 
tion, inducing  lowered  temperature,  lowered  oxidation,  even  asphyxia;  further, 
they  tend  to  paralyze  the  adrenal  system  whose  efficiency  is  essential  to  the 
destruction  and  elimination  of  the  toxics  which  induce  the  symptom-complex. 

It  is  the  adrenal  secretion,  which,  as  Sajous  has  shown,  takes  up  the  oxygen 
of  the  air,  passes  it  on  to  the  tissues  (as  the  albuminous  constituent  of  the  haemo- 
globin) and  sustains  the  whole  process  of  oxidation,  and  also  the  antitoxic 
functions  of  the  organism.  Bromides  and  the  whole  group  of  depressants  exert 
the  effect  of  obtunding  the  sensitiveness  of  the  center  which  governs  these 
all-important  functions,  hence  they  are  directly  contraindicated.  As  to  the  cure 
of  the  disease,  he  insists  on  the  use  solely  of  drugs  which  enliance  oxidation, 
and,  therefore,  the  antitoxic  functions  of  the  body.  He  also  holds  that  it  is 
equally  important  to  employ  all  those  contributory  measures  which  limit  the 
production  of  irritating  toxics  from  food,  fatigue,  etc.,  e.  g.,  the  flesh  foods 
which  contain  the  most  dangerous  factors. 

The  three  illustrative  cases  I  have  referred  to  will  show  the  practical 
bearing  of  Sajous'  views: — 

E.  B.  Age  seven  years.  A  large,  well  grown,  only  child.  Birth  normal 
and  no  incident  worthy  of  remark  in  early  history,  except  a  digestive  upset  at  10 
months.  Measles  with  congestion  of  the  limgs  occurred,  followed  by  chicken- 
pox,  followed  by  rotheln.  These  were  the  only  infections  and  were  mild.  The 
digestion  was  always  more  or  less  vulnerable,  needing  a  little  attention  from 
time  to  time.     Bowels  rather  slow. 

A  little  less  than  a  year  ago  (August,  1907)  the  mother  noticed  slight 
attacks  of  gulping,  staring  and  slight  confusion  also,  occurring  only  rarely. 
At  the  same  time  she  became  restless  at  night.  She  was  treated  for  "worms" 
and  indigestion,  but  attacks  grew  worse.  October  15,  1907,  adenoids  were 
removed,  also  tonsils,  which  seemed  to  afford  no  improvement,  except  that  the 
"choked-up  feeling"  fonnerly  complained  of  ceased,  and  also  the  susceptibility 
to  "colds."  From  the  first  of  January,  1908,  there  began  a  series  of  definite 
convulsions,  one  or  two  a  week,  gradually  growing  more  severe  and  frequent, 
nearly  always  at  night.  Despite  all  treatment — and  several  of  the  leading 
specialists  in  Boston  were  consulted — these  convulsive  attacks  increased  in 
number  and  severity  until  she  would  have  sometimes  30  or  more  in  one  night. 
My  first  observation  of  the  child  was  just  eleven  months  after  the  first 


PRACTICAL  APPLICATIONS  OF  DR.  SAJOUS'S  PRINCIPLES.  153 

attack.  She  was  under  the  care  of  another  physician,  and  seventeen  miles  from 
Bar  Harbor,  where  I  was  then  staying.  I  was  asked  suddenly  to  go  and  see  this 
child,  and  on  learning  that  Dr.  Philips,  a  prominent  practitioner  of  the  place, 
was  in  attendance,  I  called  him  on  the  'phone  and  learned  that  he  had  seen  the 
child  within  a  few  hours  and  regarded  her  as  moribund.  The  convulsions  fol- 
lowed one  another  so  rapidly  that  there  was  almost  no  intermission;  there  was 
incontinence  of  urine  and  faeces,  stupor,  extremely  weak  circulation ;  in  short,  he 
regarded  the  end  as  near.  The  family  insisted  upon  my  seeing  the  child,  how- 
ever, which  I  did.  I  found  the  condition  somewhat  better  and  brought  her  to 
the  hospital.  I  had  called  Dr.  Sajous  in  consultation  at  once,  and  besides  the 
purgation  I  had  ordered,  he  advised  Yso  grain  of  calomel  every  three  hours, 
and  later  %  grain  doses  of  dessiccated  thyroid,  three  times  a  day,  also  physio- 
logic salt  solution  taken  freely  as  a  beverage.  The  progress  was  steady  and 
rapid.  The  thyroid  was  increased  to  ^  grain  doses,  thrice  daily  and  no  more, 
and  this  again  was  gradually  reduced  as  the  convidsions  grew  rarer.  These 
ceased  after  the  first  month  of  treatment  and  have  never  recurred,  though 
seven  months  have  now  elapsed.  She  is  now  (February  15,  1909),  in  all  ways 
a  healthy,  vigorous  child,  and  was  unquestionably  saved  from  death, 

M.  K.  Aged  two  years.  First  child.  Healthy,  sober  parents.  No 
special  incident  at  birth.  Breast-fed  until  fifteen  months.  Digestion  and 
color  good.     Well  nourished. 

Attacks  noticed  first  at  the  age  of  about  two  weeks ;  at  one  month  a  violent 
one  occurred  lasting  ten  minutes;  stiffened  all  over,  open  and  shut  hands  and 
feet,  grew  ver}^  red,  eyes  stared  and  "stuck  out";  later  grew  white  and  limp, 
then  yawned  and  slept  some  ten  or  fifteen  minutes.  At  first  the  attacks  occurred 
two  or  three  times  a  week;  later  every  other  day,  exhibiting  nearly  similar 
phenomena.  Also  the  child  was  apathetic,  listless,  made  no  effort  to  stand,  or 
to  grasp  things;  could  not  learn  to  sit  up — in  short,  exhibited  no  normal 
initiative. 

The  child  was  wholly  unintelligent.  Flabby  muscles;  saliva  dribbled 
from  the  mouth;  no  Imee  jerk;  bolted  food;  made  no  effort  at  mastication. 
All  teeth  came  on  time.  Child  often  screamed  two  or  three  times  in  rapid 
succession.     Eated  as  a  middle  or  low  grade  epileptic  idiot. 

Put  under  treatment  December  23,  1908.  Calomel  gr.  ^20,  t.i.d.  for  one 
week,  then  desiccated  thyroid,  gr.  %,  twice  daily;  increased  to  ^  gr.,  thrice 
daily.  Also  back  rub})ed.  To  be  fed  by  mother  slowly  and  compelled  to  chew. 
Although  but  seven  weeks  have  elapsed  since  this  treatment  was  begun,  there 
has  been  marked  and  rapid  improvement  in  all  particulars.  The  attacks  are 
much  rarer  and  less  severe;  the  motor  power  is  greatly  increased;  the  child 
sits  alone  and  is  anxious  to  stand ;  crawls  a  little.  Notices  almost  all  happen- 
ings;   growing  steadily  in  vigor  and  intelligence. 

Miss  A.  B.  C.  Now  about  sixteen  years  of  age.  Of  healthy  stock; 
brothers  and  sisters  in  good  health.  Always  had  every  opportunity  for  vigorous 
living  and  the  best  medical  attention.  When  about  eight  or  nine  years  old 
began  to  have  slight  attacks  which  gradually  developed  into  petit  mal.  Until 
1900  and  notwithstanding  the  skilled  use  of  all  familiar  resources,  these  attacks 


154  PRACTICAL  APPLICATIONS  OF  DR.   SAJOUS'S  PRINCIPLES. 

steadily  increased.  A  careful  record  has  been  kept  by  her  physician,  Dr.  H. 
T.  Baldwin,  of  Chestnut  Hill,  Mass.,  and  with  charts  for  the  years  1906,  1907 
and  1908,  which  serve  to  show  with  great  exactness  the  steady  advance  under 
small  doses  of  thyroid  and  the  diet  measures,  including  saline  beverage, 
advocated  by  Dr.  Sajous, 

As  is  well  kno-RTi,  nothing  is  more  obdurate  than  petit  mal.  Dr.  Baldwin 
writes:  "The  tabulation  shows  how  attacks  increased  for  six  years  before 
coming  under  your  care  regularly.  During  these  years  she  was  under  various 
forms  of  bromide,  and  from  1900  to  1903  seemed  to  be  slowly  improving,  and 
then  began  gradually  to  fall  back,  toward  the  end  of  1906.  You  started  your 
treatment  in  the  summer  of  1906  and  this  chart  shows  the  result  so  clearly 
that  no  comment  is  needed.  At  the  same  time  that  the  number  of  attacks 
diminished  their  character  also  lessened  in  severity  imtil  a  stranger  would  not 
notice  anything  amiss  if  he  saw  her  during  an  attack.  Her  health  is  also  now 
much  better  and  she  is  living  a  life  more  like  other  girls.  Her  catamenia 
appeared  in  the  autumn  of  1908  without  any  marked  feature,  and  she  now 
joins  fully  in  all  her  social  opportunities." 

It  is  interesting  to  note  that  for  a  long  time,  many  years,  the  attacks  were 
complicated  by  a  hysteroid  element,  as  is  also  a  common  feature.  The  element 
of  dread  serves  not  only  to  exaggerate  slight  attacks  into  larger  ones,  but 
possibly  to  precipitate  an  attack  from  nothing.  As  was  perfectly  natural,  her 
mother,  although  a  woman  of  abundant  wisdom,  at  first  allowed  her  solicitude 
to  be  over-readily  seen  and  this  served  to  aggravate  the  condition. 

All  contributing  measures  were  employed  from  the  first,  and,  while  I  was 
a  little  more  positive  in  cutting  out  red  meats,  this  would  have  made  less  differ- 
ence than  usual,  because  it  is  permissible,  often  desirable,  to  use  a  diet  fuller 
in  albuminoids  while  taking  thyroid. 

The  uniform  progress  toward  health  can  be  attributed  wholly  to  the 
medicinal  treatment,  which  met  the  precise  needs  of  the  organism. 

The  simplifying  influence  of  Dr.  Sajous's  discoveries  as  to  the  functions  of 
the  ductless  glands  and  other  body  structures  is  clearly  shown  by  these  cases. 
All  three  were  due  to  the  retention  of  excrementitious  substances  in  the  blood, 
and  the  irritating  action  of  these  poisons  upon  the  spasmogenic  centers — the 
indications,  of  course,  being  to  destroy  these  poisons.  Drugs  known  to  do  so 
by  increasing  the  antitoxic  substances  through  the  ductless  glands — mercury, 
and  dessicated  thyroid — were  administered.  To  assist  this  antitoxic  process 
the  osmotic  properties  of  the  blood,  physiologic  saline  solution  was  given  as 
beverage.  On  the  other  hand,  the  sources  of  intoxication  were  as  much  as 
possible  eliminated  by  purgation  and  dietetic  measures  calculated  to  prevent 
the  accumulation  in  the  blood-stream  of  any  toxic  wastes,  i.e.,  wastes  imper- 
fectly prepared  for  prompt  elimination  by  the  kidneys. 

Spratling  has  remarked  that  all  epileptics  tend  to  bolt  their  food.  This 
certainly  is  my  experience,  especially  among  children.  They  are  also  voracious 
feeders.  Hence  tlie  intestines  are  constantly  overburdened  with  putrefying 
substances  ready  to  vitiate  the  blood  and  aggravate  the  trouble.  Slow  and 
thorough  mastication  must  be  taught  and  enforced;  children  should  be  fed  by 


ASTHMA. 


CARCINOMA. 


155 


hand.  Even  milk  should  be  fed  from  a  teaspoon  to  secure  insalivation  and  to 
prevent  formation  of  curd  masses.  Cereals  and  also  all  foods  must  be  held 
in  the  mouth  an  appreciable  length  of  time.  Eewards  or  punishments  should 
be  employed  to  compel  riglit  habit-formation.  A  laxative  is  frequently  neces- 
sary. Castor  oil  is  most  thorough  and  bland.  A  pinch  of  table-salt  swallowed 
along  with  a  glassful  of  water  on  waking  frequently  suffices.  Colonic  saline 
irrigations  are  helpful,  not  only  to  cleanse  the  bowel  but  to  assist  by  imbibition, 
the  irrigation  of  the  adjacent  structures.  To  check  voracity  for  nourishing 
food  it  is  a  good  plan  to  give  raw  fruit  as  a  first  course.  Soups  are  pernicious. 
They  overburden  the  stomach  and,  when  made  of  meats,  introduce  -waste 
products,  which  stimulate  and  disturb.  Vegetable  purees  are  not  adequately 
insalivated.  The  foods  should  be  confined  chiefly  to  vegetables,  fruits,  milk 
and  milk  preparations,  especially  the  lactacid  milks.  When  the  habits  of 
mastication  are  well  formed  a  larger  dietary  can  be  permitted,  but  never  the 
red  meats. 


Cjjclopecdia  of  Current  I^iterature 


ASTHMA:      ITS  CAUSE  AND  TREATMENT. 

There  are  three  causative  factors  in 
asthma:  (1)  the  presence  of  hypersen- 
sitive areas  in  the  nasal  mucosa  or  a 
special  sensitiveness  of  the  gastric 
mucosa;  (2)  a  special  irritant  of  the 
pulmonary  nervous  system  which  con- 
stitutes the  asthmatic  idiosjmcrasy  with 
which  the  patient  was  born;  (3)  the 
presence  of  an  irritant,  e.g.,  odors,  dust, 
smoke,  dietetic  errors,  etc. 

Treatment  follows  according  to  this 
classification.  In  a  given  paroxysm  in- 
quiry should  be  made  as  to  the  last 
meal,  and  any  obvious  exciting  cause 
removed.  If  the  patient  is  in  a  bad 
atmosphere,  he  should  be  removed.  He 
should  be  gotten  out  of  bed,  and  bol- 
stered up  in  an  armchair  before  a 
cushioned  table,  on  which  he  may  rest 
his  elbows  and  throw  himself  forward. 
Ipecac  powder  will  occasionally  cut 
short  an  attack  and  permit  of  a  good 
night.  Some  patients  can  get  the  same 
relief  from  pipe  tobacco,  but  all  such 
remedies  must  be  used   early.     Plain, 


strong,  hot  coffee  is  one  of  the  surest 
remedies.  Alcohol,  cocaine  and  chloro- 
form are  all  serviceable,  but  the  danger 
of  habit  formation  must  not  be  forgot- 
ten. Stramonium  smoking  and  nitre 
paper  fumes  are  often  efficient.  The 
author's  experience  with  the  iodide  of 
potash  has  been  disappointing.  The 
food  should  be  nutritious  and  easily 
digestible.  Asthmatics  should  dine 
early,  so  as  to  retire  on  empty  stom- 
achs. Intranasal  abnormalities  must  be 
rectified.  For  ordinary  intranasal  irri- 
gation the  normal  salines  are  better 
than  the  usual  antiseptics  emplo^^ed  for 
this  purpose.  W.  Lloyd  (British  Med- 
ical Journal,  January  16,  1909). 

CARCINOMA,  EXCITATION  OF  THE  LEUCO- 
CYTES IN  CASES  OF. 
Attention  is  directed  by  the  authors 
to  the  possibility  of  cancer  being  the 
local  manifestation  of  a  disease  which 
is  dependent  on  changes  in  the  blood, 
difficult  to  account  for,  but  yet  so  con- 
stant  that   their   association   with   the 


156 


CARCINOMA. 


CHOREA. 


neoplasm  cannot  be  disregarded.  This 
consideration  led  to  the  application  of 
a  method  for  distinguishing  dead  leuco- 
cytes from  living  ones  by  the  fact  that 
live  cells  resting  on  agar  Jelly  that  con- 
tains, besides  neutralized  sodium  citrate 
and  sodiiun  chloride,  a  certain  propor- 
tion of  meth5'lene-blue  and  atropine  sul- 
phate, will  exhibit  exaggerated  amoeboid 
movements.  The  stain  is  the  most  im- 
portant constituent  of  this  excitant.  In 
neutral  jelly  the  excitation  somewhat 
inconstantly  occurs  without  addition  of 
the  alkaloid,  but  on  the  addition  of  an 
alkali  in  amount  proportionate  to  the 
temperature  of  the  room  sufficient  to 
produce  diffusion  of  the  stain,  marked 
excitation  occurs  only  when  the  alka- 
loid is  present.  Certain  alkaloid-like 
toxcemic  symptoms  found  in  cases  of 
cancer  suggested  that  in  the  blood  of 
cancer  patients  there  might  be  some 
substance  which,  in  the  presence  of  an 
alkaline  plasma,  acts  as  a  stimulant  to 
the  normal  cells,  thereby  in  some  way 
giving  rise  to  the  new  growth.  The 
authors  had  in  the  wards  a  patient  with 
carcinoma  of  the  pylorus,  who,  while  not 
taking  any  narcotics,  presented  toxremic 
symptoms  resembling  those  that  might 
be  produced  by  an  alkaloidal  poison. 
Eoss  had  previously  ascertained  that 
the  plasma  of  persons  known  to  be  suf- 
fering from  carcinoma  did  not  com- 
paratively shorten  the  lives  of  the  leu- 
cocytes of  healthy  persons,  in  contra- 
distinction to  the  effects  produced  by 
the  plasma  of  persons  suffering  from 
several  infective  diseases — this  fact  in- 
dicating that  cancer  is  not  an  infective 
disease. 

The  authors  determined  to  ascertain 
whether  the  plasma  of  cancer  patients 
contained  any  excitant,  pathologic  in 
character,  for  the  leucocytes  of  healthy 
persons.     A  large  number  of  previous 


examinations  had  shown  that  leucocytes 
mixed  with  the  citrated  plasma  of 
healthy  persons  never  displayed  exag- 
gerated movements.  The  mixture  of 
the  citrated  plasma  of  the  cancer  pa- 
tient's blood  with  one-eighth  of  its 
volume  of  the  blood  of  a  healthy  per- 
son, showed  the  remarkable  movements 
which  were  more  marked  than  those 
seen  when  the  artificial  atropine  exci- 
tant was  used.  It  seemed,  therefore,  that 
there  was  actually  a  pathologic  excitant 
in  the  blood  of  this  cancer  patient. 
Nine  other  cancer  cases  consequently 
were  similarly  investigated,  the  results 
corresponding  in  every  way.  The  au- 
thors, therefore,  consider  that  in  cancer 
cases  there  may  be  present  some  sub- 
stance resembling  an  alkaloid  in  its  ac- 
tion, which,  in  the  presence  of  an  alka- 
line plasma,  excites  the  amoeboid  move- 
ments of  healthy  leucocytes.  They  fur- 
ther point  out  that  methylene-blue  is  a 
coal-tar  derivative,  and  that  cancer  is 
common  in  coal-tar  workers.  They  sug- 
gest that  this  reaction,  if  confirmed  by 
further  investigation,  may  prove  useful 
in  the  differential  diagnosis  of  cancer. 
C.  J.  Macalister  and  H.  C.  Ross  (Lan- 
cet, January  16,  1909). 

CHOREA,  NASOPHARYNGEAL  ORIGIN  OF. 
The  author  found  that  a  severe 
chorea  in  a  girl  of  nine  subsided  at 
once  after  treatment  of  inflamed  tonsils 
and  adenoids.  This  occurred  twelve 
years  ago,  and  since  then  he  has  fre- 
quently found  indications  for  local 
treatment  in  the  throat  of  cases  of 
chorea,  and  invariably  the  effect  was 
most  striking  in  the  prompt  subsidence 
of  the  chorea.  The  nasopharynx  is  the 
source  of  infection  of  various  kinds,  es- 
pecially for  the  rheumatism  infection 
and  for  chorea.  Enlarged  tonsils  and 
adenoids  do  not  always  become  infected, 


TUBERCULIN  TEST. 


NASAL  AFFECTIONS. 


157 


and  the  infection  may  be  of  varying 
virulence  and  the  soil  of  varying  recep- 
tiveness,  but  the  influence  on  the 
chorea  of  suitable  treatment  of  the 
throat  and  nose  will  convince  the  most 
skeptical,  he  says,  of  the  unmistakable 
connection  between  them.  L.  de  Pon- 
thiere  (Annales  de  medicine  et  chir- 
urgie  infantiles,  November  1,  1908; 
Journal  of  the  American  Medical  Asso- 
ciation, December  19,  1908). 

CONJUNCTIVAL  TUBERCULIN  TEST. 

From  a  study  of  1087  conjunctival 
tuberculin  tests  by  a  uniform  method, 
the  writer  concludes  that  the  test  per- 
formed with  weak  solutions  by  a  single 
instillation  has  some  value  in  confirm- 
ing the  presence  of  tuberculosis  in  the 
early  stages.  It  has  little  value  in 
confirmation  when  the  symptoms  of 
tuberculosis  are  only  suspicions.  Its 
value  in  distinguishing  "active  latent" 
from  healed  tuberculosis  in  apparently 
healthy  persons  has  not  yet  been  de- 
termined. 

Eepetition  of  the  test  in  the  same  eye 
has  no  advantage  over  the  cutaneous 
and  subcutaneous  tests  in  the  percent- 
age of  reactions  produced,  and  may  be 
misleading  and  dangerous.  Eepetition 
in  the  other  eye  by  the  author's  method 
offers  so  little  advantage  that  it  cannot 
be  recommended.  The  conjunctival  re- 
action is  unreliable  for  prognosis.  Used 
with  the  proper  precautions,  danger  to 
the  eye  is  slight,  and  need  not  preclude 
the  test  when  other  methods  are  inap- 
plicable, as  when  fever  is  present.  It 
should  be  restricted  to  adults,  since  the 
cutaneous  test  has  been  found  equally 
valuable  for  children  and  is  harmless. 

The  cutaneous  test  by  the  simultane- 
ous use  of  dilute  and  strong  tuberculin 
offers  a  method  of  detecting  at  once  or 
excluding  tuberculous  infection  with  no 


danger  or  inconvenience.  Experience 
is  needed  to  show  the  value  of  this 
method. 

The  subcutaneous  test  should  be  re- 
stricted to  those  cases  in  which  a  focal 
reaction  at  the  site  of  the  disease  is 
desired,  and  when  the  other  tests  result 
negatively.  E.  E.  Baldwin  (Journal  of 
the  American  Medical  Association, 
February  20,  1909). 

NASAL   AFFECTIONS,   RUBBER   BALL 
TREATMENT  OF. 

The  author  applies  the  general  prin- 
ciples of  resting  an  inflamed  part  and 
keeping  further  irritation  away  from  it. 
The  nasal  mucosa  is  peculiarly  exposed 
to  thermic,  mechanic  and  chemic  irrita- 
tion— its  physiologic  task  is  to  arrest 
such  irritating  agents  to  prevent  their 
further  invasion  of  the  air  passages  be- 
low. If  the  nasal  mucosa  becomes  in- 
flamed, a  vicious  circle  results,  con- 
stantly growing  worse.  Healing  is  pos- 
sible by  removing  all  possibility  of  fur- 
ther irritation  and  giving  the  inflamed 
mucosa  a  chance  to  heal.  This  the  au- 
thor accomplishes  by  the  use  of  a  ball 
of  very  soft  rubber,  about  12  milli- 
meters in  diameter,  pushed  into  the 
nostril  to  occlude  the  passage.  He  has 
the  ball  introduced  alternately  into  the 
nostrils  and  left  in  place  for  half  to 
three-quarters  of  an  hour,  several  times 
a  day.  There  is  a  small  handle  to  the 
ball,  and  this  is  all  that  shows.  The 
ball  not  only  keeps  away  irritation  and 
rests  the  mucosa,  but  it  induces  local 
hypergemia  and  a  warmer  temperature, 
and  the  patient  experiences  great  re- 
lief, while  healing  rapidly  proceeds. 
Sprenger  (Berliner  klinische  Wochen- 
schrift,  November  16,  1908;  Journal 
of  the  American  Medical  Association, 
January  2,  1909). 


158  BOOK  REVIEWS. 

OUR  CONTEMPORARIES. 

The  January  issue  of  the  American  Journal  of  Clinical  Medicine  is  entitled  to  great 
praise.  It  inaugurates  several  changes,  and  new  and  important  features  which  will  tend  to 
make  the  journal  most  valuable  to  its  readers.  Among  the  articles  we  note:  "How  I  Treat 
Pulmonary  Tuberculosis,"  by  W.  F.  Waugh;  "The  Social  Evil  and  Its  Remedies,"  by  G.  F. 
Lydston;  "The  Treatment  of  Typhoid  Fever  from  Beginning  to  End,"  by  C.  F.  Wahrer; 
"Typhoid  Fever  in  Hospital  and  Private  Practice,"  by  A.  V.  Lyon;  "Bismuth-Paste  Treat- 
ment of  Rectal  Fistula,"  by  J.  R.  Pennington;  "A  Little  Journey  to  the  Home  of  Benjamin 
Rush,"  by  G.  F.  Butler;    "The  Physician  as  a  Business  Man,"  by  G.  G.  Burdick. 

An  unusual  feature  of  medical  journalism  will  be  presented  in  the  March  issue  of  the 
American  Journal  of  Surgery.  The  entire  original  subject-matter  in  this  issue  will  be  con- 
tributed by  New  York  City  surgeons  of  note,  and  a  number  of  new  operations  will  be  first 
presented  therein.  Among  the  contributions  to  appear  are:  "A  New  and  Simple  Method  of 
Intestinal  Anastomosis"  (illustrated),  by  Howard  Lilienthal,  M.D.,  Attending  Surgeon,  Mt. 
Sinai  Hospital;  "Sigmoiditis  and  Perisigmoiditis,"  by  James  P.  Tuttle,  M.D.,  Professor  of 
Rectal  Surgery,  New  York  Polyclinic,  New  York;  "Cancer  of  the  Breast,"  by  Willy  Meyer, 
M.D.,  Professor  of  Surgery,  Post-Graduate  INIedical  School,  and  Attending  Surgeon  of  Ger- 
man Hospital,  New  York;  "The  Localization  and  Removal  of  Foreign  Bodies  with  Especial 
Reference  to  Those  in  the  Skeletal  Tissues"  (illustrated),  by  Dr.  Walter  M.  Brickner, 
Assistant  Adjimct  Surgeon,  Mt.  Sinai  Hospital,  and  Editor-in-Chief,  American  Journal  of 
Surgery,  New  York;  "Dislocation  of  the  Cervical  Vertebrje"  (illustrated),  by  James  P.  War- 
basse,  M.D.,  Special  Editor,  American  Journal  of  Surgery,  and  Attending  Surgeon  to  Seney 
and  German  Hospitals,  Brooklyn. 


5ool<  Reviews 


Diseases  of  the  Nervous  System.  For  the  General  Practitioner  and  Student.  By  Alfred 
Gordon,  A.M.,  M.D.  (Paris),  Member  of  the  American  Neurological  Association,  etc., 
etc.     130  Illustrations.     Philadelphia:    P.  Blakiston's  Son  &  Company,   1908. 

This  book  of  Dr.  Gordon's  will  be  found  of  particular  value  to  the  general  practitioner 
and  student.  Its  small  size  and  convenient  form  recommend  it  especially  to  those  who  wish 
to  study  the  subject  without  having  had  much  previous  familiarity  with  it.  It  is,  strictly 
speaking,  an  outline  with  sufficient  illustration  for  its  avowed  purpose,  and  arranged  with 
excellent  system,  having  black  letter  headings  for  important  points,  excellent  typical  illus- 
trations, and  omitting  undue  controversy  on  mooted  points,  or  excessive  elaboration  of  inter- 
esting points,  which  is  not  always  profitable  in  obtaining  a  clear  first  impression.  It  omits 
also  that  excessive  presentation  so  often  found  in  microscopic  tissues;  yet  it  presents  a  fair 
number  of  typical  clinical  gross  appearances.  Dr.  Gordon's  training  is  especially  thorough, 
he  being  a  graduate  of  the  University  of  Paris  and  of  the  LTniversity  of  Berne.  He  was 
interne  at  the  Salpetri&re  under  Charcot,  and  studied  under  Brissaud,  Dejerine,  Marie, 
Ballet,  Mangan,  Voisin  and  Joffroy.  His  familiarity  with  mental  disease  has  been  amplified 
by  acting  as  examiner  of  the  insane  at  the  Philadelphia  Hospital  for  several  years,  and  also 
lecturing  at  the  Jefferson  College  on  neurolog}^  and  neuropathology,  and  at  Blockley  and  the 
Philadelphia  Hospital  on  clinical  psychiatry. — J.  M.  T. 

An  Alabama  Student  and  Other  Biographical  Essays.  By  William  Osier,  M.D.,  F.R.S., 
Regius  Professor  of  Medicine,  Oxford;  Honorary  Pro'fessor  of  Medicine,  Johns  Hopkins 
University,  Baltimore.  Oxford  University  Press,  American  Branch,  New  York:  29-35 
West  Thirty-second  Street;    London:    Henry  Frowde.  1908. 

History  records  the  names  of  many  men  whose  lives  have  been  notable  in  one  way  or 
another.  Nothing  stimulates  the  lagging  energies  of  the  physician  more  than  the  knowledge 
of  the  deeds  of  great  men  of  the  same  profession.  To  picture  a  noble  character  in  its  true 
colors  is  a  faculty  which  the  author  well  possesses,  and  in  the  present  vohmie,  which  is 
composed  of  a  series  of  addresses,  this  ability  is  very  evident. 

The  title  of  the  book  was  suggested  by  the  life  of  an  Alabama  student.  Dr.  John  Y. 
Bassett,  of  Hvmtsville,  "a  man  of  whom  you  have  never  heard,  whose  name  is  not  written 
on  the  scroll  of  fame,  but  who  heard  the  call  and  forsook  all  and  followed  his  ideal."  He 
left  his  wife  and  family,  whom  he  dearly  loved,  and  suffered  hardships,  because  of  his  devo- 
tion to  his  profession,  and  because  of  his  determination  to  perfect  himself  for  his  chosen 
work.     While   looking  over   the   first  two   voliunes   of   Fenner's   Southern  Medical   Reports, 


BOOK  REVIEWS.  159 

issued  in  1849-50  and  1850-51,  the  author  became  impressed  with  several  articles  written 
by  this  interesting  character,  and  the  investigation  of  his  life  followed. 

Another  man,  forming  the  subject  of  rather  a  lengthy,  but  very  interesting  essay,  is 
Elisha  Bartlett — A  Rhode  Island  philosophei- — "who  left  no  deep  impression  on  local  history 
or  institutions."  The  calibre  of  the  man  and  his  lofty  ideals  is  shown  in  the  following 
expression  of  his  object  from  his  translating  of  the  "Lives  of  Eminent  French  Physicians": 
"First,  the  delineation  of  distinguished  professional  character  and  attainment,  and,  secondly, 
by  the  influence  of  such  high  examples  to  awaken  in  the  younger  members  of  the  medical 
body  a  more  devoted  and  worthy  emulation  of  the  great  masters  of  our  art." 

The  subjects  of  other  addresses  are:  Thomas  Dover,  Physician  and  Buccaneer;  John 
Keats,  the  Apothecary  Poet;  Oliver  Wendell  Holmes;  John  Locke  as  a  Physician;  A  Back- 
wood  Physiologist,  being  an  interesting  account  of  the  work  of  Svirgeon  Beaumont;  The 
Influence  of  Louis  on  American  Medicine;  William  Pepper;  Alfred  Stille;  Sir  Thomas 
Browne;    Fracastorius;    and  Harvey  and  His  Discovery. 

The  author's  keen  sense  of  obsers-ation  and  his  ability  to  collect  historical  facts,  his 
marked  degree  of  earnestness,  and  his  easy  style  of  \vriting,  make  this  series  of  essays  very 
interesting  as  well  as  instructive. — R.  B.  S. 

The  Probleji  of  Age,  Growth  and  De.\th.  Based  on  Lectures  at  the  Lowell  Institute.  By 
Charles  S.  Minot,  LL.D.  (Yale,  Toronto);  D.Sc.  (Oxford);  James  Stillman,  Professor 
of  Comparative  Anatomy  in  Harvard  Medical  School.  Illustrated.  New  York  and  Lon- 
don:   G.  B.  Putnam's  Sons,  Knickerbocker  Press,  1908. 

This  book  is  dedicated  to  Angelo  Mosso,  Professor  of  Physiology  at  the  University  of 
Turin,  and  the  introductory  chapter  is  addressed  to  him,  in  which  the  general  scope  and 
purpose  of  the  book  is  set  forth.  We  cannot  do  better  than  quote  from  this  introduction 
the  paragraph  which  makes  clear  the  author's  intent,  which,  it  may  be  well  to  mention,  is 
admirably  realized  in  the  text  in  a  most  interesting  and  agreeable  fashion: — 

"Form  the  age  of  zero  at  the  moment  of  sexual  impregnation,  animals  and  plants, 
broadly  speaking,  both  pass  through  a  series  of  changes  until,  barring  accidents,  they  reach 
their  limit  of  life;  by  which  we  mean  the  maximum  longevity  achieved  by  each  individual 
under  the  optimum  of  conditions.  Organisms  are  created  young  and  grow  old,  and  the  old 
produce  young  successors.  Senescence  is  a  problem  of  living  matter,  and.  so  far  as  knowm, 
has  no  parallel  in  non-living  matter.  It  is  an  essential  feature  of  life.  It  finds  its  most 
familiar  expression  in  the  gradual  loss  of  the  functional  powers  of  the  organism,  its  end  is 
death.  My  book  is  the  outcome  of  an  attempt  to  learn  something  as  to  the  essential  charac- 
ter and  the  cause  of  that  loss I  can  make  no  pretense  of  having  solved  the 

manifold  problems  of  senescence,  but  I  hope  that  you  will  at  least  find  some  of  them  more 
clearly  formulated  than  hitherto,  and  also  some  real  additions  to  our  positive  knowledge." 

—J.  M.  T. 

Blood  Examtnatton  in  Subgical  Diagnosis.  A  Practical  Study  of  Its  Scope  and  Technic. 
By  Ira  S.  Wile,  M.D.,  New  York.  Duodecimo;  161  Pages;  35  Illustrations  and  1 
Double-page  Colored  Plate.  New  York:  Surgery  Publishing  Company,  1908.  Cloth, 
price,  $2.00;    Oil  Cloth  for  Laboratory  Use,  $2.50;    De  Luxe,  Ooze  Leather,  price,  $3.00. 

The  importance  of  the  blood  picture  in  the  determination  of  the  various  infections  is 
indicated  by  the  growing  frequency  of  blood  examinations.  The  physician  many  times  relies 
upon  such  an  examination  to  corroborate  his  diagnosis,  and  the  surgeon  often  places  depen- 
dency upon  it  to  determine  the  presence  or  the  extent  of  suppurative  conditions. 

The  purpose  of  the  book  under  review  is  to  cover  briefly  surgical  hjematology.  The 
author  outlines  the  equipment  for  this  special  line  of  work,  and  then  takes  up  the  technic 
of  the  various  procedures  in  the  examination  of  the  blood.  The  changes  in  the  diflferent 
diseases  is  also  pointed  out.  A  noteworthy  efl'ort  is  made  to  overcome  the  confusion  which 
has  long  interfered  with  the  definite  or  the  satisfactory  diflerentiation  of  certain  elements 
of  the  blood.  This  appears  clear  in  theory,  but  the  difficulty  comes  in  the  examination  of 
the  actual  specimen,  when  the  cells  causing  dispute  do  not  always  harmonize  with  the  descrip- 
tion in  the  text.  Authorities  of  equal  prominence  have  many  times  disagreed  on  the  proper 
classification  of  certain  mononuclear  colls,  being  unable  to  determine  from  the  size  and  the 
staining  properties  of  the  cell  whether  it  is  a  large-small  or  a  small-large  mononuclear  leuco- 
cyte. Nevertheless,  the  author's  classification  is  a  good  one,  and  may  help  to  overcome 
certain  of  the  difficulties. 

The  marginal  notes  in  red  are  handy  and  worthy  of  mention.  While  the  double-page 
colored  plate  of  six  blood  affections  is  well  executed,  the  drawings  of  the  various  cells 
throughout  the  book  are  crude  and  often  not  very  distinct.  The  text  frequently  lacks  in 
detail,  due  no  doubt  to  limited  space,  but  the  subject  appears  well  enough  covered  to  make 
this  small  volume  of  some  value  to  the  surgeon  as  well  as  to  the  physician.  Mention  is 
made  of  a  few  typographical  errors  which  have  crept  in. — R.  B.  S. 


160  BOOK  REVIEWS. 

Genebax  Subgeby.  a  Presentation  of  the  Scientific  Principles  upon  which  the  Practice  of 
Modern  Surgery  is  Based.  By  Ehrich  Lexer.  RI.D.,  Professor  of  Surgery,  University  of 
Konigsberg.  American  Edition  edited  by  Arthur  Dean  Bevan,  M.D.,  Professor  and  Head 
of  tlie  Department  of  Surgery,  Rush  Medical  College,  in  affiliation  with  the  University 
of  Chicago.  An  Authorized  Translation  of  the  Second  German  Edition,  by  Dean  Lewis, 
M.D.,  Assistant  Professor  of  Surgery,  Rush  IMedical  College,  in  affiliation  with  the 
University  of  Chicago.  With  449  Illustrations  of  the  Text,  partly  in  Color,  and  two 
Colored  Plates.     New  York  and  London:    D.  Appleton  &  Company,  1908. 

The  translation  of  Professor  Lexer's  book  has  been  undertaken  because  the  editors 
believe  that  it  presents  the  present  status  of  the  subject  of  general  surgery  in  a  more  thor- 
ough and  complete  way  than  any  other  text-book.  They  have  not  hesitated  to  make  such 
additions  and  changes  as  seem  desirable  to  make  the  book  more  complete.  A  chapter  on 
"Blastomycosis,"  beautifully  illustrated  and  written  by  Dr.  Ormsby,  has  been  added;  con- 
tributions on  blood  examinations  in  surgery,  the  subject  of  opsonins  and  the  Wright  vaccina- 
tion treatment  have  been  made  by  Dr.  Rosenow;  while  an  abstract  of  Dr.  Crile's  recent 
work  on  the  direct  transfusion  of  blood  has  been  published. 

The  various  subjects  from  the  standpoint  of  general  surgei-y  are  duly  considered.  The 
first  one  undertaken  is  the  treatment  and  repair  of  woimds,  under  which  heading  several 
very  good  histological  cuts  appear,  showing  the  regenerative  changes  taking  place  in  the 
tissues.  Sterilization  and  aseptic  surgery  receive  ample  consideration.  General  and  local 
anesthesia,  the  methods  for  inducing  the  same,  and  the  treatment  of  accidents  during  the 
anaesthetic  period  are  discussed  more  or  less  in  detail.  A  m_ost  interesting  chapter,  though 
rather  brief,  is  the  one  dealing  with  the  different  plastic  procedures.  The  pyogenic  infections 
of  the  various  tissues  also  command  much  attention.  In  the  chapter  on  the  diseases  of  the 
blood  and  the  lymphatic  vessels,  the  Matas  operation  for  the  obliteration  of  aneurysm  is 
described  and  well  illvistrated.  The  subject  of  tumors  is  well  covered,  and  the  accompanying 
illustrations  add  much  to  the  intelligent  understanding  of  the  text.  Not  only  are  the  gross 
specimens  pictured,  but  some  very  good  histological  sections  are  presented. 

While  it  is  natural  to  expect  the  impossibility  of  considering  more  than  the  essential 
points  in  a  book  on  general  surgery  of  1000  pages,  we  feel  the  necessity  in  this  volume  for 
a  more  even  balance  of  the  subjects.  For  example,  there  is  no  doubt  that  a  more  detailed 
discussion  of  surgical  hsematology  would  be  of  greater  benefit  to  the  man  practicing  surgery 
than  the  consideration  of  diphtheria,  eczema  and  various  other  subjects,  which  are  usually 
considered  medical  conditions. 

The  number  of  illustrations  throughout  the  book  suggests  access  to  a  large  number  of 
patients,  and  the  character  of  these  indicates  the  ability  of  the  author  to  select  the  most 
interesting  and  instructive  cases  for  demonstrative  purposes.  The  table  of  contents  is  exten- 
sive and  the  index  complete.  At  the  end  of  each  chapter  is  a  list  of  the  more  important 
literature  covering  the  subjects  under  discussion. — R.  B.  S. 

Medical  Lectubes  and  Aphobisms.  By  Samuel  Gee,  M.D.  Oxford  Medical  Publications. 
London:    Henry  Frowde,  and  Hodder  &  Stoughton,  1908. 

This  book  consists  of  crisp,  emphatic  statements  from  the  standpoint  of  a  man  of  much 
experience,  clear  vision  and  wide  scientific  training.  It  deals  with  a  large  clinical  realm 
which  is  admirably  interpreted,  beginning  with  the  narrative  of  the  history  of  a  case  of 
cerebral  haemorrhage;  then  taking  up  the  meaning  of  certain  words  significant  of  diverse 
morbid  phenomena  in  diseases  of  the  nervous  system,  and  of  the  lungs,  kidneys,  peritoneum, 
etc.  Chapter  XV,  a  large  one,  consists  of  "Clinical  Aphorisms,"  excellent  to  know  and  useful 
to  remember.  The  lecture  form  is  preserved,  which  gives  a  personal  touch,  fixing  well  the 
attention.— J.  M.  T. 

Seven  Hundbed  Subgical  Suggestions.  Practical  Brevities  in  Surgical  Diagnosis  and 
Treatment.  By  Walter  M.  Brickner,  B.S.,  M.D.,  Assistant  Adjunct  Surgeon,  Mount  Sinai 
Hospital,  New  York;  Editor-in-Chief,  American  Journal  of  Surgery,  Eli  Moschcowitz, 
A.B.,  M.D.,  Assistant  Physician,  INIount  Sinai  Hospital  Dispensary,  New  York,  and 
Harold  M.  Havs,  M.A.,  M.D.  Third  Series.  Duodecimo;  153  Pages.'  New  York:  Sur- 
gery Publishing  Company,  92  William  Street.  Price,  Serai-de-Luxe,  $1.00;  Full  Library 
de  Luxe,  Ooze  Leather,  Gold  Edges,  $2.25. 

Since  the  review  a  little  over  a  year  ago  of  the  second  series  of  these  valuable  sugges- 
tions, alwut  200  more  have  been  added.  Most  of  the  additions  have  been  made  by  Dr.  Hays, 
who  appears  to  be  one  of  the  editors  of  the  present  series,  which  contain  about  700  sugges- 
tions. The  commoner  branches  of  surgery  are  fairly  well  covered,  and  even  the  special 
branches,  such  as  the  eye,  ear.  nose  and  throat  receive  considerable  attention. 

The  necessity  for  the  appearance  of  the  third  edition  of  this  small  work  in  a  little  over 
two  years  is  an  indication  of  the  popular  reception  it  has  received  and  of  its  excellence. — R.  B.  S. 


ONTHLY   Cyclopaedia 

AMD 

Medical  Bulletin 


(PUBLISHRD  THB  LaST  OF  EACH  MONTH) 


Medical  Bulletin  Section 


Vol.  II.  PHILADELPHIA,  MARCH,  1909.  No.  3. 


Clinical  Lecture 


LUPUS  VULGARIS. 

By  JOHN  V.  SHOERIAKER,  M.D.,  LL.D., 

Professor  of  Materia  IMedica,  Therapeutics,  Clinical  Medicine,  and  Diseases  of  the  Skin, 

in  the  Medico-Chirurgical  College  and  Hospital  of  Philadelphia. 

PHILADELPHIA. 

Gentlemen:  The  patient  before  us  this  morning  presents  the  typical 
lesions  of  lupus  vulgaris. 

History. — The  history  regarding  this  case  is  negative  and  he  presents 
nothing  abnormal  by  physical  examination. 

Present  Illness. — The  patient  is  a  boy,  fifteen  years  of  age,  whose  face,  as 
you  all  see,  is  involved,  particularly  the  cheeks  and  alse  of  the  nose.  He 
states  that  this  affection  first  made  its  appearance  as  a  pimple  on  his  right 
cheek,  which  was  soon  followed  by  a  similar  pimple  on  the  left  cheek.  These 
pimples  were  about  the  size  of  a  pea  and  possessed  a  yellowish-red  color. 
Having  neglected  and  paid  little  attention  to  these  pimples,  they  increased  in 
size  and  number  and  approached  the  surface  of  the  skin  very  gradually.  In 
the  meantime  they  became  softer  than  the  surrounding  tissue,  thus  forming 
the  characteristic  gelatinous  tubercles  of  lupus  vulgaris  which  the  patient  states 
are  not  painful  to  the  touch.  We  notice  that  the  skin  of  his  left  cheek  presents 
a  punctated  appearance  which  is  due  to  the  well-defined  spots  situated  beneath 
the  surface  through  which  we  are  able  to  see  their  color.  The  lesions  on  his 
right  cheek  have  infiltrated  the  surrounding  tissue  of  the  face  and  present  a 
more  or  less  serpentine  form,  which  is  undergoing  absorption.  After  absorp- 
tion there  will  be  left  behind  a  desquamating  and  atrophied  skin  which  is 
called  lupus  exfoliativus.  In  other  cases  disintegration  and  ulceration  take 
place  in  the  surrounding  infiltrated  skin,  constituting  what  is  known  as  lupus 
exulcerens  or  exedens. 

6  MGl) 


162 


LUPUS  VULGARIS. 


Diagnosis. — The  diagnosis  of  this  disease  is  based  upon  the  fact  that  it 
occurs  in  early  life  and  that  the  primary  eruptions  have  gone  through  a  number 
of  changes,  first  forming  papules,  then  tubercles,  ulcers  and  finally,  unsightly 
cicatrices.  Also  upon  the  peculiar  color  and  shape  of  the  patches,  the  central 
scar,  the  absence  of  subjective  symptoms  and  the  chronic  course,  which  should 
'serve  to  distinguish  it  from  any  other  skin  affection. 

Differential  Diagnosis. — This  affection   should  be   differentiated  from 
syphilis,  epithelioma  and  lupus  erythematosus. 


Lupus  Vulgaris. 

1.  Usually    develops    before    the    age    of 

puberty. 

2.  Course  extremely  slow. 

3.  Generally   concomitant   signs   of   tuber- 

culosis, 

4.  Lesions  are  flatter  and  softer. 

5.  Lesions  possess  a  brownish  or  yellowish- 

red  color. 

6.  Ulcers  tend  to  coalesce. 

7.  Ulcers     are     comparatively     superficial, 

with  irregular,  undermined  edges; 
discharge  slight,  crusts  scant  and 
reddish-brown. 

Lupus  Vulgaris. 

1.  Usually    develops    before    the     age     of 

puberty. 

2.  Several  or  many  nodules  which  are  soft. 

3.  Lupoid  ulceration  is  superficial,  margin 

non-everted,  not  hardened;  the  sur- 
face is  covered  with  bright  red  gran- 
ular tissue,  and  there  is  a  tendency 
to  repair  ending  with  cicatrices. 

Lupus  Vulgaris. 

1.  The    nodules    and    gelatinous    tubercles 

are  deep-seated. 

2.  Does  not  affect  the  sebaceous  glands  or 

ducts. 

3.  Lesions  discrete  and  ulcerate. 

4.  Occurs  in  childhood  and  youth. 


Syphilis. 

1.  Uusually    develops     after     the     age    of 

puberty. 

2.  Course  rapid. 

3.  Concomitant  signs  of  syphilis. 

4.  Lesions  are  round,  hard  and  larger. 

5.  Lesions  possess  a  coppery  hue. 

6.  Ulcers  generally  remain  far  apart. 

7.  Ulcers  are  deep,  with  sharp  cut  edges. 

discharge  copious,  crusts   bull<y  and 
greenish. 


Epithelioma. 

1.  Usually  develops  after  the  age  of  pub- 

erty. 

2.  Single    nodule,    which    is    particularly 

hard. 

3.  Ulcerated  epithelioma  is  usually  deep, 

the  margin  everted,  hardened  and 
imdermined;  there  is  no  attempt  to 
form  cicatrices;  the  adjacent  glands 
are  usually  involved. 

Lupus  Erythematosus. 

1.  The  lesion  is  superficial,  with  no  papules 

or  tubercles. 

2.  Sebaceous  ducts  are  patulous. 

3.  Lesions    are    well    defined    with    scaly 

patches. 

4.  Occurs  after  puberty. 


Etiology. — The  cause  of  this  disease  is  somewhat  doubtful  and  it  originates 
in  childhood  and  youth.  The  best  authorities  have  contended  that  this  disease 
is  independent  of  tuberculosis  and  in  support  of  their  views  point  out  the 
microscopic-pathologic  difference  of  lupus  vulgaris  and  tuberculosis  of  the  skin. 
Doutrelepont  recognizes  lupus  vulgaris  as  tuberculosis  of  the  skin,  due,  there- 
fore, to  the  invasion  of  the  tubercle  bacillus.  This  view  has  been  opposed  by 
Ilc'bra  and  Leloir.  Tuberculosis  of  the  skin  has  been  produced  by  injecting 
lupus  tissue  into  other  animals.  Those  afl'ected  with  lupus  vulgaris  generally 
have  tuberculous  foci  elsewhere.  The  disease  occurs  in  about  equal  proportion 
in  both  sexes.  The  mode  of  inoculation  appears  to  be  by  direct  infection  from 
without. 


LUPUS  VULGARIS. 


163 


Pathology. — The  views  respecting  the  pathology  of  lupus  vulgaris  are  still 
at  variance.  The  morbid  process  has  its  primary  seat  in  the  corium  which 
consists  of  round  cell  infiltration  and  appears  to  be  a  chronic  inflammation 
which  finally  spreads  to  all  the  layers  of  the  skin. 

Microscopic  examination  deep  into  the  corium  shows  sharply  circum- 
scribed nests  of  small  cells  containing  refractive  nuclei.  After  this  has  existed 
for  some  time  retrogressive  changes  take  place  at  the  center  in  which  a  part 
of  the  nodule  is  absorbed  or  thrown  off,  due  to  the  interference  with  the  blood 
supply.  Another  part  organizes  into  connective-tissue  and  contracts.  These 
same  changes  are  accompanied  by  cicatricial  contraction  of  the  whole  affected 
part  which  has  been  infiltrated  with  the  small  cells.  Ulceration  follows  when 
the  lupus  lesions  are  exposed,  due  to  the  destruction  of  the  cells  of  the  rete 
mucosa.  The  hair  papilla  atrophy  causing  the  hair  to  fall  out  and  there  is 
hypertrophy  and  degeneration  of  the  epithelium  lining  of  the  cutaneous  glands. 

Treatment. — My  observations  have  led  me  to  believe  that  the  disease  is 
largely  constitutional  and  I  have  found  it  to  occur,  as  a  rule,  in  poorly 
nourished  children  and  chloratic  and  tuberculous  patients.  Thus  I  have 
obtained  my  best  results  by  resorting  cliiefly  to  constitutional  treatment.  Of 
course,  local  treatment  must  be  resorted  to  as  well,  to  prevent  the  further 
progress  of  the  ravages  of  the  disease. 

While  there  is  no  remedy  that  has  special  curative  effects,  but  general 
hygienic  attention,  good  diet,  with  alterative  and  tonic  treatment  and  proper 
local  measures  will,  beyond  a  doubt,  be  productive  of  the  best  results. 

We  will  place  this  patient  on  a  mixture  containing: 

IJ  Stryckninse  sulphatis    gr.  % 

Liquoris    acidi    arsenosi    '  _   f3j[j 

Acidi   hydrochloric!   diluti f sjy 

Glyceriti  pepsini   '.  .Vq. 's.  ad.'  f^iij. 

Misce.     Signa.     One  teaspoonful  in  a  little  water  a  half  hour  after  each  meal. 

Locally. — Where  ulceration  is  in  progress  we  will  apply  every  second  day, 
pure  phenol  to  the  parts  involved.  This  will  destroy  the  diseased  tissue  and 
stimulate  healthy  granulations.  A  stimulating  ointment  should  be  applied 
twice  daily  and  as  such  we  will  prescribe  for  him : 

IJ  Olei  eucalypti, 

Cresoti    ( beechwood ) ,   of   each ^  x 

Hydrargyri   ammoniati    gr.  x 

Unguenti   zinci   oxidi    \\ 

Misce.     Signa.     Apply  to  the  afiected  parts  night  and  morning. 

Prognosis. — As  to  a  perfect  cure  and  restoration  of  the  destroyed  tissue, 
we  cannot  possibly  hope  for,  but  we  can  so  arrest  the  progress  of  the  disease, 
that  the  patient  can  go  on  through  life  without  much  inconvenience.  It  will, 
of  course,  require  constant  and  persistent  treatment. 


164  EFFICIEMCY  AND  SUFFICIENCY  OF  U.  S.  P. 

Original  Articles 


THE  EFFICIENCY  AND  SUFFICIENCY  OF  THE  UNITED  STATES  PHARMA- 
COPOEIA AND  NATIONAL  FORMULARY  PREPARATIONS  FOR 
THE  GENERAL  PRACTITIONER/ 

By  J^UIES  M.  ANDERS,  M.D.,  LL.D., 

Professor  of  Medicine  and  Clinical  Medicine  of  the  Medico-Chirurgical  College ;  Consult- 
ing Physician  to  the  Jewish  Hospital ;  Consulting  Physician  to  the 
Widener  Home  for  Crippled  Children,  etc. 

For  a  considerable  period  of  time  the  medical  profession  had  been  abandon- 
ing official  preparations  for  mitried  and  too  often  unethical  proprietaries  and 
nostrums  in  the  treatment  of  disease.  Fortunately,  however,  there  has  occurred 
an  awakening  on  the  part  of  progressive  and  reputable  physicians,  who  are 
now  engaged  in  a  reconstructive  movement,  having  for  its  purpose  the  placing 
of  American  therapy  upon  a  moral  and  scientific  basis. 

This  propaganda,  wliich  insists  upon  absolute  publicity  as  regards  the 
composition  of  the  drugs  and  preparations  entering  into  the  physician's  arma- 
ment, has  already  accomplished  excellent  results.  It  is  gratifying  to  note 
that  a  similar  movement  operating  through  the  American  Pharmaceutic  Asso- 
ciation and  its  various  branches,  is  now  in  progress.  Unquestionably,  efforts 
to  promote  legitimate  pharmacy  and  higher  ethical  standards  on  the  part  of 
the  profession  of  medicine,  are  timely,  but  if  not  systematically  maintained, 
will  fail  of  their  ultimate  object,  which  is  the  complete  overthrow  of  quackery, 
charlatanism,  the  "club-practice"  evil,  unethical  proprietaries  and  secret 
nostrums.  Moreover,  such  a  consummation  can  be  brought  about  only  through 
the  collaboration  of  these  two  professions  working  hand  in  hand  under  the 
most  cordial  relations. 

To  this  end  much  would  be  gained  by,  according  to  the  United  States 
Pharmacopoeia  and  ISTational  Formulary,  their  proper  place  in  American  thera- 
peutics. It  may  be  argued  by  some  that  the  physician  could  not  depend  solely 
upon  the  preparations  to  be  found  in  these  two  works,  and  it  must  be  confessed 
that  certain  ethical  synthetic  preparations  are  available,  which  preparations  it 
is  permissible  to  employ,  if  occasion  demands.  On  the  other  hand,  the 
numerous  unethical  proprietaries  and  nostrums  to  be  found  on  the  market  witli 
their  unsavory  and  misleading  advertisements  should  be  scrupulously  avoided 
by  the  general  practitioner.  There  seems  to  be  a  widely  disseminated  profes- 
sional error  to  the  effect  that  every  new  thing  in  therapeutics  exploited  by 
manufacturing  druggists  and  chemists  has  decided  advantages  over  older,  tried 
remedial  agents.  Indeed,  the  credulity  manifested  by  a  supposedly  intelligent 
and  educated  profession  regarding  the  efficacy  of  all  classes  of  unofficial 
preparations,  is,  to  say  the  least,  on  sober  reflection,  truly  phenomenal. 

1  Read  before  the  local  branch  of  the  American  Pharmaceutical  Association,  Feb. 
2,  1909. 


EFFICIENCY  AND  SUFFICIENCY  OF  U.  S.  P.  165 

It  is  only  necessary  to  note  the  results  of  the  investigations  by  the  Council 
on  Pharmacy  and  Chemistry  of  the  American  Medical  Association,  to  convince 
the  most  skeptical  that  the  immense  majority  are  unworthy  of  professional 
confidence.  Thus  said  Council  analyzed  670  proprietary  preparations  of  which 
40  per  cent,  were  refused  recognition,  15  per  cent,  held  in  abeyance  and  only 
45  per  cent,  found  worthy  of  approval.  It  is  sad  to  contemplate  that  such 
well-known  and  popular  favorites  as  anasarcin,  lactopeptine,  phenol-sodique, 
peptenz}Tne,  cellasin  and  vin  Mariani,  among  others  should  have  been  weighed 
in  the  balance  and  found  wanting. 

I  have  a  fixed  belief  that  in  the  present  campaign,  one  of  the  most 
important  questions  for  consideration  and  united  action  is  to  bring  about 
further  enlightenment  of  the  medical  profession  with  regard  to  the  composi- 
tion of  many  unethical  proprietaries.  The  general  public  is  also  in  need  of 
added  facts  and  data  concerning  the  methods  of  the  nostrum  vender  and  the 
manufacturer  of  secret  preparations  as  well  as  the  imscientific  and  simple 
character  of  the  preparations  on  which  they  have  been  and  are  basing  their 
hopes  and  expectations  of  relief  and  cure. 

Kothing  has  done  more  in  the  past  to  retard  the  advancement  of  the  art 
of  therapeutics  than  the  exhibition  of  remedies  and  preparations  whose  physi- 
ological effects  and  composition,  even,  was  unlmown  to  the  practicing  physician. 
As  elsewhere  stated,  "The  same  practice  has  fostered  and  encouraged  self- 
drugging  among  the  general  public — an  evil  which  urgently  demands  the 
serious  attention  of  the  organized  medical  profession." 

The  time  has  come  to  sound  a  note  of  warning  to  the  public  concerning 
the  definitely  grievous  injuries,  which  often  result  from  self-prescribing.  Too 
commonly  the  observant  physician  can  trace  with  certainty  a  drug-habit  to 
this  pernicious  practice.  Both  morphine  and  acetanilid  addiction  are  some- 
times traceable  to  the  use  of  certain  popular  remedies  containing  these  drugs, 
for  headache,  migraine  and  neuralgia.  Among  other  drugs  which  have  been 
much  abused  by  the  public  and  can  be  too  generally  purchased  without  a  physi- 
cian's prescription  are  trional  and  veronal  for  the  relief  of  insomnia. 

The  so-called  headache  powders  so  recklessly  used  by  the  laity,  are  some- 
times unpleasant  and  rarely  decidedly  damaging  in  their  effects,  according 
to  the  character  of  the  remedy  used.  These  have  been  held  responsible  in  part, 
and  doubtless  with  justification  for  the  increase  in  cardio-vascular  diseases 
during  the  last  quarter  of  a  century. 

It  has  seemed  to  me  that  the  profession  of  pharmacy  is  scarcely  alive  to 
its  serious  responsibility  in  relation  to  the  question  of  the  possible  untoward 
effects  of  recommending  to  the  lay  public  potent  proprietaries,  for  the  relief 
of  various  common  ills,  such  as  headache,  dyspepsia,  ordinary  "colds,"  con- 
stipation and  the  like.  This  remark  is  not  intended  as  either  a  reflection  upon 
or  criticism  of  the  profession  of  pharmacy,  but  is  designed  for  serious  con- 
sideration with  the  hope  that  the  ill  results  of  self-drugging  and  counter- 
prescribing  may  be  minimized.  It  must  be  recollected  that  no  matter  how 
light  or  trivial  the  complaint  in  hand  may  be,  its  special  etiologic  factors 
demand  respectful  consideration  when  determinable,  before  drags  are  to  be 


166  EFFICIENCY  AND  SUFFICIENCY  OF  U.  S.  P. 

administered.  In  other  words,  to  combat  human  ills  successfully,  the  cases, 
whatsoever  their  nature,  must  be  carefuUy  studied  and  individualized. 

The  principal  object  of  the  present  paper,  however,  is  to  show  that  a 
wise  and  judicious  selection  of  remedies  by  the  general  practitioner  from  the 
United  States  Pharmacopoeia  and  National  Formulary,  including  certain  non- 
secret  proprietaries  and  synthetic  preparations,  whose  genuineness  and  thera- 
peutic worth  have  been  proven  by  the  Council  on  Pharmacy  and  Chemistry 
of  the  American  Medical  Association,  will  give  him  the  most  satisfactory  results. 
Whilst  therapeutics  is  an  art  and  not  a  science,  it  is,  as  elsewhere  stated,  based 
in  a  measure  at  least,  upon  scientific  principles,  upon  the  known  effects  of 
drugs,  on  animals  and  healthy  man,  or  pharmacodynamics. 

Not  only  a  knowledge  of  the  physiological  effects  of  the  drugs  employed  is 
a  prerequisite  to  successful  therapy,  but  also  as  before  stated,  a  knowledge  of 
the  ingredients  contained  in  the  various  preparations  employed  in  medicine. 
Again,  as  has  been  well  said,  "No  physician,  however,  has  any  right,  either  moral 
or  professional,  to  prescribe  a  preparation,  concerning  the  ingredients  of  which 
he  knows  absolutely  nothing."  When  the  physician  appreciates  their  precise 
composition,  he  is  less  apt  to  be  deceived  by  the  vaunted  therapeutic  virtues 
of  the  proprietaries. 

Physicians,  who  were  formerly  in  the  habit  of  prescribing  ammonol, 
orangeine,  phenalgin,  antikamnia,  did  so  without  knowing  the  ingredients 
entering  into  their  composition,  until  these  so-called  medicinal  agents  had  been 
investigated  by  the  Council  on  Pharmacy  and  Chemistry  of  the  American 
Medical  Association,  and  the  results  of  the  latter  body  published.  The  recent 
disclosures  of  said  Council  hare  shown  a  remarkably  wide  discrepancy  existing 
between  the  claims  of  the  manufacturers  of  many  proprietary  medicines  and 
the  actual  composition  and  virtues,  either  positive  or  negative  of  the  same, 
should  tend  to  arouse  a  supreme  interest  among  the  members  of  the  medical 
profession  in  the  proprietaries  they  prescribe  for  their  patients.  Indeed  the 
situation  at  present  is  of  such  a  character  as  to  produce  throughout  the  medical 
profession  a  wide-spread  feeling  of  antagonism  against  proprietaries.  In  view 
of  the  reliable  information  published  by  the  Council  on  Pharmacy  and 
Chemistry,  it  will  be  readily  apparent  to  tliinking  physicians  that  the  unbroken 
support  and  use  of  any  but  thoroughly  investigated  non-official  preparations, 
would  be  undignified  and  inexcusable. 

If  for  no  other  reason,  professional  experience  in  the  past  regarding  the 
unreliable  composition  and  poor  quality  of  the  medicinal  agencies  composing 
the  general  practitioner's  armamentarium,  should  make  clear  the  necessity 
for  a  return  to  official  remedies  to  be  found  in  the  United  States  Pharma- 
copoeia. 

With  regard  to  the  National  Formulary,  there  is  probably  just  room  for 
criticism  since  it  has  failed  in  a  measure  to  fulfil  its  mission.  We  may,  how- 
ever, confidently  assure  ourselves  that  a  marked  improvement  in  the  character 
and  efficacy  of  the  formuliB  contained  therein  will  result  from  future  revisions 
of  the  work.  Moreover,  the  general  practitioner  will  find  it  to  be,  on  the  whole, 
a  reliable  guide  in  practice.     At  all  events,  he  will  be  in  possession  of  a  knowl- 


UTERINE  MOLES.  167 

edge  of  the  composition  and  strength  or  dosage  of  the  preparations  he  is 
employing. 

If  we  except  a  few  non-secret  proprietaries  and  approved  synthetic  products, 
a  resumption  of  the  use  of  official  remedies,  including  those  to  be  found  in  the 
National  Formulary,  will  give  the  general  practitioner  the  best  possible  results 
— far  better  on  the  average  than  if  he  neglects  these  agents  that  have  stood 
the  test  of  time  for  new,  indefinite  compounds,  whose  efficiency  has  not  as  yet 
been  proven. 

There  is  one  aspect  of  the  present  movement  or  controversy  upon  which  it 
would  be  well  to  concentrate  the  combined  attention  of  the  professions  of 
pharmacy  and  medicine;  I  refer  to  the  particular  form  in  which  remedies  are 
to  be  administered.  Surely,  the  more  elegant,  palatable  and  attractive  to 
the  eye,  are  the  agents  prescribed,  the  more  acceptable  are  they  to  the  average 
patient.  From  this  viewpoint,  modern  requirements  and  conditions  demand 
that  a  well-planned  readjustment  be  effected.  On  the  other  hand,  the  state- 
ments which  are  so  often  put  forward  to  show  the  inadequacy  of  the  efficient 
official  drags,  fail  to  carry  conviction  to  the  minds  of  those  who  have  taken  the 
trouble  to  acquaint  themselves  thoroughly  with  the  remedies  to  be  found  in  the 
United  States  Pharmacopoeia  and  have  observed  their  effects  when  judiciously 
employed. 

Again,  while  there  are  some  instances  in  which  the  physician  may  right- 
fully prescribe  combinations  of  drugs  already  compounded  in  the  form  of  pills, 
tablets  and  fluid  mixtures,  it  is,  as  a  rule,  better  and  more  in  accordance  with 
scientific  methods  to  formulate  prescriptions  at  the  bedside,  using  single  drags, 
however,  to  meet  the  indications  presented  by  individual  cases,  whenever 
practicable. 


UTERINE  MOLES  WITH  SPECIAL  REFERENCE  TO  THE 
HYDATIDIFORM  MOLE. 

By  JAMES  STRICKER  RAUDENBUSH,  M.D., 

Assistant   Obstetrician   to   the   Medico-Chirurgieal   Hospital,   Instructor   to    the   Senior 
Class,  Medico-Chirurgical  College,  Philadelphia,  Pa. 

Uterine  moles  are  very  infrequent;  they  are  said  to  occur  once  in  1000 
to  20,000  obstetrical  cases,  yet  many  are  overlooked  and  some  patients  with 
these  conditions  may  never  send  for  a  medical  attendant,  or,  at  least,  not  in 
time  for  him  to  be  able  to  recognize  the  condition.  It  is  occasionally  just  as 
important  to  write  upon,  or  to  refer  to,  the  unusual  as  the  usual.  Unusual 
pathologic  conditions  with  possible  dangerous  consequences  should  be  well 
understood.  The  dangers  of  uterine  moles  are  haemorrhage,  sepsis,  malignanc}'', 
and  death.  Usually,  yet  not  always,  the  embrj'o  or  foetus  is  dead  and  may  be 
entirely  absorbed.  The  causes  in  most  instances  are  not  definitely  known,  the 
diagnosis  is  difficult  or  impossible  until  after  the  expulsion  of  the  mole,  of  what- 
ever variety  it  may  be.     The  treatment  consists  of  prompt  and   complete 


168  UTERINE  MOLES. 

evacuation  of  the  uterine  cavity  and  the  removal  of  all  diseased  tissues,  should 
there  be  any  malignancy. 

Generally  speaking,  a  uterine  mole  is  a  product  of  conception  with  pro- 
liferative, degenerative  and  hsemorrhagic  changes;  either  the  death  of  the 
embryo  precedes  these  changes  in  the  placental  tissues  which  remain  in  ntero, 
or  follows  them.  Invariably  abortion  results.  A  living  foetus  at  full  term  is 
possible  only  when  the  pathologic  changes  do  not  begin  very  early  in  pregnancy 
and  when  they  are  slight  in  involvement  of  the  placental  tissues. 

We  have  the  following  varieties  of  uterine  moles  to  deal  with: 

Cystic  Mole. 

Synonyms. — Hydatidiform  mole,  hydatid  mole  (do  not  confuse  this  term 
with  the  ecchinococcic  'Tiydatid  cyst"),  hydatid  pregnancy,  molar  pregnancy, 
vesicular  mole,  grape  mole,  bladder  mole,  dropsy  of  villi  of  chorion,  myxoma 
of  placenta,  syncytloma  henignum,  myxoma  cliorii  racemosum. 

This  variety  of  uterine  moles  consists  of  a  mass  of  translucent  vesicles 
which  are  held  together  by  pedicles;  the  whole  mass  resembling  a  bimch  of 
grapes,  or,  as  one  writer  says,  "the  seaweed  known  as  bladder-wrack."  These 
moles  may  be  of  enormous  size,  varying  from  a  few  vesicles  in  number  to 
several  quarts  in  quantity. 

While  the  majority  of  writers  state  that  this  is  a  myxomatous  or  mucoid 
degeneration  of  the  chorionic  villi,  a  few  claim  that  it  is  a  hydropic  one. 
There  is  a  proliferative  degeneration  of  the  syncytium  as  well  as  of  the  sub- 
syncytial  (Langhans  cells)  layer  with  a  myxomatous  degeneration  of  the 
stroma  of  the  villi,  thus  producing  these  enlarged  translucent  vesicles  of  various 
sizes,  some  as  large  as  an  acorn.  Marchand  is  represented  by  a  few  writers, 
to  claim  that  there  is  no  mucin  in  these  cysts,  that  the  process  is  hydropic 
rather  than  myxomatous,  and  that  the  increased  growth  of  the  syncytium  and 
the  Langhans  cells  produces  a  mechanical  dropsy  of  the  stroma  of  the  villi. 

If  a  section  is  made  of  one  of  these  vesicles,  it  is  found  to  consist  of  the 
epithelial  layers  of  syncytium  and  Langhans  cells,  which  are  very  thin,  the 
contents  are  a  colorless  gelatinous  fluid  and  more  or  less  resembles  the  liquor 
amnii;  in  the  early  stages  mucin  is  said  to  be  abundant,  but  later  and  in  the 
larger  cysts  it  is  scant  and  albuminous  substances  are  said  to  predominate  in 
the  more  watery  contents. 

If  these  degenerative  changes  begin  before  the  atrophy  of  the  chorionic 
villi  (i.  e.,  the  formation  of  the  chorion  Iceve),  the  whole  chorion  becomes 
involved,  but  if  later,  then  only  the  placental  {chorion  frondosum)  portion. 
The  blood  supply  is  greatly  decreased,  hence  the  colorless  appearance  of  these 
vesicles  which  are  formed  from  the  vascular  structures  of  the  foetal  membranes. 
Sometimes  the  entire  placenta  is  transformed  into  a  vesicular  mole  while  at 
other  times  only  small  portions  of  it  degenerate  in  this  manner.  Blood-clots 
and  masses  of  fibrin  may  be  found  between  and  around  these  cysts  (see  below, 
''blood  mole"). 

In  some  instances  the  death  of  the  embryo  or  foetus  precedes  the  formation 
of  these  vesicles,  in  others  its  destruction  follows.     When  the  degenerative 


UTERINE  MOLES.  169 

processes  begin  very  early  so  that  the  entire  mass  becomes  a  mole,  then  the 
embryo  does  not  live  and  is  generally  entirely  absorbed.  This  is  what  Tamier 
calls  a  "non-embryonic  mole."  Occasionally  the  embryo  is  expelled  and  the 
placenta,  being  attached  to  the  decidua,  continues  to  receive  nourishment  and 
imdergoes  this  form  of  degeneration.  When  the  embryo  is  found  it  is  called 
an  "embryonic  mole"  (Tarnier).  If  the  hydatidiform  changes  begin  late  in 
gestation,  or  are  only  slight  in  extent  of  involvement  of  the  tissues,  then  the 
foetus  may  live,  and  in  very  mild  cases,  go  to  full  term.  Cases  have  been 
reported  in  twin  pregnancies  where  one  ovum  went  to  full  term  while  the  other 
underwent  vesicular  changes. 

These  moles  are  sometimes  very  adherent  to  the  uterus,  and  the  vesicles 
in  some  instances  have  entered  the  uterine  sinuses  and  thus  by  pressure  caused 
atrophy  of  the  uterine  wall,  so  that  portions  of  it  are  exceedingly  thin. 

That  the  etiology  is  not  known  is  generally  admitted,  yet  the  following 
causes  are  given  by  various  writers :  Age,  from  20  to  40  years ;  multiparity ; 
age  rather  than  the  actual  number  of  pregnancies;  advanced  age;  previous 
occurrences;  syphilis;  uterine  diseases;  fibroids;  cancerous  dyscrasias;  irri- 
table uterus;  endometritis;  diseases  of  the  decidua;  deciduitis;  early  months 
of  gestation  (one  writer  claims  it  cannot  occur  later  than  the  third  month) ; 
death  of  foetus;   diseases  of  ovum;   faulty  formation  of  allantois. 

The  s}'mptoms  are  not  characteristic.  Symptoms  of  pregnancy,  of  course, 
exist,  at  first  normal,  then  abnormal.  About  the  second,  third  or  fourth  month 
the  patient  begins  to  feel  badly.  There  may  be  nausea  or  vomiting.  The  most 
characteristic  feature  before  the  expulsion  of  the  mole  is  the  sudden  and  great 
disproportion  between  the  uterine  enlargement  and  the  duration  of  pregnancy. 
In  addition  to  this,  bleeding  appears  with  pains  in  the  back.  The  pains  finally 
resemble  those  of  an  abortion  or  miscarriage.  This  bleeding  may  be  irregular 
and  repeated  or  continuous  and  slow.  The  discharges  of  blood  are  watery,  some- 
times fetid ;  the  quantity  is  usually  not  great  but  may  become  so.  Occasionally 
imruptured  vesicles  will  appear  in  the  discharge,  but  these  are  seldom  dis- 
covered. By  examination,  the  uterus  is  found  to  be  unduly  enlarged,  irregular 
to  the  touch  and  doughy,  no  distinct  fluctuation,  no  foetus  can  be  discovered,  no 
foetal  heart-sound  is  heard.  Before  the  os  is  dilated  nothing  can  be  elicited 
per  vagina,  except  that  there  is  no  ballottement ;  if  the  os  is  dilated,  then  the 
mole  can  be  felt,  it  is  a  peculiar  boggy  mass,  the  fingers,  which  can  readily 
penetrate  it,  receive  the  impression  of  a  submerged  net-work  of  stringy  tissue. 

A  diagnosis  cannot  always  be  made  until  vesicles  appear  in  the  discharges 
or  the  mole  is  ex  utero.  The  distinguishing  points,  however,  should  be  remem- 
bered, viz. :  a  normal  beginning  of  pregnancy ;  a  rapid  and  enormous  dispro- 
portion of  the  uterus  to  the  duration  of  pregnancy;  no  distinct  fluctuation; 
an  absence  of  the  foetus;  no  ballottement;  a  watery  sanguineous  discharge 
which  is  usually  not  great  in  quantity,  is  intermittent  or  continuous  and  slow; 
the  patient  is  not  well  and  may  be  anjcmic. 

The  following  conditions  may  be  confused  with  a  hydatidiform  mole  and 
require  differentiation :  Polyhydramnios;  here  there  is  distant  fluctuation, 
ballottement,  and  the  foetus  can  be  palpated.     Twins;   two  foetal  bodies,  two 


170  UTERINE  MOLES. 

fcetal  heart-sounds,  a  firm  uterus.  Threatened  abortion;  normal  size  of  uterus 
for  the  duration  of  pregnancy ;  evidences  of  a  foetus,  as  a  rule,  may  have  a  more 
abundant  flow  of  blood,  which  is  not  watery.  False  moles  (see  below). 
Hydatid  cysts;  these  are  due  to  ecchinococci,  here  no  tissues  resulting  from 
conception,  no  maternal  changes  or  symptoms  due  to  pregnancy.  Syncytioma 
malignum;  here  a  continued  bleeding,  even  after  the  uterus  is  empty;  micro- 
scopically the  tissues  will  show  cells  of  a  malignant  character. 

The  prognosis  is  very  bad  for  the  foetus  and  not  very  good  for  the  mother. 
These  moles  may  remain  in  the  uterus  for  more  than  a  year,  with  or  without 
local  or  general  harm ;  this  is  not  usual,  however,  for  if  they  have  not  already 
followed  an  abortion,  they  invariably  lead  to  it.  When  any  of  the  vesicles  are 
expelled,  the  pregnancy  is  usually  interrupted,  and  this  happens,  as  a  rule, 
before  the  sixth  month.  A  hydatid  mole  may  undergo  retrogi-ade  changes  and 
a  blood  mole  combine  with  it  or  result  therefrom.  If  the  mole  is  entirely 
expelled,  there  is  usually  no  more  bleeding  and  the  patient  may  have  a  normal 
recovery,  as  after  a  complete  abortion.  There  is  a  tendency  in  these  patients 
to  a  recurrence  of  this  condition  in  subsequent  pregnancies.  If  the  uterus  is 
not  emptied,  or  if  portions  are  retained,  then  there  is  a  contiaued  bleeding  as 
in  ordinary  incomplete  abortion,  the  general  health  is  impaired,  the  strength 
suffers,  and  death  may  occur  from  haemorrhage  or  exhaustion.  Infection  is 
also  very  likely  and  death  may  result  from  this.  As  stated  before,  the  vesicles 
may  penetrate  the  uterine  siauses,  cause  absorption  of  the  wall  so  that  it  may 
readily  rupture  and  be  followed  by  fatal  haemorrhage  or  peritonitis;  in  fact, 
these  very  accidents  may  occur  when  an  attempt  is  made  to  remove  everything 
from  the  uterine  cavity. 

These  hydatidiform  moles  have  a  great  tendency  to  become  malignant, 
especially  when  the  cysts  penetrate  and  infiltrate  the  uterine  wall,  still  we  can- 
not tell  when  a  mole  has  this  character  until  we  have  further  symptoms.  When 
a  syncytioma  malignum  follows  a  hydatidiform  mole  it  is  exceptionally  fatal, 
more  so  than  at  other  times. 

Unless  the  mole  is  small  and  begins  late  in  development  the  foetus  is  lost, 
it  dies  and  is  generally  entirely  absorbed.  It  ma}^,  however,  have  been  previously 
expelled  from  the  membranes. 

As  to  the  treatment,  the  uterus  should  be  emptied  under  strict  antiseptic 
precautions  as  soon  as  the  condition  is  known.  In  order  to  do  thorough  and 
careful  work  the  patient  should  be  anjBsthetized.  The  treatment  for  this 
condition  is  the  same  as  for  inevitable  or  incomplete  abortion.  The  patient's 
bowels  are  thoroughly  evacuated,  the  bladder  catheterized,  the  parts  thoroughly 
antiseptisized.  If  the  cervix  is  not  at  all  patulous  the  Goodell  dilator  or  the 
Hegar  graduated  steel  dilators  are  used  until  the  fingers  can  be  employed  and 
the  dilatation  carefully  completed  by  the  manual  method.  The  mass  is  then 
removed  by  the  fingers  either  in  entirety  or  in  pieces.  With  the  fingers  every 
particle  can  be  separated  and  one  can  tell  when  all  the  tissues  are  removed. 
Again,  the  fingers  are  safer  than  instruments  in  these  instances  where  there  is 
so  much  danger  of  perforation  of  the  uterine  wall.  As  noted  above,  in  this 
particular  pathologic  condition,  such  an  accident  would  positively  result  in  the 


UTERINE  MOLES.  171 

death  of  the  patient.  After  the  uterus  is  empty,  ergot  in  some  form  or  other, 
should  be  given,  as  well  as  strychnine.  The  uterine  cavity  is  washed  out  with 
a  bichloride  of  mercury  solution,  1 :  4000  to  1 :  2000  and  then  followed  by  sterile 
water  or  normal  saline  solution.  The  uterine  cavity  is  then  swabbed  out  with 
pure  tincture  of  iodine  on  a  brush.  If  the  uterus  is  well  contracted  and  the 
patient's  general  condition  is  good  this  is  all  that  will  be  required  and  the  case 
can  be  conducted  as  an  ordinary  puerperal  one. 

The  various  writers  recommend  two  plans  of  treatment,  the  "expectant" 
and  the  "active."  I  prefer  the  latter,  since  it  has  always  given  me  perfect 
results  in  all  kinds  of  abortion  cases  that  I  had  to  treat,  whether  infected  or 
not,  and  this  I  cannot  say  of  the  expectant  plan.  I  will,  however,  give  an 
outline  of  both  methods  as  given  by  different  writers. 

The  expectant  plan.  If  haemorrhages  are  small.  No  active  treatment 
until  haemorrhage  occurs.  Control  hemorrhage.  Promote  expulsion  of  foetus. 
Non-interference  so  long  as  uterus  remains  passive.  This  is  only  allowable 
when  the  patient  can  be  watched  and  assistance  given  at  once  if  necessary. 
Absolute  rest  in  bed.  An  opiate  may  be  given.  Ergot  is  given  to  prevent 
haemorrhage  and  promote  expulsion  of  mole.  Hot  antiseptic  vaginal  douches 
to  check  hemorrhage.  When  ergot  is  given  in  full  and  repeated  doses,  then 
must  tampon  vagina  for  the  safety  of  the  patient.  The  dangers  of  this  method 
are,  excessive  loss  of  blood,  death  as  a  result  from  haemorrhage  and  shock. 

The  active  plan.  When  hemorrhage  becomes  or  is  pronounced,  or  when  it 
cannot  be  stopped.  Many  writers,  however,  recommend  this  plan  for  all  cases 
as  soon  as  the  diagnosis  is  made.  Empty  the  uterus — ^the  sooner  the  better. 
Antiseptic  precautions.  Dilatation  of  cervix;  Goodell's  dilator,  Hegar's 
dilators,  Barnes'  bags,  Tamier  dilators.  Remove  mass  but  avoid  violent 
measures.  Use  fingers.  If  placental  forceps  or  curette,  be  very  careful  and 
remember  the  great  liability  of  perforation,  haemorrhage  and  death.  Remem- 
ber you  may  find  no  evidence  of  a  foetus.  Do  not  be  too  energetic  when  mole  is 
very  adherent.  Hot  antiseptic  intra-uterine  douches  to  prevent  haemorrhage 
and  infection.  Ergot  may  now  be  given  in  continued  doses,  but  with  care. 
Tampons  are  used  by  some  to  prevent  subsequent  haemorrhage  and  to  stimulate 
the  uterus  to  contractions. 

Citation  of  a  Case. 

Mrs.  C,  age  50  years.  Ten  or  eleven  children.  Five  years  ago,  twins 
(both  living).  When  not  pregnant  she  was  always  regular  in  menstruating, 
duration  three  days,  but  suffered  severely  from  dysmenorrhoea.  Always  a  well 
woman  but  did  very  hard  work  all  her  life.  In  the  beginning  of  July,  1908, 
she  had  her  last  period.  On  account  of  her  age  she  did  not  suspect  pregnancy 
and  paid  very  little  attention  to  the  fact  that  she  was  not  feeling  perfectly 
well.  In  the  beginning  of  October  (three  months  later),  she  had  a  fall  and 
began  to  bleed  and  feel  badly;  two  weeks  later  she  went  "to  see  her  physician. 
Dr.  J.  J.  McNulty,  but  refused  an  examination;  she  had  been  bleeding  all 
this  time,  was  anaemic,  had  a  rapid  pulse  but  no  fever.  Her  physician  did 
not  hear  from  her  until  two  weeks  later  when,  on  Sunday  morning,  November 


172  UTERINE  MOLES. 

8th,  he  was  called  to  the  house  and  found  the  woman  "flooding,"  her  clothing 
and  everything  saturated,  the  patient  feeling  very  sick,  weak  and  fainty.  The 
free  hseniorrhage  was  going  on  for  24  hours,  yet  she  kept  on  her  feet.  The 
doctor  noted  her  general  appearance,  examined  her  abdomen,  found  the  uterine 
fundus  at  the  umbilicus  and  the  uterus  more  or  less  hardened;  by  internal  ex- 
amination he  felt  what  he  thought  was  a  bleeding  cancerous  cervix.  In  the 
afternoon  I  was  called  in  consultation.  My  external  abdominal  examination  gave 
me  no  definite  diagnostic  points,  and  with  the  anajmia  and  the  patient's  weather- 
beaten  appearance  in  the  face,  I  also  strongly  suspected  that  the  doctor's 
diagnosis  was  correct.  I  removed  the  blood  clots  from  the  vagina  and  then 
found  the  cervix  dilated  to  the  extent  of  5  cm.  (3  in.),  and  a  soft,  boggy  mass 
like  that  of  the  placenta  lying  within.  My  first  thought  was,  of  course,  of 
placenta  previa,  but  I  soon  caught  on  to  a  small  particle  which  I  withdrew  and 
foimd  to  be  a  vesicle.  This  enabled  me  at  once  to  make  a  positive  diagnosis 
of  hydatidiform  mole.  I  again  examined  the  uterus  externally  and  found 
Hick's  sign  of  rythmical  hardening.  Although  it  was  only  four  months  since 
her  last  regular  menstruation,  her  uterus  was  the  size  of  a  six  months'  preg- 
nancy.    The  patient  was  kept  in  bed,  tonics  given,  bowels  well  cleaned  out. 

The  following  morning  the  patient  was  anaesthetized  and  I  removed,  in 
fragments,  from  the  uterus  two  and  one-half  quarts  of  pedunculated  vesicles. 
No  trace  of  a  foetus.  Placental  tissue  scant;  about  9  cm.  (3^  in.)  long,  3  cm. 
(1^  in.)  wide,  1  cm.  (%  in.)  thick.  I  used  my  fingers  only.  Douched  with 
bichloride  of  mercury  and  sterile  solutions.  Touched  the  uterine  cavity  with 
pure  tincture  of  iodine.     The  patient  was  in  a  splendid  condition. 

Ergot  was  given  for  a  day  or  two  to  keep  the  uterus  contracted  and  thus 
prevent  haemorrhage  as  well  as  the  absorption  of  septic  material,  if  present. 
Strychnine  was  also  administered.  Later,  strychnine,  ergotin,  quinine,  reduced 
iron  and  arsenic,  as  indicated.  Antiseptic  vaginal  douches  for  a  few  days  only. 
On  the  tenth  day  she  had  three  very  severe  chills,  temperature  100.8°  F.,  pulse 
120.  Vaginal  irrigations  resumed.  Six  days  after  this  she  got  out  of  bed, 
but  when  on  her  feet  she  bled;  back  to  bed  for  one  week  more.  She  then  got 
up  and  was  soon  allowed  to  go  down  stairs,  when  she  began  to  bleed  again;  she 
was  given  ergot  and  since  then  has  had  no  trouble.  I  received  the  post- 
operative report  from  the  doctor  on  February  25,  1909,  at  which  time  the 
patient  was  perfectly  well. 

Blood  Mole. 

The  "hematomatous  mole,"  "subchorial  hematoma"  or  mola  sanguinea 
results  from  a  so-called  "internal  abortion,"  and,  in  fact,  is  an  incomplete 
abortion  with  certain  pathologic  changes.  Primarily  there  is  a  haemorrhage, 
variously  described  as  utero-placental  or  deciduo-subchorial,  in  which  there  is 
a  formation  of  blood  clots.  The  haemorrhage  occurs  between  the  decidua  and 
the  chorion,  or  the  blood  enters  between  the  layers  of  the  foetal  membranes 
but  seldom  into  the  amniotic  sac.  The  foetus,  however,  is  dead  and  may  be 
expelled  by  itself  without  the  mole,  or  it  may  be  completely  absorbed.  The 
formation  of  the  hematoma  may  precede  or  follow  the  death  of  the  foetus. 


TUBERCULOSIS  OF  THE  BREAST.  173 

Lusk  says  that  these  moles  are  seldom  larger  than  an  orange  and  that  they 
are  usually  expelled  between  the  third  and  fifth  months. 

Eemember  this  form  of  a  mole  may  follow  changes  in  the  hydatidiform 
mole  or  exist  with  it. 

The  subjective  sjonptoms  resemble  those  of  a  hydatidiform  mole  in  many 
instances,  in  other  cases  an  ordinary  abortion. 

The  treatment  is  like  that  of  an  inevitable  or  incomplete  abortion, — the 
patient  is  anesthetized,  strict  antisepsis  is  observed,  the  cervix  is  dilated  and 
the  uterus  emptied  and  thoroughly  cleansed.  The  after-treatment  is  the  same 
as  it  is  in  an  abortion  case. 

Fleshy  Mole. 

The  "flesh  mole,"  "fibrin  mole"  or  mola  carnosa  is  simply  an  original 
blood  mole  in  which  the  blood  becomes  decolorized  and  more  or  less  absorbed, 
deposits  of  fibrin  occur,  and  the  mole  resembles  a  mass  of  flesh,  hence  the  name. 
The  foetus  is  dead  in  all  cases  and  may  be  absorbed.  The  placental  tissues  are 
retained  within  the  uterus  a  long  time  and  the  cases  have  been  reported  in  which 
these  masses,  when  expelled,  were  casts  of  the  uterine  cavity.  Of  course,  in 
these  as  in  the  original  blood  moles,  there  are  frequent  hsemorrhages.  The 
treatment  is  the  same  as  that  advised  for  the  blood  mole. 

Stone  Mole. 

In  the  beginning  this  is  a  blood  mole,  then  it  imdergoes  the  changes  of  a 
fleshy  mole  and  at  the  same  time  receives  calcium  deposits  which  give  it  a 
hard  feel,  hence  the  name.  The  symptoms  do  not  differ  from  those  of  the 
preceding  varieties  and  the  treatment  is  the  same. 

False  Mole. 

"False  moles  are  not  the  result  of  conception"  (Quain,  1883).  These  are 
not  referred  to  in  the  literature  of  to-day.  They  consist  of  shreds  of  vaginal 
mucous  membranes,  the  uterine  mucosa  from  membranous  dysmenorrhoea, 
altered  blood  clots,  polyps,  etc.  These  must  be,  and  can  be,  differentiated  from 
true  uterine  moles  (results  of  conception),  by  the  history  of  the  case,  symp- 
toms and  microscopical  examinations  of  the  expelled  material.  A  correct 
diagnosis  is  sometimes  imperative  from  a  medico-legal  standpoint. 


TUBERCULOSIS  OF  THE  BREAST. 


By  W:M.  L.  RODMAN,  M.D.,  LL.D., 

Professor    of    Surgery    in    the    Mcdico-Chirnrgical    College;     Surgeon    to    the    Medico- 
Chirurgical,  Presbyterian,  Jewish,  and  Philadelphia  General  Hospitals. 

PHILADELPHIA. 

ViRCHOW  did  not  include  tuberculosis  as  one  of  the  affections  to  which 
the  mammary  gland  was  liable.  Although  Sir  Astley  Cooper  and  Velpeau 
had  discussed  tuberculous  diseases  in  a  somewhat  vague  and  indefinite  way,  it 
was  not  until   1881   that   Dubar  made   a   careful,   systematic   and   scientific 


174  TUBERCULOSIS  OF  THE  BREAST. 

classification  of  the  disease.  He  was  the  first  to  demonstrate  the  tubercle 
bacillus  in  connection  with  the  breast. 

Though  undoubtedly  rare,  tuberculosis  of  the  mammary  gland  is  more 
common  than  it  has  been  previously  thought  to  be.  In  fifteen  hundred  cases 
of  mammary  disease  admitted  to  St.  Bartholomew's  Hospital,  London,  there 
were  1.5  per  cent,  due  to  tuberculosis. 

Tuberculosis  of  the  breast  may  be  primary  or  secondary.  It  cannot 
be  stated  that  the  lesion  is  primary  unless  at  autopsy  a  careful  and  systematic 
examination  is  made  to  exclude  the  possibility  of  a  focus  elsewhere.  If  no 
such  focus  be  found,  it  is  fair  to  assume  that  the  disease  is  primary.  When 
primary,  infection  may  either  take  place  through  the  blood  or  directly 
from  without.  When  occurring  in  the  latter  way,  infection  may  take  place 
either  through  an  open  wound  or  through  the  galactophorous  ducts.  Yerneuil 
believed  strongly  in  the  latter  mode  of  infection.  Inasmuch  as  the  lesions 
are  more  pronounced  in  the  alveoli  than  in  the  ducts,  and  furthermore,  as  the 
ducts  themselves  are  not  more  diseased  at  their  exit  at  the  nipple  than  in  the 
substance  of  the  gland,  it  is  questionable  whether  infection  through  the  duct 
is  common.  If  infection  occurred  through  the  duct  it  is  reasonable  to  suppose 
that  the  lesion  would  be  more  pronounced  at  the  beginning  of  such  ducts  than 
elsewhere.  Kitt,  who  has  made  a  thorough  study  of  bovine  tuberculosis,  is  of 
the  opinion  that  tuberculosis  of  the  udders  is  nearly  always  of  hsematogenous 
origin. 

Secondary  tuberculosis  of  the  breast  may  result  from  the  extension  of  the 
disease  from  the  ribs  or  pleura,  or  be  carried  by  the  lymphatics  from  diseased 
axillary  or  other  neighboring  l}anphatic  glands,  or  through  the  blood  current 
from  a  focus  even  remotely  situated. 

It  has  been  fairly  well  established  that  the  disease  begins  within  the  acini 
rather  than  in  the  connective  tissue  of  the  breast. 

Etiology. — Mammary  tuberculosis  is  far  more  often  encountered  in  females 
than  in  males,  and  is  particularly  obnoxious  to  young  women.  Of  thirty-two 
cases  studied  by  Delbet,  there  were  eighteen  in  the  decennium  from  twenty- 
five  to  thirty-five.  Schley  was  of  the  opinion  that  it  occurred  with  equal 
frequency  in  the  third,  fourth  and  fifth  decades.  Although  more  often  found 
in  young  women,  tuberculosis  may  be  found  at  any  time  of  life.  One  case  I 
have  encountered  in  literature  in  a  woman  of  seventy. 

Heredity  exerts  little,  if  any,  influence.  Trauma  and  inflammatory 
affections,  by  lowering  the  vitality  of  the  breast,  predispose  it  to  subsequent 
tuberculosis.  Tuberculosis  in  other  parts  of  the  body  markedly  predisposes 
one  to  secondary  involvement  of  the  breast.  Mandry  foimd  tuberculosis  else- 
where in  one-half  of  the  cases  that  he  carefully  investigated. 

Pathalogy. — We  shall  not  consider  miliary  tuberculosis,  which  is  a  general 
process,  and  therefore  not  confined  to  the  breast.  There  are  both  discrete  and 
confluent  varieties.  In  the  former  there  are  isolated  tubercles  separated  by 
healthy  tissue.  These  tubercles  may  undergo  changes,  either  remaining 
isolated,  or  by  their  coalescence,  forming  larger  masses,  this  constituting  the 
confluent  form  of  the  disease.     The  isolated  tubercles  vary  widely  in  size, 


TUBERCULOSIS  OF  THE  BREAST.  175 

some  being  smaller  than  a  pea,  others  as  large  as  a  hazelnut.     When  caseation 
and  liquefaction  occur,  abscesses  result. 

In  the  confluent  variety,  a  swelling  of  considerable  proportions  results. 
It  is,  however,  not  sharply  limited,  being  ill-defined  and  irregular  with 
bosselations  here  and  there.  If  cut  into  during  the  early  stages,  it  is  white 
or  grayish  in  color  and  rather  firm  in  consistency.  Later  on,  however,  the 
center  will  have  become  yellow  in  color,  although  the  periphery  may  still  retain 
the  original  appearance.  When  liquefaction  occurs,  the  so-called  cold  abscess 
of  Eoux  results. 

Cases  of  tuberculosis  of  the  breast  co-incident  with  carcinoma  have  been 
recorded.  In  one  of  four  cases  reported,  the  symptoms  of  tuberculosis  pre- 
dominated and  the  macroscopic  appearance  was  that  of  tuberculosis  rather 
than  carcinoma.  Microscopic  examination  demonstrated  carcinoma  as  well. 
I  have  seen  one  well-marked  instance  of  such  associated  disease,  a  photograph 
of  the  lesion  being  shown  in  my  book  on  diseases  of  the  breast.  Of  two  such 
cases  reported  by  A.  S.  Warthen,  of  Ann  Arbor,  Michigan,  tuberculosis  was 
primary  in  one,  and  carcinoma  undoubtedly  the  primary  lesion  in  the  other. 
Pilliet  and  Piatot  reported  another  such  case  in  a  male,  aged  fifty-one. 

Eokitansky,  who  taught  that  tuberculosis  and  carcinoma  never  occur  simul- 
taneously, afterwards  acknowledged  his  error  and  admitted  that  the  two  dis- 
eases were  infrequently  associated. 

We  cannot,  at  the  present  time,  say  whether  or  not  the  association  is 
fortuitous,  or  whether  one  lesion  predisposes  to  the  other.  It  is  not  diflficult 
to  understand  how  the  irritation  produced  by  the  tubercles  might  easily  cause 
abnormal  proliferation  of  epithelial  cells  ending  in  cancer. 

Symptoms. — The  onset  of  the  disease  is  insidious  except  when  it  occurs 
during  lactation,  when  it  is  of  more  rapid  growth.  It  may  last  for  years. 
Only  one  breast  is  affected,  there  being  no  case,  so  far  as  I  know,  where  both 
organs  were  involved. 

In  the  discrete  variety  indurated  areas  may  be  detected  here  and  there 
throughout  the  substance  of  the  gland,  but  separated  apparently  from  the 
surrounding  tissue.     In  other  cases  the  outline  is  indefinite. 

The  skin  is  not  adherent  until  late  in  the  disease.  When  it  is,  fistulge  soon 
form.  Pain  is  a  rare  symptom  early  in  the  disease,  and  when  present  does 
not  exist  to  a  pronounced  extent.     It  may  be  severe  as  a  late  symptom. 

The  confluent  form  pursues  a  more  rapid  course,  fistulse  forming  early  in 
its  evolution.  A  mass  varying  in  size  from  a  hazel-nut  to  an  orange,  of 
irregular  outline,  hard  or  soft,  is  found  usually  in  the  upper  and  outer 
quadrant.  The  axillary  glands  are  early  involved,  rapidly  increase  in  size,  and 
may  suppurate.  It  is  to  be  noted  that  the  glands  do  not  fuse  and  become 
matted  together  as  in  carcinoma.     This  is  of  importance  as  a  differential  sign. 

Diagnosis. — The  recognition  of  mammary  tuberculosis  may  at  times  be 
far  from  easy,  especially  if  the  case  is  encountered  before  there  is  destruction 
of  tissue.  When  fistulas  are  present,  together  witli  enlarged  axillary  glands, 
there  should  be  little  difficulty  in  the  diagnosis.  Its  recognition  will  be  easier 
if  there  are  known  to  be  tuberculous  foci  elsewhere. 


176  TUBERCULOSIS  OF  THE  BREAST. 

The  disease  may  be  confounded  with  actinomyeocis,  but  the  presence  of 
the  ray-fungus  in  the  latter  affection  enables  a  positive  diagnosis  to  be  made. 
Tuberculosis  has  been  mistaken  for  carcinoma  and  vice  versa.  In  cancer  the 
skin  very  early  in  the  affection  becomes  adherent ;  whereas,  it  is  a  late  symptom, 
if  it  occurs  at  all,  in  tuberculosis.  In  cancer  the  axillary  glands  may  enlarge 
slowly,  are  harder  and  become  fused  together,  which  is  not  the  case  in  tuber- 
culosis. Tuberculous  disease  generally  occurs  in  young  women.  Carcinoma  is 
usually  found  after  forty. 

Prognosis. — In  primary  tuberculosis  the  prognosis  is  excellent.  In  the 
secondary  form  it  will  depend,  of  course,  upon  the  nature  and  extent  of  the 
primary  lesion.  Of  sixteen  patients  reported  by  Braendle,  of  the  Tubingen 
clinic,  fifteen  were  cured  by  operation  and  were  shown  to  be  well  one  to  nineteen 
years  afterwards.  Three  of  these  patients  succumbed  to  phthisis  subsequently. 
There  was,  however,  no  local  recurrence. 

Treatment. — Tuberculosis  of  the  breast  should  be  treated  by  excision  of  a 
wedge-shaped  portion  of  the  gland,  curetteing  and  cauterizing  the  sinuses,  or 
by  amputation  of  the  breast,  owing  to  the  extent  and  variety  of  the  disease. 
Where  the  process  seems  to  be  discrete  and  localized  in  a  definite  portion  of 
the  breast,  partial  resection  of  the  gland  is  a  warrantable  procedure.  Where 
a  large  part  of  the  breast  is  involved,  however,  nothing  short  of  amputation  is 
to  be  considered.  If  sinuses  are  not  too  numerous,  they  may  be  curetted  and 
cauterized.  In  one  of  my  cases,  a  girl  of  twenty-two,  an  excellent  result 
followed  plastic  resection  of  a  part  of  the  breast.  She  was  entirely  cured  with 
practically  no  resulting  deformity.  It  is  of  importance,  I  think,  that  the 
mammary  gland  of  young  marriageable  women  should  not  be  sacrificed  need- 
lessly. I  consider  it  necessary  that  the  axilla  should  be  explored  in  all  cases, 
and  if  enlarged  glands  are  found,  they  should  be  removed.  An  incision  along 
the  lower  border  of  the  breast,  after  Warren's  method,  freely  exposes  both  the 
entire  breast  and  the  axilla  to  our  view.  The  scar  cannot  be  noticed  sub- 
sequently. 

In  cases  which  refuse  operation,  or  in  others  possibly  as  an  adjuvant  to  it, 
Wright's  bacterial  vaccines  should  be  used.  I  have  had  no  experience  with 
this  treatment,  but  its  value  in  other  forms  of  local  tuberculosis  warrants  its 
employment  in  tuberculosis  of  the  breast. 

Bier's  treatment  may  also  be  given  a  fair  trial.  A  hemispherical  glass 
vessel,  somewhat  larger  than  the  breast  itself,  in  the  dome  of  which  there 
is  a  glass  nipple  attachment,  is  placed  over  the  breast.  A  rubber  tube  is  placed 
over  the  nippple  and  a  suction  pump  being  attached,  sufficient  negative  pressure 
is  made  to  cause  a  decided  hyperemia  of  the  skin.  This  is  kept  up  for  five 
minutes,  then  removed  for  five  minutes,  after  which  it  is  reapplied.  This  is 
repeated  for  thirty  to  forty-five  minutes.  There  is  no  reason  why  a  combina- 
tion of  Wright's  and  Bier's  treatments  may  not  be  employed,  for  in  this  way 
the  opsonic  index  of  the  blood  may  be  relatively  increased. 


INTERNATIONAL  TUBERCULOSIS  EXHIBITION.  177 

Editorial 


INTERNATIONAL  TUBERCULOSIS  EXHIBITION. 

The  International  Tuberculosis  Exliibition  which  is  now  in  view  at  921 
Walnut  Street,  has  aroused  the  interest  of  every  man,  woman  and  child  in 
the  City  of  Brotherly  Love.  It  has  awakened  them  from  the  drowsy, 
lethargic  mode  in  which  they  have  been  immersed  for  some  time.  Thousands 
of  people,  irrespective  of  the  weather,  daily  visit  the  exhibition  where  they 
follow  the  demonstrators  and  in  this  manner  they  display  their  intense  interest 
in  emphasizing  the  City's  part  in  the  warfare  against  this  great  white  plague. 
The  curiosity  and  eagerness  concerning  an  intelligent  knowledge  of  the  disease 
displaj-ed  by  the  people  is  surprising  to  the  medical  profession.  The  laity 
seem  to  have  joined  this  crusade  with  a  most  profound  patriotic  spirit  for 
the  eradication  of  the  death-dealing  malady.  The  importance  of  this  noble 
crusade  cannot  be  overestimated  when  it  is  realized  that  it  costs  our  country 
about  a  million  dollars  a  year.  Nevertheless,  we  have  remained  indifferent  to 
the  fact  that  imtold  misery  and  large  number  of  lives  and  great  sums  of 
money  are  lost  every  year  from  a  disease  that  can  and  ought  to  be  eradicated. 
At  last  we  are  awakening  from  our  lethargy.  The  change  has  been  gradually 
induced  by  the  insistent  pressure  of  the  ravages  of  the  disease.  The  great 
interest  shown  testifies  the  awakening  of  mankind  to  the  necessity  of  making 
further  investigations  and  greater  efforts  in  order  to  reduce  the  ravages  of  the 
disease  and  infection  to  a  minimum.  At  the  present  time  the  campaign  is 
being  carried  on  with  greater  energy  than  ever  before  as  is  shown  by  the  enlisting 
of  the  laity  into  societies  for  the  support  of  sanatoria  where  tubercular  patients 
may  seek  relief.  The  spirit  is  still  further  shown  by  the  formation  of  fresh 
air  societies  and  leagues,  whose  chief  object  it  is  to  erect  sanatoria  to  carry 
out  this  plan  in  the  treatment  of  the  disease. 

Since  Professor  E.  Koch's  great  discovery  of  the  tubercle  bacillus  in 
1882,  and  the  publication  of  his  exhaustive  researches  therefrom,  the  medical 
profession  has  proven  and  demonstrated  that  tuberculosis  can  be  prevented 
and  cured.  Science  has  demonstrated  that  this  affection  can  be  wiped  out 
of  existence,  but  the  rapidity  with  which  this  can  be  accomplished  depends  upon 
the  promptness  with  which  this  new  doctrine  can  be  inculcated  into  the  minds 
of  the  people. 

The  exhibition  occupies  a  large  building  consisting  of  three  large  floors 
full  of  every  conceivable  safeguard,  curative,  and  preventative  known  to  the 
profession  universally.  Among  the  exhibits  are  pathologic  specimens,  models, 
photographs,  plans  of  sanatoria,  instruments,  various  treatments,  methods  of 
sterilization,  etc.  Some  of  especial  interest  are  models  of  the  slums  showing 
how  closely  packed  together  the  poor  people  live  surrounded  by  unhygienic 
and  unsanitary  conditions  which  are  very  favorable  for  the  development  of 
tuberculosis.  A  very  striking  picture  is  that  of  a  poor  family  living  in  a 
tenement  house  of  the  slums.     The  father,  a  dying  consumptive,  unable  to 

G 


178  INTERNATIONAL  TUBERCULOSIS  EXHIBITION. 

work  and  support  his  family,  living  ia  a  dark  and  dirty  room,  where  his 
children,  wife  and  pets  are  all  exposed  to  infection.  Notliing  else  can  illus- 
trate more  graphically  the  danger  of  living  with  a  consiunptive  under  such 
circumstances  than  this.  Nothing  is  more  appealing  to  the  laity  than  this 
reproduction.  This  sad  picture  teaches  the  people  of  the  dangers  surrounding 
the  children  of  the  poor  in  their  restricted  homes,  where  the  father  or  mother 
may  have  become  a  victim  of  tubercular  infection.  Near  by  is  another 
reproduction  which  shows  a  properly  disinfected  and  properly  furnished  room 
for  the  treatment  of  poor  consumptives  at  a  low  cost.  Other  groups  of  models 
show  the  great  superiority  of  light,  air  and  general  hygiene  for  the  cure,  pre- 
vention and  treatment  of  this  disease.  In  addition  to  the  highly  instructive 
material  exhibited  and  demonstrated,  short  lectures  are  delivered  daily  by 
many  physicians  coming  from  different  parts  of  the  State  of  Pennsylvania 
on  the  various  points  pertaining  to  this  disease.  Scattered  throughout  the 
exhibition  are  large  signs  containing  the  plain  facts  concerning  tuberculosis  in 
its  various  stages. 

Many  years  ago  this  affection  was  regarded  by  many  as  hereditary  and 
incurable,  consequently  its  existence  was  ignored  and  concealed  and  thus 
became  a  source  of  great  danger  and  infection  to  others,  resulting  in  the  great 
number  of  tubercular  patients  at  present.  But  now  things  have  changed  and 
we  can  cure  the  majority  of  those  infected.  Post-mortem  examinations  of 
those  dying  by  accident,  show  that  many  of  the  people  living  in  the  cities  have 
had  tuberculosis  of  the  lungs  without  knowing  it. 

This  exhibition  teaches  the  consumptive  the  nature  of  the  disease  and 
instills  into  him  the  facts  that  it  can  be  prevented  and  cured,  and  that  he  can 
protect  himself  from  reinfection  and  thus  hasten  his  cure  by  religiously  adlier- 
ing  to  the  instructions  given  by  the  demonstrators  and  lecturers,  concerning 
the  disposition  of  his  sputum  and  mode  of  life.  It  is  consequently  a  matter  of 
great  concern  both  to  those  who  suffer  from  tuberculosis  and  those  who  asso- 
ciate or  are  brought  in  contact  with  them.  The  work  of  this  exliibition  brings 
the  results  of  the  latest  studies  and  investigations  not  only  before  the  laity  but 
before  the  profession  at  large,  and  places  in  the  hands  of  our  physicians  all 
the  newest  and  most  approved  methods  of  treating  the  disease.  A  knowledge 
which  will  add  many  years  of  valuable  life  to  our  people  and  will,  therefore, 
increase  our  public  health,  happiness  and  wealth. 

If  this  exliibition  accomplishes  more  for  the  education  of  the  laity  than 
for  the  advancement  of  science  as  regards  the  knowledge  of  this  disease,  our 
efforts  will  be  amply  rewarded. 

In  order  to  appreciate  the  value  of  such  an  exhibition  we  must  look  back 
a  few  centuries  aud  compare  it  with  the  present  and  so  draw  our  inferences 
and  conclusions  from  it,  to  see  whether  this  exhibition  will  have  a  good  or  bad 
effect  upon  the  laity  at  large.  This  horrible  and  dreadful  disease,  which  has 
previously  swept  one  seventh  of  the  population  of  the  universe,  has  wrought 
sorrow  to  many  unfortunate  families  by  robbing  them  of  their  chief  advisor 
and  protector  and  has  left  children  as  outcasts  with  no  protection  whatever. 

Since  the  investigations  of  the  various  pioneers  in  this  field,  the  medical 


INTERNATIONAL  TUBERCULOSIS  EXHIBITION.  179 

profession  has  been  stimulated  to  such  a  degree  that  we  do  not  give  up  all 
hope  of  recovery  as  we  have  done  years  before.  We  do  not  consider  life  a 
question  of  days;  the  disease  is  no  longer  as  it  was.  We  have  lived  up  to  the 
latin  proverb,  "Facilia  est  omnia  volentia.'' 

As  the  laity  walk  through  the  different  corridors  gazing  upon  the 
specimens  which  illustrate  graphically  the  havoc  wrought  by  this  disease  upon 
the  human  system  and  that  this  affection  is  caused  by  contagion,  he  will 
naturally  exert  all  his  efforts  to  prevent  his  contact  with  tubercular  patients. 
On  the  other  hand,  those  suffering  with  this  malady  will  dispose  of  their 
sputum  according  to  the  hygienic  rules  displayed.  They  will  also  be  greatly 
encouraged  to  fight  the  disease  by  noting  the  number  of  cases  in  which  the 
ravages  and  progress  of  this  disease  has  been  retarded  or  cured.  Naturally 
they  will  institute  strict  measures  to  save  themselves  and  indirectly  save  others. 
They  cannot  help  learning  that  infection  results  via  the  respiratory  and 
digestive  tracts  and  through  open  wovmds.  They  will  also  be  induced  to 
report  to  the  health  officers  all  tubercular  patients  which  are  a  source  of  danger 
to  others,  thus  affording  an  opportunity  in  due  time,  that  proper  medical  and 
hygienic  attention  may  be  instituted  for  the  sake  of  their  families,  friends  and 
neighbors. 

Many  new  cases  of  infection  arise  through  ignorance  of  the  infectivity  of 
tuberculosis  and  through  the  absence  of  any  knowledge  as  how  to  live  without 
spreading  infection.  To  teach  the  laity  these  principals,  the  local  authorities 
have  distributed  leaflets  conveying  simple  instructions  for  the  every-day  life 
of  tubercular  patients. 

The  knowledge  concerning  this  disease  is  not  only  inculcated  into  the 
minds  of  the  people  visiting  the  exhibition  but  it  is  also  brought  to  outsiders. 
This  is  accomplished  through  the  admirable  service  of  the  public  press  and 
through  the  schools.  Since  the  teachers  in  the  public  schools  have  a  great 
mission  in  protecting  the  children  from  contracting  this  disease,  it  is  absolutely 
necessary  that  they  should  be  educated  to  know  the  general  symptoms  and 
appearance  of  tuberculosis  or  scrofula  in  order  that  they  may  detect  any 
child  who  may  present  any  of  the  symptoms  leading  to  this  disease.  Tlie 
teacher  should  teach  them  the  love  and  judiciary  use  of  fresh  air  and  sunlight 
and  also  special  health  rules,  so  that  the  little  ones,  especially  when  they  are 
the  children  of  the  poor  and  ignorant  parents,  may  serve  as  missionaries  at 
home. 

This  exhibition  will  accomplish  a  noble  object.  It  will  do  away  with  the 
odium  existing  between  the  non-consumptive  and  the  consumptive.  It  will 
teach  those  associating  with  consumptives  to  treat  them  kindly  and  con- 
siderately and  that  the  conscientious  consumptive,  provided  he  adheres  strictly 
to  the  hygienic  precaution,  can  safely  associate  with  others  and  need  not  feel 
as  though  he  were  an  outcast. 

Since  1885  statistics  have  shown  the  steady  decline  in  the  mortality  of 
tuberculosis  and  for  this  the  principle  of  general  sanitation  has  been  responsible 
chiefly.  We  may  expect,  in  the  future  that  this  improvement  will  be  main- 
tained by  the  continued  prevention  of  overcrowding,  the  enforcement  of  good 


180 


ADRENALIN. 


CANCER,  TREATMENT  OF. 


ventilation,  improvement  of  streets  and  drainage  and  more  stringent  super- 
vision of  meat  inspection,  etc.  When  these  laws  and  regulations  are  strictly 
enforced,  plus  the  cooperation  of  the  laity,  we  hope  that  our  children  will  see 
the  day  when  tuberculosis  will  be  wiped  out  of  existence.  Only  then  will  we 
be  amply  rewarded  for  our  painstaking  investigations,  mental  and  physical 
work.  The  time  will  undoubtedly  come  when  we  will  scatter  this  affection  to 
the  four  winds  and  send  it  to  the  fourth  dimension.  Since  so  much  can  be 
accomplished  through  the  medium  of  these  exhibitions,  we  should  endeavor 
to  have  more  of  them  throughout  the  country,  in  order  that  the  laity  may  be 
constantly  kept  informed  of  the  imminent  danger  of  contagion  and  spread 
of  this  disease.  Such  public  exhibitions  will  not  only  assist  to  eradicate  tuber- 
culosis, but  will  lessen  many  other  contagious  and  infectious  diseases. 


Jlateria  Jledica  and  Therapeutics 


ADRENALIN  IN  INFECTIVE  DISEASES. 
Dr.  Hoddick  directs  attention  to  the 
excellent  results  obtained  by  Heiden- 
hain  in  the  course  of  the  past  three 
years  from  injections  of  this  extract 
added  to  saline  solution  in  cases  of 
septic  peritonitis  marked  by  serious  col- 
lapse and  low  blood-pressure.  The  fail- 
ure of  copious  injection  of  simple  saline 
solution  in  cases  of  this  kind,  and  the 
views  expressed  by  Heineke  and  others 
that  the  reduced  tension  in  acute  peri- 
tonitis is  the  result  of  paralysis  of  the 
vasomotor  centre  in  the  medulla  oblon- 
gata, and  not  of  primary  cardiac  fail- 
ure, led  Heidenhain  to  make  a  trial  of 
adrenalin.  From  six  to  eight  drops  of 
a  solution  (1  in  1000)  of  the  adrenalin 
having  been  added  to  about  a  pint  and 
a  half  of  physiological  saline  solution, 
the  mixture  in  the  cases  selected  for 
this  treatment  was  injected  into  the 
median  bacilic  vein.  It  has  been  found 
advisable  in  all  cases  of  laparotomy,  ex- 
cept in  those  in  which  the  patient  is 
already  intensely  collapsed,  to  inject  the 
solution  after,  and  not  before  the  op- 
eration. 


The  results  of  these  post-operative 
injections  have,  Hoddick  states,  been 
found  striking  in  regard  to  the  preven- 
tion, or  at  least  to  the  decided  relief,  of 
the  extreme  depression  with  cyanosis 
and  low  pulse  so  often  observed  after 
laparotomy  for  acute  infective  peri- 
tonitis. A  table  is  given,  which  shows 
that,  while  in  Heidenhain's  clinic,  in 
1901,  and  the  three  following  years,  the 
relation  of  recoveries  to  deaths  from 
epityphlitic  peritonitis  was  6  to  14  dur- 
ing the  past  two  years,  and  since  the 
first  use  of  adrenalin  injections,  16  pa- 
tients out  of  19  recovered.  (British 
Medical  Journal,  September  19,  1908.) 


ADRENALIN  IN  THE  TREATMENT  01" 
CANCER. 

Dr.  Floersheim  states  that  Berdier 
and  Talbert  report  the  cure  of  a  cancer 
of  the  rhino-pharynx  by  the  daily  injec- 
tions of  adrenalin  into  the  growth. 
Deafness  was  soon  overcome,  and  after 
a  month  or  so  there  was  scarcely  a 
trace  left  of  the  growth.  In  other  cases 
the  relief  of  pain  by  the  injections  was 
noticeable,  even  when  the  cancer  was 


CAMPHOR-NAPHTHOL. 


CRANIECTOMY. 


ISl 


too  far  advanced  for  treatment  to  be 
more  than  palliative.  They  believe 
that  some  connection  between  the  su- 
prarenals  and  the  evolution  of  the  can- 
cer seems  a  plausible  assumption  from 
the  facts  observed.  Feeswigen,  in  can- 
cer of  the  rectum,  used  adrenalin  chlo- 
ride 1  to  1000  twice  a  day  over  the  can- 
cer. He  noted  a  decrease  in  the  accom- 
panying proctitis,  a  diminution  in  the 
discharge  from  the  ulcer,  and  a  decrease 
in  the  size  of  tumor.  Ulcers  became 
pale  and  hsemorrhage  checked.  G. 
Malno  relieves  pain  and  haemorrhage  in 
cancers  of  the  breast,  mouth,  throat, 
face  and  rectum  by  swabbing  the  ulcer- 
ated surface  of  the  cancer  with  adrena- 
lin.   (Am.  Med.,  October,  1908.) 


CAMPHOR-NAPHTHOL  IN  TUBERCULOSIS," 

Dr.  "Werden  describes  this  method  of 
treatment  in  twenty  cases. 

This  preparation  affects  a  tubercular 
tissue  in  two  ways:  First,  by  its  bac- 
tericidal properties,  and  second,  by  the 
favorable  influence  due  to  its  irritative 
reaction  as  brought  about  by  the  local 
active  hyperemia.  The  conclusions  of 
the  author  are  as  follows:  First,  the 
treatment  of  surgical  tuberculosis  by 
camphor-naphthol  injections,  in  con- 
junction with  good  fixation  of  the  af- 
fected organs,  gives  better  results  than 
all  other  methods  of  treatment.  Sec- 
ond, camphor-naphthol  injections  are 
absolutely  without  danger,  if  the  prep- 
aration is  only  injected  into  the  abscess 
cavities  and  into  the  fistulas,  and  if  for 
interstitial  injections,  there  are  used 
emulsions  or  camphor  phenol  with 
glycerin  in  the  ratio  of  one  part  cam- 
phor-naphthol to  5.2  parts  of  glycerin, 
according  to  the  age  and  general  condi- 
tion of  the  diseased  individual.  Third, 
the  interstitial  injections  of  camphor- 
naphthol    and   the    evacuation    of    ab- 


scesses are  absolutely  painless,  if  the 
part  affected  is  first  anaesthetized  by 
means  of  a  1-per-cent.  cocaine  solution. 
(Zeit  fiir  orth.  Chir.,  Band  xxi.  Heft 
4,  1908.)  

CRANIECTOMY  FOR  ALBUMINURIC 
RETINITIS  AND  UREMIA. 

Drs.  Gushing  and  Bradley  report  a 
case  of  albuminuric  retinitis  in  a  young 
woman  who  was  suffering  from  a 
nephritis  of  long  standing.  The  swell- 
ing of  the  optic  discs  being  6  D  and  7  D 
respectively,  while  vision  was  ^%oo  ^'^^ 
"^%oo-  The  oedema  of  the  retina  in- 
creased gradually  until  it  was  no  longer 
possible  to  distinguish  the  discs,  while 
each  fundus  was  studded  with  various 
sized  hsemorrhages.  Later  definite  signs 
of  urasmia  appeared,  such  as  intense 
headache,  vomiting  and  moderate  stu- 
por, which  increased  in  spite  of  the 
ordinary  means  of  treatment.  Lumbar 
puncture  several  times  showed  fluid 
under  high  pressure.  The  authors,  in 
view  of  the  extreme  gravity  of  the  case 
and  their  experience  that  temporary 
benefit  results  in  such  patients  from  the 
relief  of  pressure  by  lumbar  puncture, 
decided  to  try  a  decompressive  crani- 
ectomy, which  they  believe  to  be  the 
first  ever  done  expressly  for  the  relief 
of  this  condition. 

As  a  result  the  headache  and  vomit- 
ing immediately  ceased,  and  the  stupor 
rapidly  disappeared,  while  after  four 
days  the  swelling  of  the  discs  had  sub- 
sided to  one  diopeter.  Later  other 
details  of  the  fundi  were  gradually 
revealed,  and  it  was  determined  that 
the  patient  was  actually  myopic.  The 
stellate  figures  characteristic  of  albu- 
minuria gradually  disappeared  and  the 
haemorrhages  partially  absorbed.  She 
was  for  many  weeks  entirely  free  from 
headache    and    nausea    and    vomiting, 


182 


ENEMATA  OF  COLLARGOL. 


GELSEMIUM. 


though  the  kidney  condition  remained 
unchanged  and  the  blood-pressure  was 
200.  She  was  rather  reluctantly  dis- 
charged from  the  hospital,  but  two  or 
three  weeks  later  was  readmitted  in  a 
state  of  coma,  which  was  supposed  to 
be  urgemic,  but  which  the  autopsy 
showed  to  be  the  result  of  a  large  cere- 
bral haemorrhage. 

The  authors  have  advanced  the  theory 
that  many  of  the  symptoms  associated 
with  these  conditions  were  not  due  to 
toxaemia,  but  to  pressure  from  cerebral 
anaemia.  In  examining  the  eye  grounds 
in  this  affection  during  lumbar  punc- 
ture, they  have  noted  striking  changes 
in  the  vessels,  such  as  the  straightening 
and  narrowing  of  tortuous  veins,  and  in 
a  number  of  cases  a  measureable  sub- 
sidence of  swelling,  though  these 
changes  are,  of  course,  usually  tran- 
sient. Similar  observations  have  been 
made  by  them  in  eclamptic  obstetric  pa- 
tients. (American  Journal  of  Medical 
Sciences,  October,  1908.) 


ENEMATA  OF  COLLARGOL  IN  THE  TREAT- 
MENT  OF   SEPTIC   DISEASES. 

Dr.  Curt  Seidel  reports  eight  cases,  of 
which  three  were  arthritis,  in  which 
enemata  were  given  followed  by  good 
results.  This  treatment,  if  it  is  not 
employed  too  late  and  continued  for  a 
sufficient  length  of  time,  never  fails, 
even  in  severe  cases.  The  enemata 
works  quickly,  and  in  one  to  two  hours 
reaction  follows.  The  method  con- 
sists : — 

1.  A  soap  and  warm  water  enema 
daily.  > 

2.  Fifteen  minutes  after  the  evacua- 
tion of  the  enema  and  accompanying 
stool,  a  careful  irrigation  with  saline  or 
soda,  to  remove  mucus.  (Presence  of 
mucus  prevents  absorption  of  drug.) 

3.  Fifteen  minutes  later  2  to  5  drops 


collargol  in  50  to  100  drops  warm  boiled 
water.  One  to  two  times  daily  in  severe 
cases. 

4.  In  mild  or  chronic  cases  1  to  2 
drops  in  50  to  100  drops  warm  boiled 
water,  several  times  daily. 

'5.  After  improvement  begins,  dose  is 
to  recede,  but  continue  for  not  less  than 
fourteen  days. 

6.  In  change  for  worse,  renew  ene- 
mata, unless  this  is  caused  by  ab- 
scess formation  or  other  local  affection. 

The  solutions  are  to  be  at  room 
temperature.  If  the  collargol  is  not 
retained,  add  8  to  12  minims  tr.  opii 
simpl.;  or,  instead  of  twice  daily,  give 
four  to  six  smaller  enemata  daily. 
Tenesmus  or  burning  never  follows.  As 
an  irrigation  saline  is  better  than  soda, 
as  the  latter  causes  tenesmus  of  rectum. 
The  silver  is  absorbed  within  the  first 
hour  after  injection.  This  can  be  dem- 
onstrated by  radiograph.  If  mucus  is 
left,  silver  is  seen  six  to  eight  hours 
later,  the  silver  having  been  precipi- 
tated by  the  mucus.  (Deutsche  Med. 
Wochenschr.,  1908.) 


GELSEMIITM. 
Dr.  Wm.  Henry  Morse  recommends 
the  tincture  of  gelsemium  in  from 
fifteen-  to  twenty-drop  doses,  taken 
once  only,  and  at  bed-time,  as  a  means 
of  aborting  a  common  cold,  or  an  attack 
of  acute  coryza.  All  cases  that  can  be 
aborted  at  all  will  be  aborted  by  the 
gelsemium  treatment,  and  the  cases  are 
few  in  which  this  cannot  be  done.  This 
treatment,  however,  will  not  abort  the 
acute  epidemic  catarrh  that  we  call 
"grippe."  He  has  occasionally  added 
tincture  of  belladonna  to  the  gelsem- 
ium, but  has  never  observed  that  this 
was  of  any  benefit.  When  gelsemium  is 
used,  nothing  else  is  required  in  con- 
junction vsdth  it,  it  alone  doing  the  work 


ANESTHESIA  BY  RECTUM. 


INDOXYLURIA. 


183 


required,  and,  moreover,  there  is  no 
tendency  to  extension  of  the  catarrhal 
process  farther  down  the  respiratory 
tract.  He  has  always  used  the  tincture, 
but  has  no  doubt  that  any  other  good 
preparation  of  this  drug  will  be  equally 
efficient.  The  treatment  has  been  so 
successful  in  his  hands  that  he  has  be- 
come quite  enthusiastic  about  it.  (Med- 
ical World,  December,  1908.) 


operations  on  the  head  and  throat,  as  a 
supplement  to  the  ordinary  technic. 
(Correspondenz-Blatt  fiir  Schweizer 
Aerzte,  Basle,  December  15,  No.  24.) 


GENERAL  ANESTHESIA  BY  THE 
RECTUM. 
Dr.  Dumont  extols  the  encouraging 
results  from  administration  of  the 
anaesthetic  by  the  rectum  for  operations 
on  the  head  and  throat,  since  it  leaves 
the  field  of  operation  entirely  clear  for 
the  surgeon.  Before  administering  the 
anassthetic,  fifeen  drops  of  tincture  of 
opium  are  given  to  avoid  reaction  on 
the  part  of  the  intestines.  The  pulse 
and  respiration  were  even  and  tranquil 
in  his  experience  with  four  cases,  and 
no  symptoms  were  observed  on  the  part 
of  the  bowels,  except  in  the  first  case 
before  the  present  technic  has  been 
adopted.  The  main  points  in  this  rectal 
technic  are  to  prepare  the  bowel  for  the 
anaesthetic  and  to  insure  that  only  the 
fumes — not  a  droplet  of  fluid — find 
their  way  into  the  rectum.  He  used 
ether,  an  interposed  glass  sphere  in  the 
connecting  tube,  collecting  the  con- 
densed droplets  as  the  fumes  of  the 
ether  rise  from  the  graduated  jar  set 
inside  an  outer  jar  filled  with  warm 
water.  When  the  operation  is  com- 
menced the  author  advises  the  con- 
tinuation of  the  anaesthetic  by  inserting 
the  olive  tipped  glass  tube  in  the  rectum 
and  allowing  the  ether  fumes  to  enter 
as  the  patient  shows  signs  of  rousing. 
General  anaesthesia  by  the  rectum  is  not 
advisable  when  it  is  a  question  of  opera- 
tion elsewhere.     Its  true   field  is  for 


INDOXYLURIA  IN  MENTAL  DISEASES. 
Dr.  G.  Pardo  has  investigated,  by 
means  of  the  spectro-colorimeter,  the 
amount  of  indoxyl  excreted  by  certain 
patients  with  mental  disease,  and  the 
transformation  of  the  indoxyl  into 
indigotin  and  indirubin.  After  describ- 
ing the  method  employed  and  the  for- 
mation of  indirubin  from  the  urinary 
indoxyl  by  heating  with  isatin  in  alka- 
line solution,  the  author  comes  to  the 
conclusion  that  in  patients  with  epilepsy 
or  periodical  insanity  the  indoxyl  in  the 
urine  may  appear  in  the  form  of  in- 
dirubin instead  of  indigotin  after  they 
have  passed  through  a  period  of  excite- 
ment. This  indirubinuria,  he  thinks,  is 
due  to  the  grave  digestive  upset  from 
which  these  patients  have  often  suf- 
fered. Like  indoxyluria,  indirubinuria 
is  an  index  of  intestinal  putrefaction, 
and  of  deficient  activity  on  the  part  of 
the  liver  and  intestine.  (British  Med- 
ical Journal,  November  4,  1908.) 


IODINE  AS  AN  ANTIDOTE  TO  PHENOL 
POISONING. 

Dr.  J.  Maberly  has  recommended  the 
internal  use  of  the  tincture  of  iodine  as 
an  antidote  against  poisoning  by  car- 
bolic acid.  The  tincture  of  iodine  has 
also  been  used  with  good  results  as  an 
application  to  the  skin  to  counteract 
the  corrosive  action  of  carbolic  acid. 
Tlie  iodine  neutralizes  the  corrosive  ac- 
tion of  the  acid  on  the  mucous  mem- 
branes of  the  mouth  and  oesophagus, 
overcomes  the  poisonous  symptoms,  and 
is  said  to  prevent  lesions  of  the  stomach 
and  intestines  by  the  probable  forma- 
tion of  non-toxic  phenol  iodide.     The 


184 


LAPAROTOMY  IN  HERNIA. 


TETANUS. 


author  regards  the  action  of  the  tinc- 
ture of  iodine  in  carbolic  acid  poisoning 
as  superior  to  that  of  the  alkali  sul- 
phates. (La  Tribune  Medicale,  Janu- 
ary, 1909.)  

LAPAROTOMY  IN  THE  TREATMENT  OF 
GANGRENOUS   HERNIA. 

Dr.  F.  Hesse  has  performed  laparo- 
tomy in  cases  of  incarcerated  hernia 
with  the  view  of  reducing  the  risk  of 
infection  of  the  peritoneum.  He  opens 
the  abdomen  by  making  an  incision  ten 
centimeters  long  and  three  centimeters 
above  and  parallel  to  Poupart's  liga- 
ment, and  opens  the  abdomen.  The 
strangulated  loop  of  intestine  is  then 
sought  for,  the  surrounding  parts  being 
protected  by  gauze  tampons.  The  mes- 
entery of  the  afferent  and  efferent  seg- 
ments is  loosened,  the  intestine  resected 
and  lateral  anastamosis  performed. 
The  resected  gut  is  returned  to  the 
abdomen,  and  the  free  ends  of  the  ex- 
cised portion  of  intestine  are  closed 
with  strong  silk  ligatures,  to  which  long 
strips  of  iodoform  gauze  are  tied.  Tlie 
gangrenous  gut  in  the  hernial  sac  is 
then  exposed  in  the  customary  manner 
and  disinfected  as  thoroughly  as  possi- 
ble. It  is  then  drawn  through  the  her- 
nial opening,  carrying  along  the  gauze 
strips  which  have  been  tied  to  the  free 
ends  above,  and  which  protrude  from 
the  neck  of  the  sac.  This  prevents  in- 
fectious material  from  being  carried 
into  the  abdominal  cavity  from  the 
hernial  sac.  The  gauze  tampons  are 
then  removed  from  the  abdomen,  ex- 
cept the  one  surrounding  the  site  of 
anastamosis.  This,  as  well  as  another 
gauze  drain,  which  is  introduced  from 
above  into  the  hernial  opening  as  far  as 
the  ends  of  the  iodoform  gauze  strips, 
is  passed  out  throngh  the  laparotomy 
wound,  which  is  completely  closed  ex- 


cept at  this  place.  The  herniotomy 
wound  is  left  open.  (Miinch.  Med. 
Wochensch.,  December  8,  1908.) 


LIPOID     SUBSTANCES     IN     THE     TREAT- 
MENT  OF  TETANUS. 

Dr.  Bockenheimer  has  made  a  study 
of  tetanus.  He  reports  the  late  Von 
Bergman's  clinic,  and  his  conclusions 
are  based  upon  25  clinical  cases  and  ex- 
periments upon  animals.  He  states 
that  all  wounded  persons  must  be 
treated  prophylactically,  since  a  method 
of  early  diagnosis  of  tetanus  is  lacking. 
All  wounds  should  be  washed  with  a  3- 
per-cent.  solution  of  hydrogen  dioxide 
and  an  application  of  antitoxin  in  solu- 
tion or  powder.  In  extensive  wounds, 
in  addition  to  the  local  application,  an 
injection  of  antitoxin  should  be  made 
into  the  muscles  and  large  nerve  trunks 
near  the  wound.  This  treatment  is  to 
be  repeated  daily  during  the  first  two 
weeks.  Wide  removal  of  tissues  in- 
fected should  be  practiced  when  pro- 
phylactic treatment  has  not  been  in- 
stituted. This  is  very  necessary,  due  to 
the  fact  that  a  local  infection  becomes 
general,  and  we  have  no  means  to  fore- 
cast how  soon  this  may  take  puice. 
Amputation  should  be  done  in  all  cases 
if  the  symptoms  appear  before  the 
twelfth  da}'',  and  then  large  doses  of 
antitoxin  should  be  injected  and  kept 
up  several  days  after  the  convulsions 
have  ceased. 

The  object  of  the  prophj^actic  treat- 
ment is  to  keep  out  the  dust,  dirt,  and 
putrefactive  bacteria,  which  are  favor- 
able for  the  formation  of  the  toxin. 

Balsam  of  Peru,  or  vaseline,  should 
be  applied  each  day  to  the  wound,  with 
or  without  the  addition  of  antitoxin. 
The  body  should  be  kept  cool  and 
rested.  In  addition  to  this,  chloral 
should  be  given,  10  to  20  gran]s  daily, 


MERCURY. 


PERITONITIS  AND  THROMBOPHLEBITIS. 


185 


morphine  and  repeated  anassthesia. 
One  cubic  centimeter  of  a  25-per-cent. 
solution  of  magnesium  sulphate  solu- 
tion for  each  25  pounds  of  body  weight 
should  be  used  to  produce  lumbar 
au?esthesia  of  the  lower  extremities, 
(i^rchiv.  fiir  klinische  Chirurgie,  Bd. 
86,  Heft  2.)         

MEHCURY  IN  INFECTIOUS  AND  CON- 
TAGIOUS DISEASES. 

Dr.  H.  E.  Jones,  Mt.  Sidney,  Eoa- 
noke,  Va.,  highly  recommends  the  use 
of  bichloride  of  mercury  in  infectious 
and  contagious  diseases,  due  to  its  anti- 
septic and  germicidal  properties.  For 
a  number  of  years  the  writer  has  used 
this  drug  with  good  results  in  the  treat- 
ment of  scarlet  fever,  measles,  per- 
tussis, la  grippe,  pneumonia  and  ty- 
phoid fever,  provided  they  came  under 
care  early  before  complications  or  pro- 
found toxaemia  had  developed  without 
a  complication  or  death.  He  has  also 
treated  intestinal  diseases  in  children 
with  bichloride,  without  a  single  death, 
provided  the  cases  had  been  secured 
early.  The  dose  is  Yiq  to  %  grain  every 
two  or  three  hours  for  an  adult;  chil- 
dren in  proportion,  except  in  severe 
sj'philis.  In  such  cases  he  administers 
it  hypodermically  Vie  to  Yg  grain  once 
a  day  for  four  days,  and  then  twice  a 
week  for  three  weeks,  and  gives  them 
during  the  hypodermic  medication  Yiq 
to  Ys  grain  by  mouth  five  or  six  times 
daily,  and  continues  it  for  several 
months,  or  longer,  if  necessary.  He  re- 
ports a  case  of  typhoid  fever  in  a  pa- 
tient who  suffered  from  all  the  symp- 
toms peculiar  to  this  disease.  The 
patient's  pulse  was  101;  temperature 
101%°  F.,  tongue  coated,  complexion 
sallow,  conjunctiva  j'cllowish-white,  had 
cough  and  feeling  of  discomfort  and  op- 
pression over  front  of  chest,  slight  pains 


in  left  side  and  region  of  spleen;  stom- 
ach and  bowels  tympanitic  and  painful 
on  pressure.  He  ordered  calomel  to  be 
followed  by  a  saline  and  a  prescription 
composed  of  phenacetine,  aspirin,  sali- 
cylate of  quinine  and  powder  lacto- 
peptin  every  three  or  four  hours.  The 
next  day  he  gave  5  grains  of  a  soft 
quinine  capsule,  to  be  given  every  four 
hours,  and  also  continued  the  first  pre- 
scription. This  treatment  was  con- 
tinued until  May  26.  On  that  date  he 
discontinued  the  quinine  and  prescribed 
%6-grain  tablets  of  bichloride,  to  be 
given  every  two  hours  when  awake.  Six 
daj's  after  the  commencement  of  the  bi- 
chloride treatment  the  tenderness  and 
soreness  over  his  stomach  and  bowels 
disappeared.  His  temperature  went 
down,  and  he  improved  guickly. 

The  most  timid  doctor  need  not  have 
any  fear  in  giving  this  treatment.  It 
will  not  do  the  patient  injury.  Watch 
the  effect,  and  as  soon  as  the  gums 
swell  and  teeth  become  slightly  tender, 
stop  the  drug  for  a  few  days.  Eesume 
it  as  soon  as  tenderness  and  swelling 
has  disappeared.  (Virginia  Medical 
Semi-Monthly,  January  22,  1909.) 


OPERATIVE  TREATIilENT  OF  PUERPERAL 
PERITONITIS  AND  THROMBOPHLEBITIS. 

Dr.  Leopold  reports  eighteen  cases  in 
which  he  has  applied  operative  treat- 
ment, with  recovery  of  thirteen  of  the 
women  (mortality  37  per  cent.);  ex- 
ternal causes  were  responsible  for  the 
fatalities  in  nearly  every  instance.  He 
reviews  this  material  and  tabulates  it 
under  various  headings,  emphasizing 
the  importance  of  gonorrhccal  infection 
shortly  before  or  during  pregnancy  as 
fraught  with  greater  danger  for  the 
confinement  than  is  generally  supposed. 
In  such  women  high  fever  may  develop 
with  signs  of  beginning  peritonitis  as 


186 


OXYGEN  IN  TUBERCULOUS  PERITONITIS. 


early  as  the  third  day  after  delivery  or 
not  until  the  sixth  day.  The  tardy 
fever  is  especially  characteristic  of 
gonorrhoea!  infection,  and  may  soon 
lead  to  death  from  acute  peritonitis  or 
thrombophlebitis.  Especially  dangerous 
are  the  prolonged  haemorrhages  after 
abortion,  particularly  when  associated 
with  fever;  after  expulsion  of  the 
ovum  acute  peritonitis  or  thrombo- 
phlebitis may  develop.  The  gravest 
signs  of  this  are  the  high,  small  pulse, 
hiccough,  vomiting  and  chills.  Of  sub- 
ordinate importance  are  abdominal 
pain,  meteorisra,  and,  with  thrombo- 
phlebitis, pain  at  the  obturator  foramen 
and  oedema  of  the  feet  and  legs.  Acute 
puerperal  peritonitis  indicates,  not  later 
than  the  third  day,  opening  into  the 
abdominal  cavity  to  evacuate  the  pus.  In 
every  case  Douglass'  cul-de-sac  should 
be  opened,  irrigated  and  drained.  If 
the  peritoneoum  is  not  involved,  puer- 
peral, purulent  thrombophlebitis  should 
be  treated  by  ligation  and  incision  of 
the  thrombosed,  pus-filled  vein.  The 
best  method  here  is  the  transperitoneal. 
The  proper  moment  for  it  has  arrived 
when  chills  indicate  that  the  thrombi 
are  crumbling  and  are  being  swept 
along.  In  view  of  the  fact  that  after  a 
benign  course  of  thrombosis  of  the 
femoral  vein  or  the  external  iliacs  on 
one  or  both  sides,  pyemic  fever  may  de- 
velop later,  he  advocates  early  ligation 
of  the  iliac  or  the  ovarian  veins,  or  even 
of  all  four.  It  should  be  recognized 
that  the  danger  from  the  thrombophle- 
bitis is  far  more  threatening  than  that 
from  the  operation.  Delay,  however, 
reduces  the  resisting  powers  beyond  re- 
demption. (Journal  of  the  American 
Medical  Association.) 


OXYGEIT  IN  TUBEECULOTJS  PERITONITIS. 

Dr.    J.    A.    McGlinn    (Philadelphia) 

reports  four  cases  of  pelvic  peritonitis 


in  women  which  were  treated  by  the  use 
of  oxygen  introduced  into  the  peri- 
toneal cavity  through  a  median  abdomi- 
nal incision  for  about  thirty  minutes. 
This  method  has  given  him  admirable 
results.  After  treatment  the  patients 
improved  rapidly;  they  gained  in 
weight,  and  were  soon  able  to  perform 
their  household  duties. 

The  writer  recognizes  three  types  of 
tuberculous  peritonitis,  the  ascitic  form, 
the  fibrous  form  and  the  ulcerative 
form.  However,  most  authors  are  in 
accord  that  it  is  only  the  first  type  that 
is  amenable  to  treatment.  Two  forms 
of  treatment  are  recognized:  surgical 
and  medical.  Some  hold  that  the  med- 
ical treatment  is  superior  to  the  sur- 
gical, but  the  best  results  have  been  ob- 
tained by  a  laparotomy  in  addition  to 
other  methods  advocated  from  time  to 
time  by  different  authorities. 

Many  cures  have  resulted  from  the 
surgical  treatment,  but  the  reason  for 
such  cures  have  not  been  explained  sat- 
isfactorily, consequently  it  is  impossible 
to  devise  a  scientific  form  of  treatment. 
However,  only  75  per  cent,  of  the 
ascitic  forms  can  be  cured  by  plans  of 
treatment  now  in  vogue,  but  the  fibrous 
and  ulcerous  forms  of  tuberculous  peri- 
tonitis are  not  amenable  to  treatment. 
The  method  employed  by  Dr.  McGlinn 
was  as  follows :  The  water  bottle  of  the 
oxygen  apparatus  is  sterilized  and  filled 
with  sterile  water.  The  tube  leading 
from  the  bottle  and  rubber  tip  are 
sterilized.  The  tip  is  covered  v>^ith  sev- 
eral thicknesses  of  sterile  gauze.  The 
oxygen  is  introduced  through  the  ab- 
dominal incision  until  the  abdomen  be- 
comes inflated.  The  incision  is  now 
closed  with  gauze,  and  the  oxygen  is 
allowed  to  remain  for  several  minutes. 
The  gas  is  then  allowed  to  escape,  and 
the  peritoneal  cavity  is  filled  again  and 


PINEAPPLE  AS  A  MEDICINE. 


HERNIA. 


187 


again.      (New   York   Medical   Journal, 
August  23,  1908.) 


PICKOTOXIN. 

Dr.  William  F.  Waugh  considers  the 
use  of  picrotoxin  the  principal  active 
element  of  coculus  indicus.  In  small 
doses  picrotoxin  is  a  vital  incitant  and 
nervous  regulator,  as  shown  by  the  good 
results  obtained  from  its  use  in  rupture 
of  nervous  equilibrium  from  disease  of 
the  cerebro-spinal  axis  of  the  organs. 
The  vast  field  for  its  employment  is 
found  in  spasmodic  nervous  maladies, 
essential  or  symptomatic.  Planet  con- 
siders picrotoxin  one  of  the  most  power- 
ful remedies  in  epilepsy,  and  Gubler 
advised  and  employed  it  in  chorea. 
Westbrook  administered  it  hypodermic- 
ally  in  doses,  beginning  with  %oo  grain 
to  %o  grain.  This  was  repeated  every 
two  or  three  days.  In  epilepsy  Gubler 
and  Dujardin  Beaumetz  secured  by  its 
use  a  prompt  amelioration,  and  even 
disappearance  of  the  paroxysms,  a  re- 
markable result  in  a  malady  so  grave 
and  so  tenacious.  Laura  states  that  it 
is  eflBcient  in  phthisical  night  sweats, 
colliquative,  and  in  those  of  convales- 
cents, especially  those  that  resist  atro- 
pine. The  commencing  dose  for  an 
adult  should  not  exceed  half  a  milli- 
gram, and  as  it  is  rapidly  eliminated,  it 
is  a  safe  remedy,  never  accumulating, 
but  is  prompt  and  powerful  in  action. 
(Merck's  Archives,  November,  1909.) 


FIITEAPPLE  AS  A  MEDICINE. 

The  medical  value  of  pineapples  has 
recently  been  the  subject  of  consider- 
able inquiry  among  physicians,  and  in 
Hawaii  experiments  have  been  made  to 
determine  something  of  these  proper- 
ties. It  has  been  found  that  the  fruit 
of  the  pineapple  contains  a  digestive 
principle  closely  resembling  pepsin  in 


its  action,  and  to  this  is  probably  due 
the  beneficial  results  of  the  use  of  the 
fruit  in  certain  forms  of  dyspepsia.  On 
the  casein  of  milk  pineapple  Juice  acts 
as  a  digestive  in  almost  the  same  man- 
ner as  rennet,  and  the  action  is  also 
well  illustrated  by  placing  a  thin  piece 
of  uncooked  beef  between  two  slices  of 
fresh  pineapple,  where  in  the  course  of 
a  few  hours  its  character  is  completely 
changed. 

In  diphtheritic  sore  throat  and  croup 
pineapple  juice  has  come  to  be  very 
largely  relied  upon  in  countries  where 
the  fruit  is  common.  The  false  mem- 
branes which  cause  the  closing  of  the 
throat  seem  to  be  dissolved  by  the  fruit 
acids,  and  relief  is  almost  immediate. 
(Southern  California  Practitioner,  Janu- 
ary, 1909.)  

RADICAL  OPERATION  FOR  UMBILICAL 
HERNIA. 

Dr.  Martin  recommends  the  follow- 
ing operation  for  umbilical  hernia  de- 
vised upon  the  basis  of  the  Mayo  opera- 
tion. This  method  has  been  employed 
by  the  author  with  good  results,  and  in 
no  case  has  there  been  a  recurrence. 
He  has  operated  upon  six  cases:  three 
corpulent  women  with  hernias  varying 
in  size  from  that  of  a  goose  egg  to  a 
man's  fist;  two  children,  and  a  man 
with  small  hernias. 

The  method  consists  in  removing  an 
oval  portion  of  the  skin  transversely, 
dividing  the  fascia  and  both  layers  of 
the  sheath  of  the  rectus  transversely, 
opening  the  sac  by  longitudinal  incis- 
sion,  replacing  the  contents,  and  remov- 
ing the  sac.  The  peritoneum,  transver- 
salis  fascia,  posterior  sheath  of  the 
rectus,  and  rectus  muscle  are  sutured 
longitudinally,  and  the  anterior  sheath 
of  the  rectus,  the  fascia  and  the  skin 
are  sutured  transversely.    The  fascia  is 


188 


SEROTHERAPY. 


SODIUM  SALICYLATE. 


overlapped  after  the  method  of  Mayo. 
The  deeper  stiches  are  of  catgut  and 
silk,  and  those  of  the  fascia  are  alter- 
nating ones  of  iodized  catgut  and  silk. 
The  skin  is  closed  with  a  running  stitch. 
By  this  method  there  are  two  lines  of 
suture  at  right  angles  to  each  other  and 
touching  at  only  one  point.  A  very  re- 
sistant belly-wall  is  produced.  The  pa- 
tient is  put  to  bed  with  the  knees 
flexed,  and  compression  is  made  over 
the  bandage  by  means  of  a  sand-bag. 
(Deutsche  Zeitschrift  fiir  Chirurgie, 
Bd.  94,  Hefte  3  and  4.) 


SEROTHERAPY   IN   THE   TREATMENT    OF 
POST-DIPHTHERITIC  PARALYSIS. 

Drs.  G.  E.  Schneider  and  L.  A.  Van- 
deuvre  advocate  the  use  of  large  doses 
of  diphtheria  antitoxin  in  post-diph- 
theritic paralysis  as  soon  as  the  symp- 
toms appear,  whether  soon  after  the 
angina  or  after  some  weeks.  They  cite 
a  case  in  which  a  young  adult  had  an 
attack  of  diphtheria  of  moderate  sever- 
ity and  recovered  from  it.  About  forty 
days  afer  his  apparent  recovery  he  was 
taken  with  an  almost  absolute  paralysis 
of  the  motor  nerves  of  upper  and  lower 
limbs,  palate  and  pharynx.  Swallowing 
was  impossible  and  voice  nasal.  When 
brought  to  the  hospital  he  had  to  be  fed 
with  a  stomach  tube.  He  was  so 
emaciated  and  somnolent  that  he  was 
corpse-like.  Large  injections  of  diph- 
theria antitoxin  were  at  once  begun,  and 
continued  until  he  was  entirely  cured, 
five  injections  being  given  in  all.  Im- 
provement began  at  once,  and  when  dis- 
charged from  the  hospital  he  was  able 
to  walk  as  well  as  ever,  and  to  perform 
all  his  functions.  Here  there  was  a 
rapidly  extending  polyneuritis  involving 
nearly  all  the  voluntary  muscles.  The 
muscles  of  respiration,  the  diaphragm 
and   intercostal   muscles   were    spared. 


The  serum  was  well  tolerated  through- 
out, and  it  is  noticeable  that  in  cases  of 
severe  intoxication,  it  is  well  borne  even 
in  large  doses.  Antitoxin,  supple- 
mented with  pastilles  of  antidiphthe- 
ritic  serum,  may  prevent  complications. 
(Progres  Med.,  August  29, 1908.) 


SODIUM  SALICYLATE  IN  RHEUMATISM. 

Dr.  Ealph  Stockman,  of  London, 
showed  and  anal3-zed  a  large  number  of 
charts,  illustrating  the  prompt  fall  of 
temperature  which  resulted  when  a 
rheumatic  patient  came  under  the  in- 
fluence of  sodiiun  salicylate.  When  the 
initial  lesion  was  partial  or  slow,  an  in- 
crease in  the  amount  of  the  drug  would 
usually  cause  the  temperature  to  fall 
completely.  He  also  showed  charts 
illustrating  the  action  of  the  drugs 
closely  allied  in  pharmacological  com- 
position        salicin,    salicylate    of 

methyl,  etc.  In  one  group  of  cases  of 
rheumatism,  the  synovial  membranes  of 
the  joints  were  alone  or  principally  in- 
volved; in  a  second  group  of  cases, 
which  were  more  chronic  and  less  amen- 
able to  treatment,  there  was  much  in- 
volvement of  the  surrounding  fibrous 
structures,  the  tendons  and  fascige.  In 
the  latter  much  larger  closes  might  be 
required. 

Dr.  D.  B.  Lees  advocated  the  use  of 
large  quantities  of  salicylate  of  soda, 
always  combined  with  twice  the  amount 
of  sodium  bicarbonate.  The  initial  dose 
for  an  adult  should  be  150  grains  daily, 
with  a  daily  increase  of  20  to  50  grains, 
until  the  temperature  fell  and  remained 
normal.  A  temporary  reduction  in  the 
dose  should  follow  any  unpleasant  symp- 
toms that  might  arise,  and  when  they 
disappeared  the  dose  of  the  drug  should 
be  increased  very  cautiously.  Sodium 
salicylate  was  not  a  cardiac  depressant. 
Two    precautions    were    necessary — to 


SODIUM  NUCLEINATE. 


ASTHMA. 


189 


give  suflSeient  bicarbonate  of  soda  to 
render  the  urine  alkaline  and  to  prevent 
constipation.  Under  this  treatment  the 
dilatation  of  the  left  ventricle  rapidly 
disappeared.  In  rheumatic  pericarditis 
and  myocarditis  the  application  of  an 
ice-bag  was  of  great  assistance.  If  there 
was  evidence  of  dilatation  of  the  right 
auricle,  this  must  be  relieved  by  leeches 
before  the  ice  was  applied.  (British 
Medical  Journal,  December  19.) 


SODIUM  NUCLEINATE  IN  ACUTE 
INFECTIONS, 

Dr.  Laine  publishes  reports  of  ten 
cases  of  infectious  disease  in  which  in- 
jections of  sodium  nucleinate  were  used 
with  good  results.  Among  the  cases  re- 
ported were  several  of  purulent  peri- 
tonitis, following  appendicular  inflam- 
mation, pyosalpinx,  epiploitis  following 
an  operation  for  hernia,  and  phlebitis. 
The  best  results  were  obtained  by  one 
or  two  massive  doses  (5  grains)  once  or 
twice  a  day.  The  injections  must  be 
given  deep  in  the  muscles,  as  the  one 
objection  to  their  use  is  that  they  are 
somewhat  painful.  The  beneficial  re- 
sults seem  to  be  caused  by  the  produc- 
tion of  an  artificial  hyperleukocytosis. 
It  is  noted  by  the  author  that  the 
sodium  nucleinate  is  a  combination  of 
nucleinic  acid,  derived  from  fish  or  the 
flesh  of  animals,  with  soda.  (Thera- 
peutic Gazette,  November,  1908.) 


SUCTION  HYPER.a:MIC  TREATMENT  OF 
GYNECOLOGIC  AFFECTIONS. 
Dr.  Seeligman  gives  an  illustration  of 
a  glass  speculum  connected  with  a  rubber 
bulb  which  allows  Bier's  hypergemic 
technic  to  be  applied  in  chronic  metritis, 
endometritis,  amenorrhoea,  abscesses,  etc. 
He  precedes  the  application  of  the  suc- 
tion by  scarification  or  a  small  incision. 
The  method  applied  at  the  date  of  the 


menses  has  proved  useful  in  the  disturb- 
ances from  the  natural  or  induced  meno- 
pause. He  also  applied  the  method  with 
prompt  success  in  a  case  of  puerperal 
infection.  After  aspiration  of  large 
amounts  of  purulent  secretion  from  the 
uterus,  the  fever  subsided.  He  applies 
the  suction  for  only  ten  minutes,  but 
repeats  it  daily.  His  experience  con- 
firms the  advantages  of  suction  treat- 
ment of  mastitis,  stitch-hole  abscess,  etc. 
(Clinical  Journal,  London,  December  9, 
1908;  Journal  of  the  American  Medical 
Association,  January  9,  1909). 


TREATMENT  OF  ASTHMA. 

Dr.  Treupel  regards  asthma  as  a  spe- 
cial form  of  neurasthenia,  and  believes 
that  it  can  be  effectually  cured  by  im- 
pressing the  fact  of  its  curability  on  the 
patient  and  obtaining  his  cooperation. 
The  main  point  is  to  influence  and  con- 
trol the  dread  of  suffocation  and  to 
regulate  the  breathing.  The  latter  is 
accomplished  by  various  exercises,  train- 
ing the  patient  to  breathe  deep,  with  a 
slow  inspiration,  at  the  same  time  rais- 
ing the  arms  over  the  head  and  then, 
during  expiration,  applying  the  hands 
to  the  front  and  sides  of  the  chest, 
squeezing  the  walls  together  to  aid  in 
expelling  the  last  traces  of  air.  These 
exercises,  or  their  equivalents,  should  be 
repeated  once  or  twice  a  day  for  fifteen 
minutes.  Electric  light  sweat  baths  and 
potassium  or  sodium  iodide  have  proved 
very  useful  in  his  experience  when  ap- 
plied during  the  intervals  between  at- 
tacks. Sedatives  may  be  useful  in  the 
acute  attack,  but  should  be  used  only  in 
emergencies.  Exercises  and  hydro- 
therapy, with  a  transient  change  to  a 
more  favorable  climate,  the  seashore  or 
mountains,  are  important  adjuvants. 
He  adds  that  the  treatment  of  bronchial 
asthma  is  a  grateful,  but  by  no  means 


190 


APPENDICITIS  IN  PREGNANCY. 


CARCINOMA  OF  UTERUS. 


an  easy  task;  success  requires  much 
skill,  a  determined  will  and  persever- 
ance. (Deutsche  medizinische  Wochen- 
schrift,  Berlin,  December  31.) 


TREATMENT  OF  APPENDICITIS  IN 
PREGNANCY. 

Dr.  Eudaux  considers  that  as  a  pro- 
phylactic measure  all  pregnant  women 
should  be  cautioned  against  the  dangers 
of  constipation  and  advised  as  to  the  use 
of  laxatives.  The  diet  should  be  ar- 
ranged on  a  simple  and  nourishing 
basis,  and  these  precautions  must  be 
especially  emphasized  in  the  case  of  per- 
sons who  have  already  suffered  from  ap- 
pendicular attacks.  Should  an  attack 
supervene,  the  patient  must  be  kept  in 
bed  and  deprived  of  all  food  and  drinks, 
and  neither  purgatives  nor  injections 
should  be  administered.  Subcutaneous 
injections  of  serum  are  given  to  relieve 
thirst,  and  an  ice-bag  is  suspended  over 
the  right  iliac  fossa.  If  the  abdominal 
pain  is  severe,  injections  of  morphine 
and  heroin  are  useful.  When  the  symp- 
toms have  subsided  after  five  or  six 
days,  a  teaspoonful  of  Evian  water,  may 
be  given  every  half  hour  or  hour,  but 
not  more  than  half  a  pint  should  be 
given  during  the  day;  on  subsequent 
days  a  pint  may  be  allowed.  When  the 
temperature  is  normal,  spoonfuls  of 
milk,  with  either  rice-water  or  Evian 
water,  are  given.  After  four  or  five 
days  a  large  sound  should  be  inserted 
into  the  rectum  tvnce  a  day  for  half  an 
hour,  and  at  the  end  of  a  week  small 
doses  of  olive  or  castor  oil  may  be  given 
to  promote  the  action  of  the  bowels. 
The  ice-bag  should  only  be  removed 
when  all  tenderness  has  disappeared. 
Food  is  then  given  with  great  caution, 
and  the  patient  is  kept  in  bed  for  at 
least  a  month.  Surgical  intervention  is 
only  advised  when  symptoms  of  abscess 


or  of  general  peritonitis  are  observed. 
(British  Medical  Journal,  November  14, 
1908.)  

TREATMENT  OF  CHRONIC  ENDO- 
METRITIS. 

Dr.  J.  H.  Eector  describes  his  method 
of  treatment  of  chronic  endometritis. 
It  consists  of  free  drainage  of  the  organ 
and  of  its  mucous  glands  with  irriga- 
tions with  various  solutions.  Prelimi- 
nary dilatation  is  produced  by  the  use  of 
a  mild  galvanic  current  applied  with  an 
intra-uterine  electrode,  and  followed  by 
irrigation  with  galvanization.  The  cur- 
rent must  be  even  uninterrupted,  and 
the  negative  electrode  is  applied  in  the 
uterus.  The  galvanic  current  produces 
direct  stimulation  of  muscular,  gland- 
ular and  secretory  structures.  Sim- 
ple catarrhal  endometritis  produces  a 
watery  discharge,  while  the  involvement 
of  the  cervix  renders  it  thick  and  ropy. 
Proper  treatment  involves  cleansing, 
opening  the  mouths  of  the  glands,  stim- 
ulating glandular  activity,  and  replacing 
the  normal  equipoise  between  vascular 
supply,  innervation  and  muscular  rela- 
tionship. AU  these  are  accomplished  by 
galvanic  irrigation.    (Medical  Eecord.) 


TREATMENT  OF  INOPERABLE   CAR- 
CINOMA OF  THE  UTERUS. 

Dr.  Freund  states  that  in  cases  of 
carcinoma  of  the  uterus,  which  cannot 
be  removed  radically,  surgical  treatment 
remains  the  only  one  that  gives  some 
relief  from  the  symptoms,  and  tem- 
porarily at  least,  alleviates  the  suffer- 
ings of  the  patient.  The  loss  of  blood, 
the  fetid  discharge,  the  absorption  of 
toxic  material  from  the  broken  down 
cancer  may  all  be  put  a  stop  to  by  a 
proper  operation  in  the  last  stages  when 
cure  is  impossible;  it  is  also  possible  to 
prevent  a  rapid  progress  of  the  malig- 


LUPUS  VULGARIS. 


COLLOIDAL  SILVER. 


191 


nant  process  for  months,  and  even  for  a 
3'ear,  as  Freund's  experience  proves. 
The  improvement  is  prohably  due  to  the 
removal  of  the  peritoneal  ascites,  to  the 
freeing  of  important  organs  from  me- 
chanical and  chemical  injuries  caused  by 
the  growth,  and  especially  to  the  great 
capacity  of  the  healthy  tissues  to  oppose 
the  progress  of  the  disease  by  encapsu- 
lating and  limiting  them  for  a  time  at 
least.  One  of  his  cases  showed  at  the 
operation  that  the  bladder  wall  was  at- 
tacked by  the  growth,  yet  the  viscus  re- 
mained without  perforation  for  two 
years  after  the  operation.  The  unpor- 
tant  thing  to  remember  is  that  cancer 
of  the  uterus  may  be  very  fast  growing 
in  one  case  and  very  slow  in  another; 
operation  may,  therefore,  relieve  the  lat- 
ter case  very  much,  and  for  a  consider- 
able period  of  time.  Operations  by  the 
abdominal  route,  with  the  removal  of  as 
much  diseased  tissue  as  possible,  is 
therefore  indicated  even  in  very  ad- 
vanced cases  of  uterine  cancer.  (Med- 
ical Eecord.)        

UNMODIFIED  SUN  RAYS  IN  THE  TREAT- 
MENT   OF   LUPUS  VULGARIS. 

Dr.  J.  Goodwin  Thompson  extols  the 
advantages  of  the  employment  of  system- 
atic sun  exposures  in  the  treatment  of 
lupus  vulgaris  where  unclouded  sunshine 
and  other  favorable  climatic  conditions 
are  constant  and  dependable  quantities. 
Eleven  cases  are  reported  by  other 
writers  and  out  of  these  eight  were  cured 
and  the  remaining  three  were  stationary. 
Of  the  thirty-four  cases  of  scrofuloderma, 
six  cases  were  greatly  benefited  while  the 
remaining  twenty-eight  were  cured.  The 
author  reports  the  case  of  an  old  lady, 
who  had  lupus  of  the  face  for  twenty-five 
years.  She  was  recommended  by  the 
author  to  lay  out  in  the  sun,  five  hours 
every  day  for  a  period  of  four  months, 


her  head  swathed  in  a  cloth,  and  eyes 
shaded  with  a  dark  bandage.  In  about 
four  months  her  face  was  found  smooth,, 
and  the  apple-jelly  nodules  which  he  had 
seen  on  her  cheeks  four  months  previous 
to  this  treatment  had  completely  disap- 
peared. After  further  treatment  she 
Avas  entirely  cured. 

The  curative  factors  in  the  treatment 
of  these  cases  were  the  bactericidal  action 
of  the  sun's  rays,  the  tonic  action  of  the 
sea  air,  the  mildness  and  regularity  of 
the  temperature  at  Cannes,  which  allows 
an  open-air  life,  and  the  prolonged  sun- 
baths.  (British  Medical  Journal,  October 
24,  1908.)  

USE  OF  COLLOIDAL  SILVER  IN  THE 
TREATMENT  OF  PUERPERAL  IN- 
FECTION. 

Dr.  Cyrille  Jeannin  (Progres  Med., 
August  1,  1908)  gives  a  careful  review 
of  the  method  of  use  and  dosage  of 
colloidal  silver  in  puerperal  infections. 
It  is  perfectly  harmless,  and  has  an 
antiseptic  and  preventive  effect  as  well 
as  a  catalytic  action.  It  should  be  used 
as  soon  as  the  infection  assumes  a  seri- 
ous aspect,  and  its  use  late  in  the  case 
is  of  much  less  value  than  when  begun 
early.  When  the  localized  infection 
shows  signs  of  generalization  it  should 
be  begun  at  once.  The  best  method  of 
use  is  by  intravenous  injection,  made 
in  the  median  cephalic  vein,  with  care 
not  to  introduce  the  needle  into  the 
cellular  tissue  of  the  vein.  The  dose 
should  be  from  10  to  15  cubic  centi- 
meters of  a  1-per-cent.  solution  of  col- 
largol.  Inunction  may  be  combined 
with  this  method,  but  it  is  much  slower 
and  should  not  be  relied  upon  alone. 
The  injection  should  be  repeated  in 
forty-eight  hours,  since  the  action  of 
the  remedy  passes  away  quickly  and 
must  be  kept  up.     Gaseous  embolism 


192  BOOK  REVIEWS. 

has  not  been  known  to  occur.    The  im-  immediately  begins   to  feel   better,   in 

mediate  result  of  the  injection  is  a  chill  spite  of  the  rise  of  temperature.     The 

and  rise   of  temperature.     When   this  author  gives  results  of  forty-nine  cas<  s 

does  not  occur  we  know  that  the  organ-  treated  with  coUargol  at  the  Lariboi- 

ism    is    not   reacting   properly    to    the  siere.     Of  these  thirty-nine  lived  ari 

remedy.    After  the  rise  of  temperature  recovered   and    ten    died,    making   the 

it  falls  by  lysis.    If  such  a  fall  does  not  cures  76  per  cent.     (American  Journal 

occur  the  prognosis  is  bad.    The  patient  of  Obstetrics,  January,  1909.) 


5ool{  Reviews 


Oesteteic   and   Gtxecologio   Nursing.      By   Edward   P.    Davis,    A.M.,   M.D.,   Professor   of 

Obstetrics  in  the  Jetl'erson  Medical  College,  Philadelphia;    Obstetrician  and  Gynecologic o 

to  the  Philadelphia  Hospital;    Consultant  to  the  Preston  Retreat,  etc.     Third  Editio)  , 

Thoroughly  Revised.     Philadelphia  and  London:    W.  B.  Saunders  Company,  1908. 

This  new  book  on  "Obstetric  and  Gynecologic  Nursing"  comprises,  in  a  limited  number 

of  pages,  all  the  salient  facts  necessary  for  the  treatment,  both  medical  and  surgical,  in  the 

field  of  obstetrics   and  gynecology.     The  volume  is  written   strictly  in   accordance  with  the 

newer  medical  and  surgical  facts  in  the  practice  of  obstetrics  and  gynecology,  and  includes 

the  best  methods  of  nursing  the  mother   during  pregnancy,   parturition,   and  the   puerperal 

state,  and  also  the  care  of  her  child. 

The  anatomy  of  the  parts  involved  and  the  methods  of  making  a  correct  diagnosis  are 
very  clearly  described,   and  the  essential   details  of  treatment  are  beautifully  pictured  and 
explained.     The  book  is  divided  into  two  parts: — 
Part     I — Obstetric  Nursing. 
Part  II — Gynecologic  Nursing. 
All  the  various  methods  of  taking  care  of  the  diseased  woman  are  extensively  treated, 
and  nothing  is  left  to  the  imagination. 

Among  some  of  the  important  chapters  are:  "Nursing  in  the  Complications  of  Preg- 
nancy;" "New-born  Child  and  Its  Care;"  "Obstetric  Surgeiy;"  "Gynecologic  Operations;" 
"Cancer;"    "Veneral  Diseases." 

Another  feature  of  the  book  is  the  appendix,  which  contains  "Dietary;"  "Preparation 
of  Surgical  Supplies;"  "Other  Methods  of  Preparation  of  Surgical  Supplies  and  Aseptic 
Precautions." 

This  book  can  be  recommended  to  nurses  and  physicians  as  a  concise,  practical  guide 
in  the  various  details  of  obstetrics  and  gynecology. 

Lincoln's  Love  Stoey.  By  Elanor  Atkinson,  Author  of  "The  Boyhood  of  Lincoln"  and 
"Ma'm'zelle  Fifine."  Illustrated.  New  York:  Doubleday,  Page  &  Company,  1909. 
In  this  little  book  we  have  the  beautiful,  tragic  love  story  of  one  of  the  wrold's  greatest 
souls  told  witli  a  touch  that  is  tenderly  sympathetic.  The  liglit  and  shade  are  strangely 
intermingled,  deoprning  at  last  into  darkest  midnight  in  those  sad  montlis  following  the 
death  of  his  sweetheart.  The  strength,  the  devotion  and  loyalty  of  a  noble  nature  are 
graphically  and  vividly  portrayed  throughout  the  entire  story. 

Practical  Dietetics  with  Reference  to  Diet  in  Disease.  By  Alido  Frances  Pattec. 
Graduate  Department  of  Household  Arts,  State  Normal  School,  Farmingham,  Mass.; 
late  Instructor  in  Dietetics,  Belle\aic  Training  School  for  Nurses,  Bellevne  Hospital, 
New  York  City;  formerly  Instructor  at  Lakeside,  St.  Mary's,  Trinity  and  Wisconsin 
Training  School  for  Nurses.  Milwnukee.  Wis.;  St.  Joseph's  Hospital,  Chicago.  111.,  etc. 
Fifth  Edition.  Mt.  Vernon  and  New  York:  A.  F.  Pattee,  Publisher,  52  West  Thirty- 
ninth  Street. 

The  author  has  produced  in  this  book  one  of  the  best  volumes  on  practical  dietetics 
which  has  come  into  our  hands.  It  contains  all  the  essential  points  that  a  nurse  should 
know  concerning  the  feeding  of  the  sick.  The  author  has  succeeded  admirably  in  furnishing 
a  book  fulfilling  the  requirements  of  simplicity,  brevity  and  exactness,  with  reference  to 
administration  of  diet  in  disease  and  infancy. 

The  book  concludes  with  an  appendix  containing  practical  points  and  suggestions  for 
the  nurse  concerning  the  sick  room,  bath,  disinfectants,  temperature,  etc.  In  every  way  it 
is  a  splendid  work,  and  fully  sustains  the  high  standard  set  by  the  previous  editions. 


ONTHLY     CYCLOPiEDIA 


AND 


Medical  Bulletin 

(Published  the  Last  op  Each  Month) 


Monthly  Cyclopaedia  Section 


Vol.  II.  PHILADELPHIA,  APRIL,  1909.  No.  4. 


Original  Articles 


Department  in  charge  of  J.  MABJBON  TAYLOR.  A.M.,  M.D. 


GRADUATED  OUT-DOOR  LABOR  IN  PULMONARY  TUBERCULOSIS. 

By  guy  HINSDALE,  M.D., 

HOT  8PEINGS,  VA. 

Secretary  of  the  American  Climatological  Association;     Corresponding  Fellow  of  the 
British  Balneological  and  Climatological  Society,  etc. 

One  of  the  interesting  and  instructive  English  exhibits  at  the  International 
Congress  on  Tuberculosis  at  Washington  was  that  illustrating  the  use  of  grad- 
uated labor  as  carried  out  at  the  Frimley  Sanatorium  of  the  Brompton  Hos- 
pital, London.  This  exhibit  included  photographs  showing  how  patients  are 
employed  in  the  most  carefully  graded  methods  of  out-of-door  exercise.  The 
various  implements  used  were  sent  over  from  England,  so  that  they  could  be 
seen  and  handled.  These  included  baskets  of  different  sizes,  spades  of  dif- 
ferent weights,  wheelbarrows,  and  pickaxes,  small  and  large,  according  to  the 
capacity  and  rating  of  the  patient. 

Dr.  Marcus  S.  Paterson,  the  medical  superintendent  of  the  Brompton 
Hospital  Sanatorium,  read  a  paper  at  the  Congress  on  "Graduated  Labor  in 
Pulmonary  Tuberculosis,"  and  this  was  supplemented  by  another  paper  by 
his  colleague,  Mr.  A.  C.  Inman,  the  superintendent  of  the  Laboratories  of 
Brompton  Hospital,  on  the  '^Effect  of  Exercise  on  the  Opsonic  Index  of 
Patients  Suffering  from  Pulmonary  Tuberculosis."  These  papers  and  the 
previous  publications  by  these  authors  in  the  Lancet^  are  very  interesting, 
and  m.ust  be  considered  together  as  a  valuable  contribution  to  the  scientific 
treatment  of  tuberculosis. 

1  Lancet,  January  25,  1908. 
3  (l^'V 


194  OUT-DOOR  LABOR  IN  PULMONARY  TUBERCULOSIS. 

The  fact  that  the  method  advocated  involves  the  use  of  exercise  amoimting, 
in  the  end,  to  hard  labor  for  as  much  as  eight  hours  a  day  is,  of  course,  directly 
opposed  to  the  usual  treatment  in  private  practice  and  to  that  in  vogue  in 
many  sanatoria.  The  Dettweiler  system  enjoins  rest  in  the  open  air  with 
superalhnentation;  whereas  the  Nordrach  system  as  carried  out  by  Dr. 
Walther  and  by  his  predecessor.  Dr.  Brehmer,  at  Goerbersdorf,  in  Silesia, 
involves  much  exercise  in  addition  to  fresh  air  and  alimentation.  Brehmer 
advocated  hill  climbing  while  Walther  advises  graduated  walking  exercises,  in 
some  cases  to  the  extent  of  twenty  miles  a  day.  In  America,  Benjamin  Eush 
and  Benjamin  Franklin  recorded  cases  of  consumption  cured  by  horse-back 
riding,  over  a  hundred  years  ago  and  Sydenham  recorded  such  a  case  which 
antedated  them.  The  fact,  also,  that  in  such  modern  sanatoria  as  the  Free 
Hospital  for  Poor  Consumptives  at  White  Haven,  Pennsylvania,  the  patients 
were  put  at  various  occupations  from  the  outset  as  an  economic  measure  and 
that  the  performance  of  these  duties  was  found  beneficial;  and  the  general 
practice  at  most  institutions  of  assigning  more  or  less  arduous  duties  to  con- 
valescing patients  constitute  altogether  a  different  matter  from  the  stjstem 
advocated  by  Dr.  Paterson.  We  therefore  take  issue  with  the  writer  of  a 
recent  communication,  who  claims  that  the  Englishmen  have  copied  the 
Americans  in  this  method  of  treatment.^ 

The  patients  for  whom  Paterson  instituted  graduated  labor  were  selected 
cases  sent  from  the  Brompton  Hospital  in  London  to  its  sanatorium  at  Frimley 
at  an  elevation  of  380  feet  in  the  country. 

He  was  induced  to  carry  out  this  plan  of  treatment  after  seemg  tuber- 
culous patients  who  did  well  while  working  under  unfavorable  surroundmgs; 
but  he  believed  that  under  careful  regulation  of  labor  and  with  very  careful 
observation  of  the  temperature  records,  he  might  safely  proceed.  The  exercises 
adopted  involved  all  the  muscles  of  the  trunk  and  extremities  and  this  was 
thought  to  be  better  than  walking  exercises  in  which  the  lower  limbs  were 
chiefly  employed.  The  use  of  the  upper  limbs  seemed  more  likely  to  favor  the 
expansion  of  the  lungs.  It  was  not  forgotten  that  the  common  objections  to 
this  plan  of  treatment  are:  (1)  that  the  disease  would  become  active  again 
under  the  strain;  (2)  that  the  exertion  would  tend  to  produce  hemoptysis. 
Considerable  tact  and  personal  influence  must  have  been  exerted  to  get  the 
patients  to  carry  out  a  plan  which  involved  increasmg  labor  and  measures  that 
were  generally  considered  positively  harmful. 

The  first  exercise  ordered  was  walking,  the  distance  being  gradually 
increased  up  to  ten  miles  a  day.  When  a  patient  had  reached  this  stage  he 
was  given  a  basket  in  which  to"  carry  mould  for  spreading  on  the  lawns.  No 
case  of  hemoptysis  or  of  pyrexia  occurred  among  these  patients.  When  they 
had  been  on  this  grade  with  nothing  but  beneficial  results  for  from  three  weeks 


2  See  article  by  Joseph  Walsh,  M.Tt.,  Assistant  Director  Phipps  Institute,  ]\Iontiily 
Ctclop^dia  and  Medical  Bulletin,  October,  1908.  "Although  we  are  obliged  to  give 
credit  to  Europe  for  manv  of  the  theoretical  ideas  and  much  of  the  practical  work  in  con- 
nection with  medicine,  occasionally  we  do  something  on  this  side  of  the  water  worthy  of 
notice.  When  this  is  done,  and  Europe  takes  the  credit  for  it,  we  naturally  foel  a  little 
chagrined." 


OUT-DOOR  LABOR  IN  PULMONARY  TUBERCULOSIS.  195 

to  a  mouth,  they  were  given  boys'  spades  with  which  to  dig  for  five  minutes 
followed  by  an  interval  of  five  minutes  for  a  rest.  After  a  few  weeks  several 
of  the  patients  on  this  work,  who  were  doing  well,  were  allowed  to  work  as 
hard  as  possible  with  their  small  spades  without  any  intervals  for  rest.  As 
they  had  all  improved  on  this  labor  larger  shovels  were  obtained,  and  it  was 
found  that  the  patients  were  able  to  use  them  without  the  occurrence  of  hemo- 
ptysis or  a  rise  of  temperature.  About  this  time  many  of  the  patients  were 
feeling  so  well  that  it  became  necessary  to  restrain  them  from  doing  too  much. 

These  results  in  a  few  cases  created  a  most  favorable  sentiment  among  the 
other  patients,  so  that  the  system  was  extended  generally,  with  great  care  and 
minute  supervision.  Harder  work  was  prescribed  for  patients  who  could  be 
trusted  even  to  the  use  of  spades,  shovels  and  five-pound  pick  axes.  The 
patients  all  expressed  the  opinion  that  the  work  did  them  good  and  that  the 
harder  they  worked,  the  better  they  felt.  Many  patients  have  written  to  Dr. 
Paterson  to  say  that  they  date  their  improvement  from  the  commencement  of 
the  labor  and  that  they  think  the  hardest  work  did  them  the  most  good.  It 
certainly  speaks  well  for  the  strict  supervision  of  these  patients  that  no 
accidents  occurred  of  a  serious  nature  though  several  developed  fever  and,  sub- 
sequently, pleurisy.  One  patient  was  laid  up  for  two  months  and  was  much 
worse  at  the  end  of  that  time  though  eventually  he  did  well  and  returned  to 
work,  though  the  extent  of  his  disease  was  increased  through  overexertion. 

The  suitability  of  cases  for  graduated  lahor  rests  on  a  very  careful 
physical  examination,  importance  being  laid  on  the  general  muscular  and 
physical  development.  Marked  wasting  and  poor  development  is,  naturally,  a 
bar  to  this  method  of  treatment.  The  resisting  power  of  a  patient  with  a 
very  limited  lesion  is  an  unknown  quantity  and  has  to  be  determined,  whereas 
a  patient  with  a  lesion  involving  four  lobes  may  remain  at  work  for  some 
time  and  exhibit  a  good  initial  resisting  power. 

Dr.  Paterson  lays  very  great  stress  on  the  temperature  taken  in  the  mouth. 
If  this  is  or  has  been  99°  F.  or  over,  during  the  week  preceeding  admission  to 
the  sanatorium,  the  patient  is  put  to  bed  after  the  journey.  So  long  as  the 
temperature  remains  at  99°  P.  in  the  case  of  men  or  99.6°  P.  in  the  case  of 
women,  the  patient  is  not  allowed  up  for  any  purpose.  So  long  as  the 
temperature  is  unaft'ected  by  exertion  the  patient  is  gradually  allowed  up  for 
longer  and  longer  periods.  Patients  with  apparently  limited  disease,  but  who 
are  in  poor  general  condition  and  without  fever,  are  allowed  to  be  up  all  day 
but  are  not  peiTuitted  to  take  further  exercise  than  is  entailed  by  walking  to 
and  from  the  dining  hall  for  their  meals.  The  remainder  of  the  day  is  spent 
in  resting.  As  their  condition  improves  they  are  allowed  to  walk  half  a  mile  a 
day,  then  a  mile  a  day,  and  so  on,  until  a  distance  of  six  miles  a  day  is  reached. 
The  rate  of  increase  in  the  amount  of  exercise  depends  upon  such  factors  as  the 
patient's  disposition,  weight  and  appetite. 

The  grades  of  work  are  briefly,  as  follows:  (/I  1)  Walking  from  one-half 
to  ten  miles  daily;  (1)  Carrying  baskets  of  mould  or  other  material;  (2) 
Using  a  small  shovel;    (3)  Using  a  large  shovel;    (4)   Using  a  five-pound 


196  OUT-DOOR  LABOR  IN  PULMONARY  TUBERCULOSIS. 

pickaxe;    (5)   Using  a  pickaxe  for  six  hours  a  day.     Patients  in  grades  1, 
2,  3  and  4  work  four  hours  a  day. 

The  basket  work  in  which  about  eight  pounds  of  earth  are  carried  is  con- 
sidered the  most  important  and,  as  a  rule,  patients  spend  far  more  time  in  this 
work  than  in  any  other.     It  brings  into  use  all  the  muscles. 

Work  has  a  wholesome  effect  on  the  mind.  If  the  patient  is  at  first  sullen 
and  apathetic,  the  improvement  in  physical  condition  quickly  begets  a  lively 
and  cheerful  mental  attitude  and  one  that  seeks  work  rather  than  to  shirk  it. 

During  1905  and  1906  the  nimiber  of  patients  discharged  from  this  sana- 
torium was  164  and  they  aU  returned  to  their  previous  occupations,  whatever 
that  happened  to  be,  and  not  to  light  out-door  work.  They  were  fitted  by  the 
line  of  treatment  which  we  have  described  for  effective  wage  earning. 

We  have  dwelt  quite  fully  on  this  innovation  in  tuberculotherapy  because 
it  gives  promise  of  good  practical  results  and  further,  because  it  is  so  radically 
different  from  the  prevailing  methods  adopted  in  most  sanatoria.  But 
the  most  interesting  feature  is  the  explanation  which  is  offered  to  account  for 
the  benefits  which  have  accrued. 

This  explanation  is  set  forth  in  an  elaborate  study  made  by  A.  C.  Imnan, 
IiI.B.,  the  Superintendent  of  the  laboratories  of  the  Brompton  Hospital,  on  the 
"Effect  of  Exercise  on  the  Opsonic  Index  of  Patients  Suffering  from  Pul- 
monary Tuberculosis."^ 

This  study  of  Inman's  was  prompted  and  made  possible  by  the  brilliant 
work  of  Sir  Abnroth  Wright.  Wright  showed  in  his  Harveian  Lecture  in 
New  York,  that  there  are  three  great  agencies  by  which  immunizing  responses 
can  be  evoked  in  the  organism: 

1.  By  the  inoculation  of  bacterial  vaccines. 

2.  By  artificially  induced  autoinoculations. 

3.  By  spontaneous  autoinoculations. 

Wright  had  previously  elucidated  the  subject  of  vaccine  therapy  by  con- 
structing curves  from  the  opsonic  indices  of  patients  vaccinated  against  their 
infection  and  in  this  manner  traced  a  definite  train  of  events  which  f oUow  upon 
a  single  inoculation.  The  successive  phases  were  termed  the  negative  phase, 
the  positive  phase  and  the  phase  of  maintained  high  level.  Freeman,  working 
in  Wright's  laboratory,  then  took  up  the  subject  of  massage  in  its  effect  on 
gonococcal  joints  showing  that  "autoinoculations  foUow  upon  aU  active  and 
passive  movements  which  effect  a  focus  of  infection  and  upon  all  vascular 
changes  which  activate  the  lymph-stream  in  such  a  focus." 

Wright's  dictum  was  that  "where  in  association  with  a  bacterial  invasion 
of  the  organism  bacteria  or  bacterial  products  pass  into  the  general  lymph-  and 
blood-stream,  intoxication  effects  and  immunizing  responses,  similar  to  those 
which  follow  upon  the  inoculation  of  bacterial  vaccines,  must  inevitably  super- 
vene." It  is  a  perfectly  logical  conclusion,  then,  that  nature  cures  bacterial 
infections  through  such  auto-inoculations.  Inman  set  himself  to  find  out  what 
the  body  is  doing  of  itself  and  what  value  extraneous  circumstances,  such  as 


3  Read  before  the  Medical  Society  of  London,  January  1.3,  1908, 


OUT-DOOR  LABOR  IN  PULMONARY  TUBERCULOSIS.  197 

physical  exercise,  have  in  aiding  these  attempts  on  the  part  of  the  body.  In- 
man's  work  was  conducted  on  a  carefully  planned  technic,  controlled  and 
cheeked  at  all  points,  using  forty-three  patients  in  the  sanatorium  treated  by 
the  system  of  graduated  labor. 

Inman  found  that  in  41  out  of  43  cases  the  opsonic  index  was,  at  some 
time  of  the  day,  well  above  the  normal  and,  what  is  of  even  more  importance, 
in  no  case  did  the  exercise,  even  though  severe,  lower  the  index  below  the 
normal  line — that  is,  the  autoinoculation  was  never  so  great  as  to  produce  a 
negative  phase  and,  therefore,  never  in  excess.  "It  was  observed  during  these 
investigations  that  in  some  bloods  examined  tuberculo-agglutinins  appeared 
in  association  with  the  immune  tuberculo-opsonins.  This  must  be  taken  as 
another  evidence  of  an  immunizing  response  on  the  part  of  the  organism. 
When  the  difficulties  of  such  a  method  of  treatment  and  the  danger  of  the 
weapon  employed  are  taken  into  consideration  it  will  be  readily  understood 
that  every  now  and  then,  in  spite  of  the  most  careful  supervision,  an  excessive 
autoinoculation  must  take  place.  Such  an  overdose  is  readily  recognized 
clinically.  A  patient  doing  well  on  the  grade  of  work  prescribed  for  him  and 
with  no  abnormality  of  temperature,  suddenly  complains  of  feeling  tired,  of 
loss  of  appetite  and  of  headache,  and  the  temperature  chart  registers  an 
elevation  to  99°  or  100°  P.  These  are  precisely  the  symptoms  which  are 
found  during  the  negative  phase  after  an  excessive  dose  of  bacterial  vaccine." 

Thus  we  have  a  new  scientific  test  by  which  the  effect  of  physical  exercise 
on  the  blood  of  patients  has  been  traced.  As  Inman  says :  "The  opsonic  index 
has  shown  that  the  exercise  has  supplied  the  stimulus  needed  to  induce 
artificial  auto-inoculation,  and  that  this  systematic  graduation  has  regulated 
this  in  point  of  time  and  amount.  This  cooperation  with  the  natural  efforts 
of  the  blood  has  enabled  Dr.  Paterson  to  send  his  patients  back  to  their 
accustomed  work,  however  hard  it  may  be.  But  the  investigation  has  done 
more  than  explain  a  successful  mode  of  treatment.  Dr.  Paterson  agrees  with 
me  that  with  the  aid  of  the  opsonic  index  he  can  regnilate  the  stimulus  with 
scientific  accuracy  and  obtain  his  results  more  certainly  and  more  rapidly. 
This,  of  course,  involves  work  in  the  laboratory.  But  it  also  means  a  more 
rapid  and  a  more  certain  discharge  of  the  patient  which  is  the  main  object  of 
the  sanatorium." 

At  the  lung's  Sanatorium,  near  Midhurst,  England,  light  work  in  the 
garden  and  grounds  is  prescribed  in  lieu  of  some  of  the  walking  exercises 
and  forms  part  of  the  regular  treatment.  Practical  gardening  in  the  grounds 
and  flower  beds,  the  lightest  labor  consisting  of  weeding,  hoeing  and  edging 
paths  and  borders,  gathering  seeds,  plucking  dead  flowers,  priming,  etc. 
Somewhat  harder  exercise  consists  in  wheeling  soil  to  the  lawns  and  spreading 
it,  clearing  ground  of  stones  and  taking  them  away  in  barrows  and  in  leveling 
new  ground  after  being  broken  up.  The  heaviest  work  is  that  of  digging  and 
trenching  unbroken  ground,  moving,  rolling,  etc.  Paths  through  the  pine 
woods  have  also  been  constructed.  In  this  particular  work  the  breaking  up  of 
the  ground  with  picks  and  clearing  away  roots  from  neighboring  trees  were 
allotted  to  the  first  division  of  patients.     The  second  division  cleared  away 


198  OUT-DOOR  LABOR  IN  PULMONARY  TUBERCULOSIS. 

the  broken  ground  and  roughly  leveled  it.  The  third  division  finished  the 
leveling  of  the  paths  with  rakes  and  tidied  up  the  edges. 

The  patients  in  the  King's  Sanatorium  have  made  a  cinder  tennis  court; 
tliey  have  cut  down  and  sawed  firewood;  they  have  an  open  air  carpenter  shop 
and  an  instructor  in  carpentry,  who  is  himself  a  patient;  they  care  for  the 
poultry'  and  make  the  runs  for  the  fowls.  In  this  way  six  patients  are  con- 
stantly occupied.  In  the  annual  report  the  amount  of  labor  and  exercise  per- 
formed by  patients  to  the  time  of  their  discharge  is  regularly  recorded. 

It  must  not  be  assumed  that  work  is  to  be  employed  in  every  case  and 
at  all  times.  At  Frimley  the  system  begins  with  almost  more  extreme  rest 
than  in  any  other  sanatorium.  Patients  with  a  temperature  of  even  99°  F., 
by  mouth,  and  headache  are  sent  to  bed  and  are  not  allowed  even  to  wash 
themselves  and  go  to  the  lavatory.  At  all  times  and  especially  when  graduated 
labor  is  employed,  a  careful  watch  is  kept  on  temperature.  The  chief  indica- 
tions of  "autoinoculation"  are,  according  to  Dr.  Paterson: 

1.  Loss  of  appetite  (usually  means  too  hard  work). 

2.  The  patient  appears  to  do  his  work  as  if  it  were  an  effort. 

3.  An  irregular  swinging  temperature  always  below  normal. 

4.  A  temperature  of  99°  in  early  cases  in  men. 

5.  A  temperature  of  99°  and  headache. 

Inmau's  main  points  are : 

1.  During  the  active  (febrile)  stage  of  pulmonary  tuberculosis,  auto- 
inoculations  occur  spontaneously. 

2.  In  a  less  active  stage  of  the  disease  these  autoinoculations  do  not  occur 
spontaneously  whilst  the  patient  is  at  rest,  but  may  be  invoked  by  exercise  or 
movements  sufficient  to  affect  the  focus  of  disease. 

3.  These  autoinoculations,  "spontaneous"  and  "artificially  produced," 
are  evidenced  by  a  variation  in  the  tuberculo-opsonic  index.  This  variation 
does  not  occur  in  non-tuberculous  subjects. 

4.  If  graduated  exercises  or  labors  are  employed  as  methods  of  treatment 
for  pulmonary  tuberculosis  it  is  essential  to  realize  that  "tuberculin  elaborated 
from  the  patient"  is  being  used. 

5.  Ninety-five  per  cent,  of  the  patients  investigated  at  the  Brompton 
Hospital  Sanatorium  had  opsonic  indices  above  the  normal  sometime  during 
the  day.  Tbe  patients,  who  were  all  doing  appropriate  work,  had  normal 
temperatures. 

6.  A  rise  in  temperature  corresponds  with  a  negative  opsonic  phase, 
indicating  an  excessive  autoinoculation,  which  may  be  checked  by  absolute  rest. 

7.  If  the  opsonic  index  shows  no  variation  as  the  result  of  hard  exercise, 
whereas  before  such  a  variation  had  been  obtained,  this  is  presumptive  evidence 
that  the  disease  is  arrested. 

8.  Evidence  is  brought  forward  to  show  that  a  class  of  patients  who  have 
undergone  treatment  for  pulmonary  tuberculosis  may  be  classed  as  "arrest  of 
disease,  with  persistence  of  tubercule  bacilli  in  the  sputum." 


SYPHILIS  IN  NERVOUS  AND  MENTAL  DISEASES.  I99 

Fresh  air,  exercise  and  proper  food  seem  then  to  constitute  the  foundation 
of  successful  treatment  of  tuberculosis.  The  improvement  of  the  general 
condition  of  the  patient  and  life  in  the  open  air  evidently  need  to  be  supple- 
mented by  certam  exercises  so  as  to  produce  a  series  of  autoinoculations  and 
probably  the  best  method  yet  devised  is  by  the  system  of  graduated  labor  just 
described. 

All  sorts  of  exercises,  such  as  horseback  riding,  golfing,  light  dumb-bell 
exercises  and  other  calisthenics  have  been  practiced  for  many  years  in  treating 
tuberculosis ;  walking  exercises  have  been  the  feature  of  the  German  Sanatoria 
referred  to ;  patients  sent  to  the  Western  states  and  territories  almost  invariably 
practiced  outdoor  exercises,  some  with  great  harm  and  some  with  benefit. 
Neither  physician  nor  patient  in  most  instances  regulated  these  exercises 
intelligently,  but  they  were  used  empirically,  never  dreaming  of  the  under- 
lying principles  as  explained  by  the  laboratory  studies  of  Sir  Almroth  Wright, 
Paterson,  Inman  and  others. 

We  trust  that  further  studies  and  the  more  extensive  application  of  the 
same  method  in  Europe  and  America  will  fix  the  value  of  exercise  in 
tuberculosis. 

SYPHILIS  IN  ITS  RELATION  TO  NERVOUS  AND  MENTAL  DISEASES.* 

By  ALFRED  GORDON,  M.D., 

PHILADELPHIA. 

Associate  in  Nervous  and  Mental  Diseases,  Jefferson  Medical  College;    Neurologist  to 

Mount  Sinai,  Northwestern,  General,  and  Douglass  ]\fcmorial  Hospitals. 

Among  all  the  organs  and  tissues  of  the  human  body  the  nervous. system 
constitutes  a  tissue  of  predilection  for  the  syphilitic  poison.  The  importance 
of  the  manifestations  that  syphilis  is  apt  to  produce  in  this  particular  part 
of  the  human  economy  is  such  that  this  question  dominates  largely  the  prog- 
nosis of  syphilis. 

The  ravages  created  in  the  nervous  system  by  this  infectious  and  contagious 
disease  have  become  scientifically  known  only  in  the  middle  of  the  nineteenth 
century.  Before  the  beginning  of  that  era,  authors  rarely  spoke  with  precision 
of  nervous  manifestations  of  syphilis.  In  the  middle  of  the  eighteenth  century 
Astruc  and  Morgagni  treated  for  the  first  time  syphilitic  gummata  in  the 
cranium.  Gradually  anatomical  data  began  to  accumulate.  To  Virchow 
belongs  the  great  merit  of  having  established  in  a  scientific  manner  the  changes 
produced  by  syphilis  in  tissues  in  general  and  in  the  nervous  substance  par- 
ticularly. He  demonstrated  that  the  specific  lesion  has  its  point  of  departure 
m  the  connective  tissue  and  blood-vessels  and  the  nervous  system  suffers 
secondarily.  Since  then  remarkable  works  on  the  subjects  appeared  in  Ger- 
many, France  and  England,  all  corroborating  in  the  main  features,  Virchow's 
researches.     Cerebral  syphilis  was  the  chief  subject  of  those  writers.     S}T)hilis 

♦Read  before  the  County  Medical  Society  as  a  part  of  a  Symposium  on  Syphilis, 
January  27,  1909. 


200  SYPHILIS  IN  NERVOUS  AND  MENTAL  DISEASES. 

of  the  spinal  cord  was  less  known.  A  few  isolated  observations  referred  only 
to  syphilitic  lesions  of  the  vertebrae,  such  as  exostoses,  caries  and  gmnmata; 
the  specific  paraplegias  were  admitted  as  caused  by  those  bony  lesions.  It  is 
only  comparatively  recently  that  specific  lesions  of  the  cord  tissue  itself  have 
been  recognized  as  affections  proper  of  the  cord  independently  of  the  surround- 
ing skeleton.     This  was  accomplished  through  microscopical  studies. 

Nervous  diseases  of  syphilitic  origin  are  quite  frequent.  Nonne  estimates 
their  proportion  1  to  66  to  other  nervous  diseases  and  1  to  257  to  diseases  in 
general.  Localizations  of  sj^jhilitic  lesions  in  the  brain  when  compared  with. 
those  of  the  cord  are,  according  to  Foumier,  6  to  1. 

Syphilis  may  affect  the  nervous  system  at  any  phase  of  its  evolution. 
There  was  a  belief  that  the  specific  nervous  diseases  were  characteristic  ex- 
clusively of  the  tertiary  period,  but  we  know  now  that  nervous  phenomena 
may  also  appear  in  the  secondary  period  of  the  affection :  twelve,  six  and  even 
three  months  after  the  initial  chancre. 

The  effect  of  the  syphilitic  poison  upon  the  nervous  system  according  to 
our  modern  conception  may  be  manifested  speaking  generally  in  two  different 
forms.  In  one  of  them  to  which  tabes  and  paresis  belong,  the  lesions  are  not 
the  direct  and  immediate  result  of  syphilitic  infection,  but  a  late  and  secondary 
development  (degeneration)  against  which  the  antisyphilitic  treatment  is  prac- 
tically powerless.  They  are  the  "parasyphilitie  affections  of  Foumier."  The 
other  form  is  characterized  by  distinctly  specific  lesions  due  to  the  direct  effect 
of  syphilis.  They  are  amenable  to  the  antisyphilitic  treatment,  especially  at 
the  beginning. 

Let  us,  therefore,  consider  separately  cerebrospinal  syphilis  and  the  para- 
syphilitic  affections,  also  syphilis  of  the  peripheral  nervous  system  and  finally 
the  relation  of  syphilis  to  mental  disturbances. 

It  is,  of  course,  self-understood  that  a  detailed  account  of  these  affections 
cannot  be  expected  as  the  subject  is  too  vast  for  a  brief  discourse  of  a 
symposium.     Only  the  most  salient  features  will  be  emphasized. 

Cerebrospinal  Syphilis. — A  simultaneous  involvement  of  the  brain  and 
the  spinal  cord  is  by  far  more  frequent  in  syphilis  of  the  nervous  system  than 
an  isolated  affection  of  each  of  the  two  portions  of  the  central  nervous  system. 
In  the  majority  of  cases  the  cerebral  symptoms  are  more  marked  than  the 
spinal. 

Syphilis  may  affect  the  brain  in  two  ways :  either  by  localized  gummatous 
formations  or  by  diffuse  lesions.  In  the  first  case  the  condition  will  bo  that 
of  a  cerebral  timior.  The  diffuse  form  is  characterized  by  an  obliterative 
inflammation  of  the  walls  of  the  blood-vessels  and  interstitial  infiltration.  In 
diffuse  lesions  the  meninges  are  covered  with  a  thick  gelatinous  exudate  and  as 
the  cortex  is  almost  always  involved  together  with  the  meninges,  the  condition 
is  a  meningo-encephalitis.  Syphilis  has  a  special  predilection  for  the  blood- 
vessels of  the  base  of  the  brain  and  as  the  meninges  are  exteremely  vascular, 
they  are  always  involved.  Naturally  the  cranial  nerves  will  suffer  and  among 
them  the  optic  and  the  oculomotor  nerves  (third  nerve)  are  most  frequently 
affected.     Since  the  lesion  consists  mainly  of  infiltrations  of  the  vessel  walls, 


SYPHILIS  IN  NERVOUS  AND  MENTAL  DISEASES.  201 

thrombosis  or  rupture  of  the  latter  is  the  consequence.  Softening  or  destruc- 
tion of  cerebral  tissue  naturally  follows.  Should  the  damage  occur  in  the 
motor  area,  convulsions  or  symptoms  of  paralysis  will  follow  on  the  opposite 
side.  A  damage  to  the  center  or  centers  for  speech  will  give  place  to  aphasia. 
A  specific  thrombosis  or  a  hemorrhage  at  the  base  of  the  brain  will  give  place 
not  only  to  a  paralysis  on  the  opposite  side  of  the  body,  but  also  to  a  palsy  of 
one  or  more  cranial  nerves  on  the  side  of  the  lesion,  to  a  so-called  "crossed 
paralysis."  When  the  optic  nerve  is  involved,  there  will  be  amblyopia  or 
complete  blindness.  The  clinical  picture  will  therefore  vary  with  the  seat  of 
the  lesion. 

Irrespective  of  the  form  or  of  a  special  localization,  cerebral  syphilis  pre- 
sents a  prodromal  period  and  some  general  symptoms  which  in  addition  to 
focal  sjonptoms  render  the  clinical  picture  somewhat  characteristic. 

Headache  is  the  most  constant  and  the  earliest  phenomenon.  Its  essential 
feature  is  to  present  exacerbations  particularly  at  night  or  towards  evening. 
What  is  also  characteristic  of  the  syphilitic  headache  is  the  fact  that  it  yields 
with  a  remarkable  facility  to  mercurials  and  iodids.  Simultaneously  with  the 
pain  in  the  head  appear  general  apathy  and  indifference.  The  patient  is 
languid,  losses  in  appetite  and  in  weight.  Sometimes  when  the  process  is 
very  acute  as  a  result  of  acute  specific  meningitis  the  patient  after  a  period  of 
intense  headache  becomes  stuporous  and  coma  may  follow.  In  other  cases 
the  condition  may  be  the  reverse ;  delirium,  excitement,  generalized  convulsions 
take  the  place  of  depression. 

When  the  disease  runs  a  chronic  course  (chronic  meningo-encephalitis) 
psychic  disturbances  may  become  conspicuous.  They  consist  of  mental  feeble- 
ness, amnesia,  apathy  and,  in  advanced  cases,  of  dementia.  Delusions  and 
hallucinations  may  also  be  present. 

In  spite  of  this  mental  condition  the  course  of  the  disease  is  not  progress- 
ive, is  of  long  duration,  and  develops  by  successive,  graduated  attacks.  When 
it  reaches  a  certain  degree  of  development,  it  remains  stationary  even  for  years. 
The  sense  of  personality  is  preserved,  the  orientation  in  space  and  time  is 
preserved;  the  old  acquisitions  do  not  disappear,  but  there  is  a  diminution  of 
fixed  attention  and  the  fimctions  of  the  superior  life  are  reduced  to  a  minimum. 
Even  the  dementia,  when  it  makes  its  appearance,  is  fragmentary  and  sta- 
tionary, but  not  global  and  progressive. 

The  physical  symptoms  have  also  their  characteristic  features.  The 
palsies  of  limbs,  disturbances  of  speech,  palsies  of  various  cranial  nerves 
mentioned  above  are  all  usually  brief  in  duration,  fugacious,  transitory  and 
disappear  or  improve  promptly  when  under  the  influence  of  the  specific  treat- 
ment, but  they  reappear  just  as  promptly.  On  the  other  hand  because  of 
repetition  of  attacks  the  damage  done  to  the  cerebral  tissue  or  to  the  cranial 
nerves  may  be  so  intense  that  the  lesion  remains  permanently.  Therapeutic 
intervention  imdoubtedly  modifies  considerably  the  course  of  the  disease,  but 
it  is  powerless  in  hemorrhages  and  softening  in  the  cerebral  tissue.  The 
prognosis  may  be  good  when  the  disease  is  treated  early,  but  is  grave  in 
advanced  cases. 


202  SYPHILIS  IN  NERVOUS  AND  MENTAL  DISEASES. 

The  diagnosis  of  cerebral  syphilis  will  therefore  be  based  upon  the  follow- 
ing data: 

1.  Sudden  onset  of  cerebral  symptoms  in  an  individual  in  the  midst  of 
apparently  good  health. 

2.  Headache  of  a  special  form  (nocturnal  headache). 

3.  Palsies  of  cranial  nerves. 

4.  Hemiplegia,  monoplegia,  focal  or  generalized  epilepsy. 

5.  The  course  of  the  disease:  disappearance  and  reappearance  of  symp- 
toms, their  brief  duration;   multiplicity  of  symptoms. 

6.  Disappearance  or  prompt  amelioration  of  symptoms  under  the 
influence  of  mercury  and  iodids. 

7.  The  exclusive  presence  of  lymphocytes  in  the  cerebrospinal  fluid. 
Closely  related  to  syphilis  of  the  brain  from  several  standpoints  is  paresis 

or  general  paralysis  of  the  insane.  The  confusion  between  these  two  grave 
affections  dates  from  a  very  long  time  and  the  reason  of  it  lies  partly  in  the 
fact  that  syphilis  had  been  traced  in  the  anamnesis  of  paretic  individuals. 
Without  entering  inti)  the  very  interesting  historical  review  of  the  subject  I 
will  say  that  according  to  the  statistics  of  Foumier  and  Erb  91  per  cent, 
paretics  have  a  syphilitic  history  and  Bailly  counts  even  100  per  cent. 

Pathologically  similar  if  not  identical  lesions  are  observed  in  cerebral 
syphilis  and  paresis.  Here  and  there  one  sees  chronic  leptomeningitis,  adher- 
ences  of  the  piamater  and  infiltration  of  the  vascular  walls. 

Clinically  also  there  are  cases  in  which  the  general  and  focal  s}Tnptoms 
may,  with  equal  right,  be  referred  to  either  affection.  For  this  reason  cerebral 
syphilis  had  been  considered  by  some  as  an  aberrant  form  of  paresis.  These 
cases,  of  course,  are  not  frequent,  but  in  typical  forms  a  confusion  of  the  two 
maladies  is  not  easy. 

A  brief  review  of  the  chief  characteristic  symptoms  of  this  remarkable 
disease  is  now  necessary. 

After  a  more  or  less  prolonged  period  of  symptoms  resembling  neuras- 
thenia gradual  changes  take  place  in  the  physical  and  intellectual  spheres. 
Occasional  epileptic  seizures,  palsies  of  ocular  muscles,  changes  in  the  reflexes, 
irritability,  depression  or  else  excitability,  impaimient  of  memory,  of  moral 
sense,  of  obligations — these  are  the  phenomena  that  characterize  the  initial 
period  of  paresis. 

In  the  stage  of  full  development  the  above  symptoms  become  accentuated 
and  important  physical  s}Tnptoms  are  added,  viz.,  tremor  of  tongue,  lips  and 
hands;  tremulous  or  spasmodic  speech  and  disturbance  of  writing;  visual 
disorders,  such  as  Argjdl-Eobertson  pupil,  paradoxical  pupil,  optic  atrophy; 
apoplectiform  seizures;  ataxic  gait,  Eomberg's  sign;  trophic  and  vasomotor 
disturbances;  involvement  of  sphincters.  Psychically  the  paretic  shows  gross 
alterations  in  this  period.  Tlie  loss  of  memory  is  very  marked.  Dementia 
progressively  increases.  Delusions  may  be  depressive  or  expansive.  Hallucina- 
tions are  not  infrequent.     Various  morbid  impulses  are  not  rare. 

In  the  last,  terminal  period,  the  above  symptom.s  reach  the  height  of 
their  development,  apoplectiform  and  epileptiform  attacks  are  frequent,  the 


SYPHILIS  IN  NERVOUS  AND  MENTAL  DISEASES.  203 

dementia  is  extreme.  Death  occurs  either  in  the  seizures  or  from  some  inter- 
current disease. 

Despite  the  apparently  clear-cut  picture  of  paresis  just  described  and  that 
of  cerebrospinal  syphilis  described  above,  an  embarrassment  is  sometimes  ex- 
perienced especially  from  the  point  of  view  of  the  mental  symptoms.  In  such 
cases  repeated  examinations  and  prolonged  observations  are  necessary.  For- 
tunately in  the  majority  of  cases  there  are  no  special  difficulties.  It  should  be 
borne  in  mind  that  a  proper  discrimination  between  these  two  affections  is 
essential,  as  the  prognosis  is  quite  different  in  either  case.  We  have  seen 
already  that  multiplicity  of  physical  signs,  showing  various  and  simultaneous 
localizations  in  the  nervous  system;  rapidity  of  development  of  symptoms  and 
their  sudden  disappearance  and  reappearance,  slightness  of  speech  disturbance; 
early  onset  of  optic  neuritis,  absence  of  distinct  delusions,  but  presence  of 
profound  stupor,  persistent  dilfuse  headache,  mostly  nocturnal;  bladder  dis- 
turbances, disappearing  and  reappearing;  all  these  symptoms  are  in  favor  of 
cerebrospinal  syphilis. 

Finally  it  should  not  be  forgotten  that  in  paresis  a  syphilitic  infection 
antedates  many  years  prior  to  the  onset  of  its  symptoms  and  the  degenerative 
state  of  the  brain  tissue  is  a  late  development  and  not  in  direct  relationship 
with  the  sypliilitic  poison,  whatever  it  may  be.  We  deal  here  with  a  para- 
sypliilitic  affection.  In  some  cases  of  paresis  a  history  of  hereditary,  not 
acquired,  syphilis  can  be  elicited.  In  syphilis  of  the  brain  there  is  a  history  of 
a  comparatively  recent  infection  and  gummatous  deposits  or  infiltrations  are  in 
direct  relationship  with  the  syphilitic  poison.  It  is,  therefore,  a  specific 
disease  of  the  nervous  tissue. 

These  few  considerations  lead  to  a  logical  therapeutic  conduct  \i:hen  con- 
fronted with  cases  of  this  order.  It  stands  to  reason  that  in  paresis  the 
antisyphilitic  treatment  is  practically  inefficacious,  while  in  cerebral  syphilis 
it  gives  prompt  results  and  when  properly  managed  delays  the  recurrence  of 
the  symptoms. 

Syphilis  and  the  Spinal  Cord. — Similarly  to  the  brain  we  find  here 
affections  in  which  the  lesions  are  distinctly  specific  and  those  that  develop 
many  years  after  the  initial  infection.  To  the  latter  belongs  tabes.  Again 
according  to  the  statistics  of  the  most  authoritative  observers  in  95  per  cent, 
of  tabetics  a  history  of  an  old  chancre  can  be  traced,  or  else  a  hereditary 
syphilitic  infection  is  present.  Some  competent  writers  even  say:  "No 
syphilis,  no  tabes."  The  lesion  in  tabes  is  old,  chronic  and  progressive;  it 
is  always  limited  chiefly  to  the  posterior  roots  and  columns ;  it  is  a  degenerative 
condition  followed  by  a  sclerosis  of  the  sensory  neurones.  Clinically  it  is 
manifested  chiefly  by  shooting  pains  in  the  limbs,  incoordination  in  station 
and  gait,  loss  of  tendon  reflexes,  pupillary  changes  and  optic  neuritis  or  atrophy, 
finally  by  an  involvement  of  the  sphincters. 

When  we  turn  our  attention  to  distinctly  specific  lesions  of  the  cord,  we 
find  a  condition  analogous  to  that  of  the  brain.  Besides  solitary  gummatous 
formations  there  is  also  a  diffuse  condition.  The  meninges  as  well  as  the  tissue 
of  the  cord  are  involved.     It  is  usually  a  mcningomyelitis.     The  small  blood- 


204  SYPHILIS  IN  NERVOUS  AND  MENTAL  DISEASES. 

vessels  of  the  piaiuater  are  the  point  of  origm  for  syphilitic  infiltratioD.  The 
maximiun  of  cell  in  filtration  is  in  the  gray  matter  of  the  cord.  All  the  vessels, 
ai-teries  aud  veins  ia  the  cord  are  similarly  affected.  Narrowness  of  their 
lumen  naturally  follows,  hence  poverty  of  blood-supply  and  softening  of  nerve- 
tissue.  Ascending  and  descending  degeneration  is  the  consequence.  The 
membranes  surrounding  the  cord  become  thickened  and  adhere  to  each  other. 

The  symptomatology  of  this  morbid  condition  is  evident.  The  meninges 
being  thickened  compress  the  roots.  Pain  along  the  spine  radiatiug  to  the 
limbs  is  the  first  symptom.  It  is  usually  aggravated  at  night.  It  is  also 
accompanied  by  numbness,  tingling  in  the  limbs.  As  soon  as  the  cord  becomes 
involved,  paralysis,  at  first  flaccid  and  later  spastic  develops. 

Sensory  disturbances  and  sphiacter  disturbances  appear  early. 

Spinal  syphilis  may  assume  the  form  of  almost  any  of  the  cord  diseases. 
All  depends  upon  the  predominant  localization  of  the  specific  lesion.  Thus 
when  the  posterior  colunms  are  involved  it  may  resemble  tabes,  in  lesions  of 
the  posterolateral  columns — ataxic  paraplegia,  in  lesions  of  cells  of  the  anterior 
cornua — anterior  poliomyelitis;  in  lesions  of  the  gray  as  well  as  white  matter 
— transverse  myelitis.  Syphilis  may  also  play  an  etiological  role  in  multiple 
sclerosis,  as  some  observations  seem  to  demonstrate  it.^  But  what  character- 
izes especially  syphilitic  meningomyelitis  is  the  multiplicity  of  symptoms,  their 
imequal  distribution  on  both  sides  of  the  body,  their  variability  and  instability, 
their  disappearance  and  reappearance,  finally  their  modification  when  the  patient 
is  under  treatment. 

The  remarks  made  above  as  to  the  difference  in  the  nature,  diagnosis  and 
prognosis  of  paresis  and  cerebrospinal  syphilis  are  with  equal  propriety 
applicable  in  the  discussion  of  the  nature,  diagnosis  and  prognosis  of  tabes 
and  spinal  syphilis. 

Tabes  is  a  parasyphilitic  affection,  progressive  in  nature,  characterized  by 
a  lesion  strictly  confined  to  the  posterior  columns,  which  cannot  be  modified 
by  antisyphilitic  medications,  presenting  consequently  a  grave  prognosis. 
Spinal  syphilis  is  due  directly  to  a  specific  invasion  of  the  meninges  or  more 
frequently  of  both  meninges  and  cord,  runs  an  irregular  course,  is  easily 
modified  by  treatment  and  sometimes  (though  rarely)  recoverable. 

Syphilis  and  Peripheral  Nerves. — In  speaking  of  spinal  syphilis  mention 
was  made  of  a  compression  of  the  roots  by  thickened  meninges  through  which 
they  pass.  The  nerve  trunks  in  their  course  between  the  roots  and  their 
tenninations  may  encounter  syphilitic  gummata  in  the  tissues  and  undergo 
compression.  But  the  peripheral  nerves  may  be  primarily  affected  by  the 
specific  poison  present,  resulting  in  a  syphilitic  endo-  and  perineuritis  with 
obliteration  of  the  blood-vessels  and  subsequent  degeneration  of  the  nerve  fibers. 

The  clinical  manifestations  of  s}^hilis  of  the  peripheral  nervous  system 
are:  Neuralgias,  neuritis,  multiple  neuritis  and  root  neuritis.  Sypliilitic 
neuralgias  similarly  to  cerebrospinal  syphilis  occur  in  the  early  stages  of  the 
disease.     Among  aU  the  cranial  nerves  the  trigeminus  is  particularly  a  frequent 


iNouv.  Icongr.  dc  Ja  Salpf't.,  190C;    Revue  MM.  de  I'Est,  1907. 


SYPHILIS  IN  NERVOUS  AND  MENTAL  DISEASES.  205 

seat.  Of  the  cervical  plexus  the  occipitalis  major  and  minor  nerves  are  quite 
often  affected.  The  nerves  of  the  upper  extremities  present  rarely  pure  neural- 
gias, but  the  intercostal  nerves  are  not  rarely  affected.  Among  the  nerves  of 
the  lumbar  and  sacral  plexus  the  sciatic  nerve  is  the  most  frequently  involved. 

Clinically  these  neuralgias  present  the  same  symptomatology  as  neuralgias 
of  any  origin.  In  neuritis  and  polyneuritis  we  ffnd  the  usual  sensory  and 
motor  s}Tnptoms,  viz.,  hj'perasthesia  and  impairment  or  complete  loss  of  power 
of  the  affected  limbs  and  changes  of  reflexes. 

Speaking  generally  sj^hilis  rarely  affects  one  nerve  distribution.  There 
are  certain  nerves  more  easily  affected  than  others.  Some  nerves  are  very 
rarely  involved.  Thus,  for  example,  in  the  seventh  nerve,  palsy  is  not  a  frequent 
occurrence.  The  writer  has  observed  six  cases  of  tj^^ical  Bell's  palsy  distinctly 
of  s}'philitic  nature  which  all  recovered  from  exclusive  use  of  mercurials  and 
iodids.2 

The  clinical  recognition  of  sj^Dhilitic  neuritis  or  neuralgia  is  undoubtedly 
difficult,  but  when  other  remedies  fail  after  a  sufficiently  reasonable  time  to 
remove  the  condition,  and  an  antisyphilitic  treatment  promptly  yields  good 
results,  great  presumption  is  in  favor  of  the  specific  nature  of  the  disturbance, 
especially  when  a  history  of  a  comparatively  recent  infection  is  related  and 
when  aggravation  of  pain  occurs  mostly  towards  evening.  The  practicaJ 
bearing  of  these  remarks  is  too  obvious  to  dwell  upon. 

Sypliilis  and  Mental  Diseases. — Many  disturbances  may  be  encountered 
in  the  secondary  and  tertiary  periods.  Those  of  the  secondary  period  are 
genuine  psychoses  of  toxi-infeetious  nature  in  this  sense  that  they  are  due 
directly  to  the  action  of  the  specific  poison  and  not  to  cerebral  lesions  caused 
by  syphilis.  They  have  not  been  the  subject  of  a  systematic  study  and  for  this 
reason  are  not  well  known.  They  usually  appear  at  a  time  when  the  eruption  or 
any  other  acute  symptoms  such  as  mucous  patches,  adenopathies,  etc.,  develop. 
Similarly  to  mental  symptoms  ocurring  in  cases  of  other  toxic  conditions,  the 
onset  is  sudden.  Headache  with  insomnia  appears  first.  Hebetude,  stupor, 
somnolence,  mental  obtusion,  lack  of  orientation,  sometimes  delirium  and 
hallucinations  with  delusions  of  persecution,  of  poisoning,  of  assault  appear 
next.  OtheiTv-ise  speaking  we  have  here  all  the  phenomena  of  confusional 
insanity.  It  must,  however,  be  emphasized  that  the  confusional,  stuporous  or 
delirious  states  of  secondary  syphilis  present  no  special  features  distinguishable 
from  those  encountered  in  similar  states  caused  by  intoxications  or  infections 
of  any  other  origin,  except  with  regard  to  the  effect  of  the  specific  treatment. 
The  psychoses  are  always  ameliorated  and  very  often  cured  even  in  a  short 
time.  The  acute  forms  with  hallucinations  and  delirium  are  particularly 
amenable  to  the  specific  treatment.  It  is,  therefore,  evident  that  the  psychoses 
of  secondary  syphilis  are  caused  directly  by  the  poison  of  the  sj'philitic  infection. 

The  ps3'choses  of  the  tertiar\'  period  have  attracted  greater  attention  than 
the  preceding  ones.  They  differ  from  the  latter  in  this  respect  that  they  occur 
long  after  the  initial  infection  and  do  not  coincide  with  eruptions  or  other 


2  The  Archives  of  Diagnosis,  October,  1908. 


206  SYPHILIS  IN  NERVOUS  AND  MENTAL  DISEASES. 

secondary  manifestations.  They  are  due  to  meningo-enceplialitis,  obliterative 
endarteritis,  and  accompany  usually  motor  s}Tnptoms,  such  as  epileptic  or 
apoplectic  attacks,  palsies  of  cranial  nerves,  etc.  They  are  the  manifestations 
of  cerebral  syphilis.  We  have  already  discussed  the  mental  phenomena  of  the 
latter  with  its  gradually  oncoming  dementia,  We  have  also  considered  its 
characteristic  features,  viz.,  the  exacerbations  and  amelioration  and  possibly 
complete  recovery  when  energetic  treatment  is  established.  We  have  finally 
considered  its  relation  to  paresis  and  emphasized  their  differential  diagnostic 
signs. 

We  cannot  dismiss  the  subject  without  devoting  a  few  lines  to  the  relation 
of  hereditary  syphilis  to  mentality.  Since  attention  was  called  to  this  possi- 
bility, observers  began  to  recognize  that  certain  organic  nervous  diseases, 
especially  in  childhood  and  adolescence,  are  very  probably  the  result  of 
hereditary  syphilis.  It  is  admitted,  for  example,  that  juvenile  paresis  is  due  to 
hereditary  syphilis.  But  apart  from  organic  nervous  diseases,  parental  syphilis 
can  be  considered  also  as  the  cause  of  various  mental  abnormalities,  such  as 
imbecility,  idiocy,  of  various  psychoses  of  the  young,  of  psychasthenias.  Such 
individuals  not  infrequently  presented  in  childhood  or  at  puberty  some  external 
manifestations  of  syphilis,  such  as  pupillary  troubles,  iritis,  etc.  Briefly 
speaking,  hereditary  S3'philis  is  to  be  considered  as  an  etiological  factor  in 
psychopathies. 

Conclusion. — In  my  endeavor  to  present  the  subject  of  syphilis  in  its 
relation  to  the  nervous  system,  I  have  unfortunately  only  approached  it  by 
reason  of  the  limited  time  at  my  disposal.  A  thorough  description  of  its 
various  phases  requires  by  far  more  considerable  time  than  that  allotted  for  a 
discourse  as  a  part  of  a  symposium.  I  have,  however,  I  believe,  sufficiently 
emphasized  its  main  features  in  order  to  impress  upon  j'our  minds  the  import- 
ance of  the  recognition  of  the  fact  that  syphilis  is  a  veritable  poison  to  the 
nervous  system.  We  may  say  without  the  least  hesitation  that  of  all  the  organs 
and  tissues,  the  nervous  system  is  the  greatest  sufferer  in  syphilitic  individuals. 
Who  doubts  this  statement  should  take  a  glance  at  the  statistical  studies  of 
one  of  the  greatest  syphilographers.  Foumier  collected  3,429  cases  of  tertiary 
syphilis.^  Among  them  he  found  1,085  cases  in  which  the  nervous  system  was 
affected,  while  only  in  787  cases  cutaneous  manifestations  were  present. 

An  individual  who  once  contracted  syphilis,  is  always  predisposed  to  its 
assaults  upon  his  nervous  system.  But  there  are  individuals  who  escape  this 
calamity.  The  specific  poison  makes  a  special  selection  among  all  varieties  of 
nervous  constitutions,  particularly  those  who  by  reason  of  special  hereditary 
or  acquired  influences,  neuropathic  so  to  speak,  are  attacked  by  syphilis. 
When  confronted  with  such  cases,  our  therapeutic  effort  must  be  directed  not 
only  to  the  advice  as  to  mercurials  and  iodids,  but  also  and  especially,  I  may 
sa}'',  to  a  special  mode  of  living  surrounded  by  all  precautions  in  regard  to 
excesses  of  all  sort,  to  the  use  of  alcohol,  to  the  proper  hygiene  and  proper 
diet.     In  fact  no  patient  whose  nervous  system  I  am  called  upon  to  treat  for  a 


3  Congrds  Internat.  de  dermatol.  et  de  Syphiligr.,  1889,  p.  302. 


TUBERCULOSIS  OF  OVARY  TREATED  WITH  TUBERCULIN.     207 

syphilitic  invasion,  leaves  me  without  getting  the  most  emphatic  advice  as  to 
the  general  measures.  And  this  advice  must  hold  good  for  years  and  never 
cease.  It  is  preventive  medicine  that  we  must  practice,  as  this  is  the  most 
rational  and  the  most  effective  method.  What  are  in  reality  the  results  of  the 
two  most  energetic  remedies  we  have  at  our  command  ?  In  cerebral  syphilis  we 
may  have,  it  is  true,  marvelous  results,  but  also  failures.  In  syphilis  of  the  cord 
the  proportion  of  failures  is  greater  than  that  of  successes.  In  tabes  some  favor- 
able results  are  obtained  when  the  disease  is  attacked  at  its  earliest  moment; 
otherwise  there  is  absolute  failure  as  far  as  the  degeneration  of  the  nervous  sub- 
stance is  concerned.     The  same  remarks  are  applicable  to  paresis. 

It  is,  therefore,  evident  that  too  much  reliance  cannot  and  should  not  be 
placed  on  the  two  great  remedies  which,  however,  have  no  equal  in  therapeutics. 
They  are  admirable  remedies,  but  are  far  from  being  infallible  in  syphilitic 
nervous  diseases.  On  the  other  hand  when,  in  addition  to  mercury  and  iodids, 
we  submit  our  patients  to  a  most  rigorous  hygienic  mode  of  living  we  can 
expect  very  satisfactory  results.  We  also  know,  that  when  a  paretic,  a  tabetic 
or  an  individual  suffering  from  cerebrospinal  syphilis  comes  under  our  care  in 
the  earliest  stages,  our  efforts  are  the  most  satisfactory.  The  recent  discovery 
of  the  spirochaitoe,  let  us  hope,  will  perhaps  place  in  our  possession  a  specific 
serum  for  combating  one  of  the  most  dreadful  of  all  our  poisons;  dreadful 
because  it  produces  ravages  in  the  most  important  of  all  the  tissues  of  the 
organism  and  threatens  the  community  with  a  population  of  imbeciles,  idiots, 
epileptics,  tabetics  and  paretics.  The  subject  is,  therefore,  reduced  to  the 
prevention  of  the  initial  infection,  but  this  question  is  out  of  my  scope;  its 
solution  requires  the  combined  effort  of  physician,  civic  worker  and  legislator. 


REPORT  OF  CASE  OF  TUBERCULOSIS  OF  THE  OVARY  TREATED 
WITH  TUBERCULIN. 

By  C.  C.  BROAVNING,  M.D., 

MONROVIA,   CAL. 

Medical  Director  Pottenger  Sanatorium. 

Patient,  age  24,  married,  weight  100^  pounds,  applied  for  treatment  on 
August  30,  1905,  with  the  following  history : 

Several  years  ago  had  a  cough  which  lasted  for  several  months  after  which 
it  ceased.  Two  years  previous  to  application  for  treatment  she  had  left  ovary 
removed,  which  was  found  to  be  tubercular.  At  the  same  time  the  right  ovary 
showed  signs  of  tubercular  condition,  but  on  accoimt  of  the  promise  made  by  the 
surgeon  to  remove  only  one  ovai}'-,  this  was  not  removed  at  the  time. 

For  the  past  six  months  the  condition  of  the  ovary  had  grown  rapidly 
worse  and  preparations  had  been  made  for  its  removal.  She  suddenly  decided 
she  would  not  have  it  removed,  and  applied  for  treatment. 

On  examination  I  found  in  the  region  of  the  right  ovary  a  nodular  mass 
apparently  about  two  inches  in  diameter.     The  tissues  were  densely  infiltrated. 


208     TUBERCULOSIS  OF  OVARY  TREATED  WITH  TUBERCULIN. 

the  infiltration  apparently  extending  along  the  tube.  The  mass  was  very  tender 
on  pressure  and  she  complained  of  a  constant  dragging  feeling  and,  at  times, 
excruciating  pain  in  this  region.  Preceding  her  menstrual  flow  the  pain  was 
very  severe,  being  worse  each  alternate  month  for  the  past  six  months.  The 
pain  abated  somewhat  after  the  menstrual  flow  was  established,  but  the  soreness 
continued  excessive  for  several  days  following. 

Examination  of  the  chest  revealed  evidence  of  tubercular  infection  at  the 
apices  of  the  lungs,  being  most  intense  in  the  right,  which  was  active  at  this 
time.  The  chest  had  been  examined  by  Dr.  Pottenger,  March  2,  1905,  and 
similar  conditions  found  but  less  active.  Her  temperature  ranged  from  97.8  in 
the  morning  to  99.6  in  the  afternoon.     The  pulse  from  86  to  100. 

I  advised  her  to  return  to  her  surgeon  and  have  the  operation  as  first 
contemplated.  This  she  positively  declined  to  do  at  this  time,  and  she  was 
admitted  to  the  sanatorium  for  treatment. 

On  account  of  pain  she  had  moved  about  but  little  for  several  weeks.  After 
admission  she  was  kept  very  quiet  for  several  weeks,  but  was  confined  constantly 
to  her  bed  only  during  the  times  of  exacerbation  of  pain. 

She  was  given  %oo  of  a  ^g-  of  the  solid  substance  of  watery  extract  of 
tubercle  bacilli  (Yon  Ruck)  as  an  initial  dose,  which  was  gradually  increased. 
Her  temperature  gradually  declined  until  the  range  was  from  98.2  to  99  in 
about  three  weeks;  during  this  time  menstruation  had  occurred,  and  during 
the  premenstnial  period  there  had  been  slight  exacerbation  of  temperature  with 
symptoms  of  pain,  swelling  and  tenderness  greatly  aggravated. 

The  administration  of  the  watery  extract  was  continued  with  gradually 
increasing  doses.  If  increased  too  rapidly  discomfort,  together  with  some 
stimulation  of  the  mass  as  indicated  by  slight  swelling  and  increased  tenderness 
would  occur,  with  a  slight  rise  of  temperature,  giving  evidence  of  a  slight 
tuberculin  reaction.  This  occurred  several  times  during  treatment,  the  first 
time  October  6th,  thirty-six  days  after  beginning  treatment,  following  a  dose 
1.7  mg.  of  the  solid  substance  of  the  watery  extract.  This  was  accompanied 
by  slight  local  reaction  in  the  foci  in  the  lungs.  This  was  sufficient  to  remove 
any  doubt  which  might  have  existed,  as  regards  the  nature  of  the  infection. 
The  tumor  gradually  decreased  in  size,  tenderness  gradually  disappeared,  the 
discom.fort  at  the  menstrual  time  became  less,  until  finally  the  subjective  s}Tnp- 
toms  disappeared  and  there  remained  a  firm  mass  about  one-quarter  the  size 
of  the  original  tumor  when  she  presented  herself  for  treatment.  Temperature 
range  was  98.4  to  98.8.  Weight  119^X,,  a  gain  of  19^  pounds.  The  tuber- 
cular condition  of  the  lungs  was  apparently  healed. 

The  maximum  dose  of  the  watery  extract  was  given  on  September  5,  1906, 
twelve  months  after  the  beginning  of  treatment,  and  was  1500  mg.  of  the  one- 
per-cent.  solution  of  watery  extract  of  tubercle  bacilli,  or  15  mg.  of  the  solid 
extract.  On  December  8th,  gave  10  mg.  of  Koch's  tuberculin  without  reaction, 
also  gave  several  doses,  finally  reaching  500  mg.  of  onc-per-cent.  solution  of 
watery  extract  of  tubercle  bacilli,  March,  1907,  without  reaction. 

Since  treatment  was  discontinued  I  have  had  opportunity  to  observe  the 
case,  and  exnmination  within  the  last  week  showed  the  cicatricial  tissue  and 


TUBERCULOSIS  OF  OVARY  TREATED  WITH  TUBERCULIN.     209 

the  mass  smaller  than  at  the  time  of  discharge.  She  is  entirely  free  from  pain 
preceding  her  menstrual  period,  and  is  apparently  in  good  health. 

My  especial  object  in  reporting  this  case  is  to  urge  for  consideration  the 
relation  which  I  believe  to  properly  exist  between  the  constitutional  and 
surgical  treatment  of  this  class  of  cases,  as  well  as  the  ordinarily  recognized 
"surgical  cases"  of  tuberculosis  in  general.  I  do  not  wisli  to  be  understood 
that  the  culture  products  will  always  act  as  well  as  is  apparent  in  this  case, 
but  I  think  it  possible  that  if  taken  early,  many  cases  which  otherwise  would  go 
on  to  require  operation  might  be  cured  without  operation.  And  I  further 
believe  the  use  of  these  remedies  before  and  following  operative  procedure  will 
be  of  valuable  assistance  to  the  surgeon, 

I  desire  also  to  call  attention  once  more  to  the  value  of  tuberculin  as  a 
diagnostic  agent  in  doubtful  cases.  In  this  connection  I  desire  to  state  that  I 
believe,  from  recent  investigations  by  Spengler  and  others,  that  many  surgical 
cases  are  due  to  bovine  infection  and  for  the  same  reason,  and  my  own  ex- 
perience with  bovine  tuberculin,  that  tests  should  be  made  with  bovine  tuber- 
culin, if  there  is  no  reaction  with  Koch's  tuberculin. 

Principally  against  the  use  of  tuberculin  after  its  introduction  as  a  diag- 
nostic agent  was  Virchow  and  some  of  his  students.  Their  findings  were  made 
on  a  comparatively  few  patients  and  following  repeated  injections  of  large  doses. 
This  opposition  has  continued  to  manifest  itself.  As  against  these,  and  that 
others  recognize  the  value  of  tuberculin  as  a  diagnostic  and  remedial  agent  in 
surgical  cases,  I  invite  attention  to  the  following : 

1.  "Bimbaura  found  tuberculin  of  the  greatest  assistance  in  17  cases, 
both  for  differentiation  and  treatment.  One  of  his  patients  was  apparently  in 
perfect  health  nine  years  after  operative  cure  of  a  peritoneal  and  genital  tuber- 
culous affection.  She  returned  to  ask  if  she  could  marry;  the  pronounced 
reaction  to  the  tuberculin  test  decided  the  question.  In  another  case  nodules  in 
the  breast  of  a  pregnant  woman  suggested  a  tuberculous  affection,  but  the 
tuberculin  test  was  negative.  Later  surgical  treatment  showed  the  nodules  to 
be  enchondroraas.  The  foetus  did  not  seem  to  be  affected  by  the  tuberculin  in 
any  of  the  cases  in  which  it  was  given.  Bimbaum  expresses  regret  that  g}Tie- 
cologists  pay  so  little  heed  to  tuberculin."^ 

2.  "Baer  and  Kennard  detail  the  results  they  have  obtained  from  the  use 
of  tuberculin  in  orthopedic  surgery.  Forty  private  patients  were  injected. 
The  cases  were  selected  almost  invariably  in  order  to  clear  up  the  diagnosis. 
Twenty-five  gave  a  positive  and  15  a  negative  reaction.  Of  the  former,  6  were 
subsequently  operated  on  and  all  proved  to  be  tuberculous.  In  18  of  the  remain- 
ing 19  cases  the  diagnosis  was  verified  by  the  subsequent  history  and  the 
response  to  treatment.  The  remaining  case  is  a  recent  one  and  therefore  not 
available.  Of  the  15  patients  who  did  not  react,  one  was  operated  on  and  no 
evidence  of  tuberculosis  was  found;  of  the  other  14,  8  have  recovered  under 
non-tuberculous  treatment;  the  remaining  6  are  improved  and  all  suspicion 
of  tuberculosis  has  been  removed.  Txadiographs  were  taken  of  15  of  the  25 
cases  which  reacted  to  tuberculin.  Six  showed  a  focus,  in  5  the  disease  was 
suspected  only,  and  4  showed  no  lesion.     The  authors  considered  tuberculin  the 

4 


210      TUBERCULOSIS  OF  OVARY  TREATED  WITH  TUBERCULIN. 

best  and  most  reliable  diagnostic  agent  for  incij^ient  tuberculosis  of  bones  and 
joints.  Its  proper  administration  is  attended  by  no  permanent  harmful 
effects."2 

Tinker  reports  four  hundred  cases,^  confirming  the  above  results. 

3.  Dr.  Jewett  V.  Eeed  states:  "The  result  of  our  examination  of  9G5 
inmates  showed  34  to  be  in  an  advanced  stage  of  tubercular  disease,  and  102 
who  gave  a  definite  tuberculin  reaction,  making  a  total  of  126,  or  nearly  13  per 
cent."  ....  "A  year  has  now  passed  since  the  above  work  was  done, 
and  while  we  do  not  possess  accurate  statistics  as  to  the  number  of  inmates 
afflicted  with  tuberculosis  at  present  in  the  institution,  many  facts  go  to  show 
that  there  has  been  a  decrease  in  the  disease.  During  the  year  ending  August 
1,  1904,  there  have  been  ten  deaths  from  tuberculosis,  which  contrast  favorably 
with  the  eighteen  deaths  that  occurred  the  previous  year.  After  making  our 
tuberculin  tests  we  found  that  the  great  majority  of  men  who  gave  a  reaction 
were  those  who  Avere  constantly  coming  to  morning  sick-call.  During  the  past 
year  the  total  number  of  inmates  attending  sick-call  has  been  40  per  cent,  less 
than  the  year  before. 

These  few  facts  are  enough  to  convince  us  that  we  are  working  in  the  right 
direction  toward  the  management  of  prison  tuberculosis,  and  we  feel  that  the 
results  thus  far  obtained  fully  repay  us  for  our  work.'* 

4.  "S.  Kemp^  writes  of  a  case  of  tuberculosis  of  adnexa  diagnosed  with 
tuberculin.  The  patient  was  a  housemaid,  aged  24,  scrofulous  as  a  child,  and 
otherwise  healthy  until  abdominal  and  slight  pulmonary  symptoms  developed, 
varying  in  intensity  during  three  years,  with  their  reappearance  later.  Pains 
in  the  iliac  region,  especially  on  the  left  side,  were  frequent,  and  the  girl  became 
much  emaciated.  The  tuberculin  was  jiositive  and  tuberculous  lesions  were 
found  in  the  tubes  and  one  ovary,  which  were  removed,  leaving  the  other  ovary. 
The  patient  rapidly  recovered  and  no  further  symptoms  have  been  observed 
either  from  the  lungs  or  the  abdomen.  The  case  was  rendered  especially 
interesting  by  the  lack  of  any  local  reaction  in  the  lungs  after  the  injection 
of  tuberculin.  This  indicated  that  the  lung  process  had  healed,  and  encouraged 
operative  treatment  of  the  gynecologic  tuberculous  process.  With  the  excep- 
tion of  the  tuberculin  reaction,  none  of  the  symptoms  were  pathognomonic  of 
a  tuberculous  affection.  Sarwey  says  that  the  tuberculin  test  has  been  applied 
in  g}Tiecology  only  ten  times  to  date,  according  to  the  literature.  Bossi,  Meyer 
and  Bimbaum  used  it  in  ten  cases,  with  a  positive  response  in  six.  Absolutely 
negative  findings  indicate  the  non-tuberculous  character  of  the  lesions,  or  at 
least  they  do  not  require  active  operative  intervention.  A  positive  response 
without  any  local  reaction  also  speaks  against  a  gynecologic  tuberculous 
afl'ection."^ 

Many  other  references  might  be  cited  but  I  believe  these  to  be  sufficient 
for  the  purposes  for  M'hich  this  paper  was  written. 

REFERENCES. 

1  Tuberculin  Diagnosis  of  Genital  Tuberculosis,  Journal  of  the  American  Medical  Asso- 
ciation, July  21,  1906,  page  240,  paragraph  39. 


ADRENAL  EXTRACT  IN  ADDISON'S  DISEASE.  211 

2  Journal  of  the  American  Medical  Association,  Jan.  28,  1905,  page  326,  paragraph  41. 

3  Johns  Hopkins  Hospital,  Report  of  1905. 

4  Journal  of  the  American  Medical  Association,  Jan.  28,  1905,  page  326,  paragraph  41. 

5  Archiv  f.   klinische   Chirurgie   LXXXI,  Avs.   Practical   Medicine  -Series,  vol.   iv,  page 

88,  1907. 

6  Management  of  Prison  Tuberculosis,  Journal  of  the  American  Medical  Association,  Feb. 

4,  1905,  pages  385-6. 


ADRENAL  EXTRACT  IN  ADDISON'S  DISEASE. 
By  CHARLES  E.  de  M.  SAJOUS,  M.D., 

PHILADELPHIA. 

The  grafting  of  adrenals  into  the  tissues  of  cases  of  Addison's  disease 
to  compensate  for  the  functions  of  these  organs  when  these  are  more  or  less 
inhibited  by  local  disease,  has  led  to  such  unfortunate  results,  so  far,  that 
Courmontji  after  a  personal  experience  in  the  use  of  this  procedure,  declared 
that  it  should  be  considered  as  formally  contraindicated.  Indeed,  Bra,^  after 
grafting  the  suprarenals  of  a  dog  into  the  cellular  tissue  of  the  abdomen  in 
a  child  of  fourteen  years,  witnessed  its  death  in  three  days.  Jaboulay,^  hav- 
ing resorted  to  the  same  method  in  two  cases,  lost  both  within  twenty-four 
hours,  owing,  he  honestly  admits,  to  the  operation.  The  same  result  followed 
in  Courmont's  case.  If  this  question  is  closely  analj^zed,  however,  it  becomes 
apparent  that  it  is  not  the  method  proper,  or  the  operators  that  are  respon- 
sible for  the  untoward  results,  but  rather  the  fact  that  the  functions  of  the 
adrenals  were  stiU  too  obscure,  at  the  time  the  operations  were  performed, 
to  afford  the  indications  necessary  for  a  judicious  adjustment  of  the  quantity 
of  adrenal  tissue  grafted  to  the  needs  of  each  particular  case. 

Again,  E.  W.  Adams^  refers  to  a  group  of  seven  cases,  including  three 
of  those  mentioned  above,  "in  which  alarming  or  fatal  results  were  presum- 
ably or  possibly  due  to  the  treatment."  He  mentions,  for  instance,  two  cases 
reported  by  Affleck^  treated  with  "suprarenal  gland-extract."  The  chart 
notes  include  the  laconic  words:  "Alarming  collapse.  One  of  the  cases 
began  to  improve  markedly  when  the  extract  was  stopped."  In  the  original 
paper  reference  is  made  to  another  case  treated  by  suprarenal  extract  in 
which  "similar  collapse  was  noted."  The  dose  was  not  mentioned.  Such 
eases  are  apt  to  be  regarded  as  examples  of  the  sudden  death  sometimes 
observed  in  Addison's  disease,  to  which  Addison  himself,  Dieulafoy,  Ander- 
son, Bradbury  and  others  have  called  attention;  but  this  explanation  does 
not  hold.  Guiol,^  having  observed  similar  signs  of  intoxication  and  collapse, 
tried  the  "remedy"  in  a  normal  subject  and  obtained  the  same  morbid  phe- 
nomena. Here,  again,  we  are  dealing  with  fatalities  which  occurred  when 
the  physiological  functions  of  the  organs,  and  therefore  their  mode  of  action 
as  a  therapeutic  agent,  were  but  slightly  kno^vn. 

Can  we  say,  however,  that  the  ten  and  more  years  which  have  elapsed 
since  these  cases  were  reported,  have  brought  out  data  which  would  aid  us 


212  ADRENAL  EXTRACT  IN  ADDISON'S  DISEASE. 

to  explain  these  morbid  results?  Judging  from  text-books  of  physiology, 
they  have  not.  Beyond  the  fact,  discovered  fifteen  years  ago  by  Oliver  and 
Schafer,  that  the  adrenal  secretion  influences  powerfully  the  tone  of  the 
heart  and  blood-vessels,  and  Langlois^s  equally  important  demonstration  that 
it  served  to  neutralize  certain  products  of  metabolism,  we  have  Blum's  obser- 
vation that  adrenal  preparations  caused  glycosuria,  and  Josue's  that  they 
could  produce  arterial  sclerosis.  Yet  none  of  these  phenomena  can  be 
regarded  as  a  function;  it  is  not,  for  instance,  the  purpose  of  the  adrenal 
secretion  to  raise  the  blood-pressure,  to  cause  glycosuria  or  arteriosclerosis, 
etc.  Test-books  of  therapeutics,  beyond  rehearsing  these  facts,  serve  only  to 
add  obscurity  to  the  problem  as  a  whole  by  discussing  phenomena  of  intoxica- 
tion— paralysis,  for  instance — which  occur  in  frogs  and  other  animals,  but 
that  have  not  so  far,  been  observed  in  man.  In  a  word,  physiology  and  phar- 
macolog}'  to  this  day  have  failed  to  point  out  the  actual  purpose  of  the 
adrenals  in  the  body  and  to  tell  us  how  grafting  or  toxic  doses  of  adrenal 
preparations  produce  death.  As  will  be  shown  presently,  however,  my  views 
alone,  of  the  contributions  on  the  subject  recorded  during  the  last  ten  years, 
not  only  explain  the  manner  in  which  death  was  caused  by  grafting  and  by 
excessive  doses  of  adrenal  extract,  but  they  afford  the  physician  precise  indi- 
cations for  the  safe  and  rational  use  of  these  remedial  agents. 

Courmont,'''  referring  to  the  three  cases  in  which  dog's  adrenals  were 
grafted  in  cases  of  Addison's  disease,  including  one  of  his  own,  writes:  "In 
the  three  cases  the  result  was  disastrous.  In  my  own  case  the  patient  died 
in  twenty-four  hours  with  a  formMublo  hyperthermia  and  cardiac  collapse" 
while  specifying  that  there  v/as  no  infection  of  the  wound.  Now,  this  phe- 
nomenon, which  has  remained  obscure,  is  readily  accounted  for  by  the  inter- 
pretation of  tlie  role  of  the  adrenals  I  submitted  six  years  ago,^  and  wliich 
many  independent  facts  have  since  sustained,  viz.:  (1)  that  the  function  of 
the  adrenal  secretion  is  to  take  up  the  oxygen  of  the  air  in  the  pulmonary 
alveoli,  and  to  carry  this  gas  to  the  tissues  as  a  constituent  of  oxyha^moglobin, 
and  (2)  that  as  such,  it  is  the  adrenal  secretion  which,  as  far  as  the  role  of 
oxygen  is  concerned,  sustains  oxidation  and  metabolism. 

The  cause  of  the  "formidable  hyperthermia"  mentioned  by  Counnont  is 
thus  rendered  self-evident.  Schafer,^  Judging  from  the  action  of  adrenal 
preparations  on  the  blood-pressure,  states  that  "in  order  to  produce  a  maximal 
ef[ect,  a  dose  of  not  more  than  fourteen  millionths  of  a  gm.  of  the  active 
material  per  kilo  of  body-weight  is  all  that  is  necessary."  Now,  the  average 
adult  weighing  70  kilos,  one  milligram  (%o  grain)  of  the  active  material 
approximately  will  suffice  to  produce  this  maximal  effect.  What  should  we 
expect  from  two  dogs'  adrenals  grafted  into  the  tissues,  which  means  that 
the  active  material  is  being  continuously  absorbed  by  lymphatics  and  veins 
and  carried  to  tlie  lungs,  and  thence,  laden  with  oxygen,  to  all  parts  of  the 
organism?  Most  violent  oxidation,  of  course,  and  "formidable  hyper- 
thermia." 

It  becomes  a  question,  however,  whether  adrenal  preparations  actually 


ADHENAL  EXTRACT  IN  ADDISON'S  DISEASE.  213 

produce  an  increase  of  temperature.  As  I  have  occasion  to  state  elsewhere i*^ 
this  phenomenon  was  noted,  though  unexplained,  by  Oliver  and  Schafer.n 
Eeicherti2  recorded  a  rise  of  1°  F.  in  rabbits,  accompanied  by  increased 
metabolism.  MoreP-^  observed  a  rise  of  0.9°  to  1.8°  F.  in  guinea-pigs. 
Lepine^'*  states  that  the  increase  of  blood-pressure  caused  by  adrenal  extract 
is  always  followed  by  a  rise  of  temperature.  This  is  controlled  by  the 
familiar  fact,  pointed  out  by  Brown-Sequard,  that  removal  of  the  adrenals  is 
followed  by  a  steady  decline  of  temperature,  and  by  the  hypothermia  which 
attends  Addison's  disease. 

The  toxic  phenomena  observed  after  excessive  doses  of  adrenal  prepara- 
tions are  due  to  the  same  morbid  process,  i.e.,  excessive  oxidation,  the  effects 
of  v;hich  can  be  followed  at  every  step.  Tracing  the  course  of  events  from 
start  to  finish  we  have,  at  first,  the  effects  of  exaggerated  tissue  metabolism: 
in  the  tissues,  a  rise  of  temperature;  in  the  cerebro-spinal  system,  excitement; 
in  the  muscles,  tremor;  in  the  kidneys,  polyuria;  in  the  myocardium,  violent 
palpitations;  in  the  muscular  coats  of  vessels,  rise  of  blood-pressure.  As  the 
blood-pressure  increases  passive  pulmonary  congestion  occurs,  causing  dys- 
pnoea, and,  at  times,  puhnonary  oedema.  As  the  vascular  constriction  becomes 
still  greater,  the  pressure  in  the  aorta  becomes  so  marked  that  suhsternal  pain 
is  experienced,  and  the  pulmonary  circulation  being  blocked,  asphyxia  fol- 
lows— the  heart,  in  most  instances  of  poisoning,  continuing  to  beat  a  short 
time  after  respiration  has  ceased.  In  eases  of  Addison's  disease  we  have, 
besides,  the  transition  from  the  hypothermia  peculiar  to  this  affection  to  a 
febrile  state,  the  adrenal  preparation  having  restored  to  the  blood  the  prin- 
ciple which  (because  of  lesions  in  the  adrenals  or  their  extrinsic  nerve  supply) 
was  secreted  in  insufficient  quantity  to  sustain  metabolism,  i.e.,  the  vital 
process.  The  danger  lies,  in  these  cases,  in  exciting  excessive  oxidation  and 
tissue  metabolism,  thus  causing  such  intense  vaso-constriction  that  the  result- 
ing rise  of  blood-pressure  is  sufficient,  as  shown  above,  to  endanger  life  itself. 

What  can  we  expect  from  the  use  of  adrenal  extractives  in  Addison's 
disease  ? 

A  series  of  120  cases  collected  from  literature  within  my  reach,  including 
97  previously  collected  by  E.  W.  Adams,i^  in  all  of  which  adrenal  preparations 
had  been  used  in  some  form,  gave  the  following  results : 

1.  Cases  in  which  death  can  be  ascribed  to  grafting  or  adrenal 

preparations  8 

2.  Cases  in  which  the  benefit  was  slight  or  nil 51 

3.  Cases  in  which  marked  improvement  occurred 36 

4.  Cases  in  v/hich  permanent  benefit  was  obtained 25 


120 


Analysis  of  these  cases  shows  clearly  that,  far  better  results  can  be 
obtained  in  the  future  by  a  careful  adjustment  of  the  dosage  to  the  actual 
needs  of  each  individual  case.  Addison's  disease  being  due,  from  my  view- 
point, to  inadequate  oxygenation  and  metabolic  activity,  the  result  in  turn 


214  ADRENAL  EXTRACT  IN  ADDISON'S  DISEASE. 

of  a  deficient  production  of  the  adrenal  secretion,  it  follows  that  the  tempera- 
ture and  blood- pressure  indicate  the  degree  to  which  the  adrenals  are  still 
performing  their  functions.  It  is  plain,  therefore,  that  our  aim  should  be  to 
supply  only  just  enough  adrenal  extractive  to  compensate  for  the  deficiency  of 
adrenal  secretion  produced. 

It  is  astonishing  with  what  small  proportion  of  the  subject's  own 
adrenals,  the  rest  being  destroyed  by  organic  disease,  will  sustain  the  vital 
process.  Gourfein^*^  showed  that  one-twentieth  of  both  organs  sufficed. 
Moreover,  a  number  of  cases  on  record  indicate  that  a  mere  vestige  will  do 
so,  and  that  it  is  only  when  this  vestige  is  destroyed  that  life  ceases.  In  a 
case  of  Bramwell's,!'^  for  instance,  the  organs  were  replaced  by  masses  of 
fat.  In  one  of  Osier's^*  the  adrenals  "were  sclerotic  and  had  completely  dis- 
appeared." The  prevailing  practice  of  giving  a  full  dose  of  an  adrenal  prep- 
aration to  begin  with  and  then  pushing  the  remedy  until  enormous  doses  are 
given — supposedly  because  of  the  most  unscientific  notion  that  if  a  small  dose 
wdll  do  good  very  large  doses  will  do  correspondingly  more  good — is  therefore 
most  dangerous. 

The  25  cases  of  Addison's  disease  in  wliich,  out  of  the  120  referred  to 
above,  permanent  benefit  occurred,  include  one,  treated  by  Bate^^  in  which 
but  Yi^  grain  (0.005  Gra.)  of  adrenal  extract  three  times  daily  caused  very 
great  and  lasting  improvement  with  marked  lessening  of  the  bronzing. 
When  the  remedy  could  not  be  obtained  temporarily,  which  occurred  twice, 
the  case  relapsed.  On  the  other  hand,  Suckliug^o  began  with  10  grains  daily 
and  gradually  increased  until  175  grains  were  given  each  day,  and  also 
obtained  favorable  results.  That  in  Bate's  case  the  adrenals  were  still  able 
almost  to  carry  on  their  function  is  self-evident;  while  in  Suckling's  the 
remedy  practically  compensated  for  the  adrenals  (while  the  local  morbid  proc- 
ess in  them  was  still  active,  and  such  as  to  paralyze  their  functions — a  fact 
Avell  showTi  by  the  severity  of  the  case  when  the  use  of  the  extract  was  begun). 
The  average  dose  is  probably  that  used  by  Weigall-i  in  a  very  severe  case — 
5  grains,  increased  to  10  grains,  of  the  extract  three  times  a  day.  The 
patient  increased  six  pounds  in  two  weeks,  and  after  about  three  months  fifty- 
six  pounds.  In  other  words,  in  the  25  cases  of  permanent  benefit,  although 
the  remedy  was  used  empirically  it  so  happened  in  all  probability,  that  the 
doses  employed  coincided  with  the  iieeds  of  the  organism.  In  the  51  cases  in 
which  no  benefit  was  obtained  several  occur  in  which  failure  was  evidently 
due  to  inadequate  dosage  or  to  too  early  cessation  of  the  treatment,  while  in 
others  excessive  doses — practically  in  every  instance  a  too  rapid  or  excessive 
increase  of  the  dose — as  clearly  prevented  a  successful  issue. 

In  the  cases  in  which  grafting  was  resorted  to,  the  dose  represented,  we 
have  seen,  was  out  of  all  proportion  in  excess  of  the  needs  of  the  patients, 
although  the  belief  that  tlie  two  adrenals  grafted  into  tlie  abdominal  tissues 
were  necessary  to  replace  the  supposedly  destroyed  adrenals  seemed  to  be  war- 
ranted. It  is  important  to  bear  in  mind,  however,  in  this  connection,  that  it 
does  not  follow  that  because  we  have  two  adrenals,  the  full  activity  of  the 
organs  is  brought  into  play.     We  have  seen  that  all  evidence  available  indi- 


ADRENAL  EXTRACT  IN  ADDISON'S  DISEASE.  215 

cates  that  but  one-twentieth  of  their  secretion  suffices  to  sustain  physiological 
oxidation.  Two  ungoverned  adrenals,  inserted  into  the  tissues,  cannot  but 
evoke  the  phenomenon  observed,  therefore,  i.e.,  excessive  and  even  deadly 
oxidation. 

On  the  whole,  the  one  great  factor  in  the  treatment  of  Addison's  disease 
by  means  of  adrenal  extractives  is  to  drop  their  empirical  use,  and  it  is  only 
(and  this  applies  to  the  use  of  any  disease)  when  the  importance  of  this  fact 
will  have  been  thoroughly  grasped  that  the  proportion  of  recoveries  will  be 
materially  increased.  ' 

The  salient  guides  in  the  use  of  these  preparations  are  the  low  hmpera- 
ture,  which  denotes  deficient  oxidation  and  metabolism,  and  the  wealc  pulse, 
which  points  to  a  low  vascular  tension  and  inadequate  cardiac  dynamism. 
Improvement  of  a  given  case  is  indicated  by  a  gradual  resumption  of  normal 
conditions  in  these  two  directions,  and  by  the  return  of  bodily  vigor,  with 
more  or  less  fading  of  the  pigmentation.  As  a  rule,  the  more  these  various 
morbid  phenomena  are  marked,  the  larger  will  be  the  initial  dose  required. 
In  other  words,  marked  hypothermia,  a  very  feeble  pulse,  advanced  bronzing 
and  great  debility  will  indicate  that  a  mere  vestige  of  both  adrenals  is  still 
active;  the  dose  indicated  then  is  that  which  will  supply  enough  additional 
principle  to  raise  the  temperature  and  the  blood-pressure  to  normal,  but  not 
leyond.  A  study  of  the  120  above-mentioned  cases  has  shown  that  5  grains 
(0.30  Gm.)  of  the  extract,  three  times  daily,  was  the  most  satisfactory  dose 
to  start  with.  If  this  fails  to  raise  the  temperature  and  the  pulse  tension, 
the  dose  should  be  increased  by  5  grains  per  day  until  it  does,  the  case  being 
watched  closely.  As  soon  as  the  normal  temperature  is  reached,  the  dose 
should  cease  to  be  increased,  unless  a  tendency  to  recurrence  of  the  hypo- 
thermia (gradually  as  the  adrenals  are  being  destroyed  by  the  local  morbid 
process)  should  render  it  necessary.  In  less  advanced  cases,  the  initial  doses 
should  be  correspondingly  small  4,  3,  2  or  even  1  grain  of  the  extract  being 
administered  three  times  daily,  the  dose  decreasing  in  proportion  as  the  dis- 
ease is  less  advanced.  ' 

Can  we  expect  a  cure  from  adrenal  preparations  ?  In  most  cases  of  Addi- 
son's disease  the  local  process  is  tubercular — often  limited  to  the  adrenals.  A 
number  of  examples  suggest,  however,  that  the  tubercular  process  itself  was 
benefited,  and  even  cured  by  the  use  of  adrenal  extract.  This  is  quite  in 
accord  with  the  view  I  have  advanced,  and  sustained  by  considerable  evi- 
dence,^ that  the  adrenal  secretion  sustains  the  efficiency  of  the  immunizing 
mechanism. 

A  number  of  cases  are  on  record  in  which,  after  apparent  recovery,  the 
cases  died  suddenly  soon  after  ceasing  the  use  of  adrenal  preparations.  It  is 
evident  that  even  the  possibility  of  curing  the  morbid  process  in  the  adrenals 
does  not  replace  the  destroyed  adrenal  tissue.  It  is  here  that  grafting  would 
be  of  curative  value,  but  only  provided  small  fragments  of  adrenal  tissue  be 
inserted,  and  gradually  increased  in  number  until  the  temperature  and  pulse 
indicate  that  compensation  for  the  functionless  areas  in  the  adrenals  has  been 
insured.  ' 


216  ACROMEGALY,  CARDIOVASCULAR  CHANGES  IN. 

The  120  cases  analyzed  show,  and  my  own  experience  has  further  dem- 
onstrated, that  what  is  generally  known  as  "adrenal  extract/'  but  which,  in 
reality,  is  the  desiccated  adrenal  gland  {the  glandulce  snprarenales  sicca  of  the 
U.  S.  P.)  is  by  far  the  most  satisfactory  agent  to  use.  Injections  of  adrenal 
fluid  extracts  are  exceedingly  painful — a  fact  which  compromises  the  issue  by 
introducing  the  element  of  shock — while  the  active  principles,  epinephrin, 
adrenalin,  suprarenalin,  Qic,  sometimes  fail  altogether  to  act,  owing  to  their 
becoming  oxidized  and  rendered  inert  while  being  absorbed.  The  fresh  gland 
is,  as  a  rule,  repulsive  to  the  patient,  and  tends  to  aggravate  the  tendency  to 
nausea  and  vomiting. 

BIBLIOGRAPHY. 

1  CouBMONT:     Congrds  de  M^deeine  Interne,  Montpellier,  1898. 
2BiiA:     Cited  by  E.  W.  Adams,  Practitioner,  Oct.,  1903. 
SJaeoulay:     Lyon  Medical,  March  21,  1897. 

4  E.  W.  Adams  :     Practitioner,  Oct.,  1903. 

5  Affleck:     Lancet,  Dec.  31,  1898. 

CGuiOL:     Bull,  de  la  Soc.  mfidico-cliir.  du  Var,  Dec,  1906. 

7  CouEMONT :     Titres  et  Travaiix  Scientifiques,  p.  90,  1907. 

8  Sajous  :     "Internal  Secretions  and  the  Principles  of  Medicine,"  vol.  i,  1903,  and  vol. 

ii,  1907;    see  also,  N.  Y.  Med.  Jour.,  Feb.  20  and  27,  1909. 
eScHAFEB:     "Text-Book  of  Physiol.,  vol.  i,  p.  957,  1898. 

10  Sajous:     N.  Y.  Med.  Jour.,  p.  363,  Feb.  20,  1909. 

11  Oliveb  and  Schafeb:     Jour,  of  Physiol.,  vol.  xviii,  p.  230,  1S95. 
isReichebt:     Univ.  of  Penna.  Med.  Bull.,  April,  1901. 
13M0BEL:     Le  Progrds  Medical,  Aug.  3,  1903. 

14L£:pine:     La  Semaine  Mcdicale,  Feb.  18,  1903. 

15  E.  W.  Adahs  :     Log.  cit. 

16G0UEFEIN:     Rev.  Intern,  de  Th§rap.  et  de  Pharm.,  May  17,  1896. 

17BBAMWELL:     Brit.  Med.  Jour.,  Jan.  9,  1897. 

18  Oslee  :     Cited  by  Adams,  loc.  cit. 

19  Bate:     Amer.  Praet.  and  News,  Aug.  1,  1899, 

20  Suckling:     Brit.  Med.  Jour.,  May  28,  1898. 
21WEI0ALL:     Australasian  Med.  Gaz.,  Oct.  20,  1905. 


C^clo|>a2dia  of  Current  hitztatuvz 


ACROMEGALY,  CARDIOVASCULAE  stantly  present.     These  changes  in  the 

CHANGES  IN.  heart  and  vessels  should  be  considered  as 

Enlargement  of  the  heart,  either  much  a  part  of  the  clinical  picture  as  the 

simple  or  associated  with  a  myocarditis,  changes  in  the  bones,  and  they  are  prob- 

is  the  condition  usually  found  in  aero-  ably  due  to  the  prolonged  hypertension 

megaly.     Sclerosis   of   the   arteries   and  of  the  vessels,  the  result  of  hypersecre- 

degenerative  lesions  affecting  the  walls  of  tion  of  the  pituitary  body.     John  Phil- 

the  veins,  with  dilatation  and  subsequent  lips   (Medical  Eecord,  February  20, 

obliteration    of    their   lumen,    are    eon-  1909). 


BROMIDE    ERUPTION. 


BRONCHITIS,   TREATMENT   OP. 


217 


ANTITOXINS,      ORAL      ADMINISTSATION 
OF. 

Inhibition  of  digestion  permits  the 
absorption  of  toxins  and  antitoxins  from 
the  stomach.  By  treating  children  as 
follows,  the  oral  introduction  of  anti- 
toxin has  given  imiform  and  satisfactory 
results:  When  possible  no  food  for  at 
least  four  hours  before  administering  the 
serum ;  one  hour  before  giving  the  serum 
a  glass  of  one-per-cent.  sodium  bicar- 
bonate solution  is  given;  and  with  the 
antitoxic  serum  is  given  one  minim  of  a 
fluidextract  of  opium  and  from  four  to 
ten  minims  of  a  saturated  solution  of 
salol  in  chloroform.  In  19  children  and 
hundreds  of  animals  treated  along  these 
lines  serum  sickness  did  not  occur.  The 
authors  believe  that  the  oral  method  may 
be  preferred  for  prophylaxis  because  of 
the  ease,  the  absence  of  danger,  and  the 
small  cost.  For  curative  purposes,  how- 
ever, the  hypodermic  method  can  not  yet 
be  replaced.  In  animals  toxins  by  the 
mouth  may  produce  a  high  immunity  by 
absorption  of  the  toxin  promoted  by  the 
means  mentioned.  C.  T.  McClintock 
and  W.  King  (Journal  of  Infectious  Dis- 
eases, Februaiy,  1909). 

BROMIDE  ERUPTION. 

Bromide  eruption  may  occur  in  those 
who  are  susceptible,  independent  of  the 
dose  of  the  drug  or  the  length  of  the 
administration.  The  larger  the  dosage, 
and  the  longer  the  ingestion,  the  greater 
is  the  chance  of  an  outbreak.  There  are 
practically  no  constitutional  or  subjective 
symptoms  in  most  cases.  Because  of  the 
slow  elimination,  the  eruption  may  con- 
tinue to  appear  for  some  weeks  after  the 
drug  has  been  discontinued.  Almost  any 
type  of  eruption  may  be  present;  in 
childhood  the  lesions  are  usually  larger 
and  more  persistent  than  in  adult  life. 


The  extremities  and  the  face  are  the  parts 
most  frequently  attacked;  the  most  ex- 
tensive eruption,  in  the  majority  of  the 
cases,  occurs  upon  the  legs.  Lesions  have 
a  great  tendency  to  occur  at  points  of 
previous  inflammation,  such  as  on  vac- 
cination scars,  injuries,  etc.  F.  C. 
Knowles  (New  York  Medical  Journal, 
March  20,  1909). 

BRONCHITIS,  CHRONIC,  TREATMENT  OF. 

Causal  treatment  does  not  receive  suffi- 
cient consideration  in  chronic  bronchitis, 
due  to  the  fact  that  its  etiology  is  very 
complex  and  not  always  discoverable.  A 
patient  with  bronchitic  tendencies  is 
always  in  a  state  of  insufficient  resistance 
to  bacterial  invasion  and  should  as  much 
as  possible  be  kept  away  from  exposure 
to  infection.  Autoinfection  is  more  com- 
mon than  is  supposed. 

The  writer  emphasizes  the  importance 
of  the  removal  of  secretion  and  describes 
the  various  classes  of  remedies  employed 
therefor.  The  remedies  are  divided  into 
those  that  act  by  increasing  fluidification 
of  the  expectoration,  by  rousing  irrita- 
tion so  that  increased  efforts  are  made  for 
its  propulsion,  and  by  drying  up  the 
secretion.  In  chronic  bronchitis  it  is 
rarely  necessary  to  employ  the  second  of 
these  three  kinds.  Of  the  first  group  the 
author  prefers  ammonium  chloride, 
ipecac,  the  alkalies  and  pilocarpin;  of 
the  last  group,  turpentine,  benzoates, 
creosote  and  its  preparations  or  deriva- 
tives, eucalyptus  and  tar.  The  same 
effects  follow  inhalations  as  are  produced 
by  medicines.  Intratracheal  injection 
seems  to  be  followed  by  good  results.  In 
ordinary  cases  postural  treatment  is  best 
for  the  removal  of  secretion  from  the 
bronchial  tubes.  Heroin  may  be  tried  in 
small  doses  (0.004  to  0.008  gram,  Mo  to 
Ys  grain),  but  it  is  more  toxic  than  mor- 
pliin    and    heroinism    does    occur.      F. 


218 


ECTOPIC  GESTATION. 


FOOD  INTOXICATION  IN  INFANCY. 


Forchheimer   (American  Journal  Medi- 
cal Sciences,  Pebniary,  1909). 

ECTOPIC  GESTATION. 

The  diagnosis  must  first  be  assured. 
Patients  with  suspicious  symptoms,  spot- 
ting, cramps,  fainting,  collapse,  amenor- 
rhoea,  accessory  symptoms  of  pregnancy, 
insufficient  change  in  the  shape  of  the 
uterus,  assuming  pregnancy  to  be  present, 
or  a  mass  near  the  uterus,  should  be  kept 
under  close  observation  or  placed  in  a 
hospital.  Forcible  examinations  should 
not  be  made,  nor  should  curettage  be  per- 
formed until  every  possibility  of  ectopic 
gestation  has  been  excluded.  If  the  con- 
dition does  not  improve  in  two  or  three 
da5's  and  haematocele  has  not  formed, 
abdominal  section  should  be  performed. 
It  should  be  done  at  once  if  fainting  or 
collapse  occurs  during  the  period  of  wait- 
ing. In  well  defined  haematocele  vaginal 
section  with  evacuation  and  drainage  may 
suffice.  If  a  patient  is  first  seen  in  col- 
lapse, immediate  operation  is  safer  than 
waiting.  If  in  extreme  collapse  there 
should  be  rapid  abdominal  section  fol- 
lowed by  measures  to  combat  both  ha3mor- 
rhage  and  shock.  It  is  better  to  interfere 
unnecessarily  early  than  too  late.  E.  T. 
Frank  (American  Jouraal  of  Obstetrics, 
February,  1909). 

ECZEMA,  CHRONIC,  IN  INFANTS. 

lical  chronic  eczema  of  infants  is  a 
constitutional  disease  and  must  be  differ- 
entiated from  various  forms  of  dermatitis 
that  likewise  affect  infants.  The  etiology 
of  such  eczema  depends  upon  two  factors, 
congenital  predisposition  and  feeding. 
Two  forms  must  be  distinguished,  one  of 
them  the  weeping  eczema  of  the  head, 
and  the  other  the  disseminated  dry 
eczema.  The  first  usually  attacks  well- 
nourished  children  with  a  pasty  com- 
plexion.    In  addition  to  the  hairy  parts 


of  the  scalp,  the  regions  of  the  ears,  nose 
and  cheeks  may  be  affected  by  the  erup- 
tions. Hands  and  arms  may  likewise 
show  the  same  lesions.  Overfeeding  and 
chronic  constipation  are  the  usual  con- 
comitants of  this,  the  seborrhoeic  form  of 
eczema.  Improvement  and  cure  usually 
follow  the  change  from  pure  milk  diet  to 
mixed  diet  at  the  end  of  the  first  year. 
The  second  variety  of  eczema  occurs 
almost  exclusively  in  artificially  fed 
children.  Such  cliildren  are  weak,  pale 
and  thin.  The  eruption  is  not  as  strik- 
ingly evident  as  in  the  first  form,  and 
consists  of  scattered  patches  of  dry,  scaly 
infiltrated  lesions  that  may  be  found  over 
the  whole  body. 

While  local  treatment  of  these  forms  of 
disease  must  be  used  in  every  case  to 
make  the  children  comfortable,  the  cure 
depends  not  upon  this  treatment,  but 
upon  changes  in  the  diet  of  the  children. 
Reduction  of  milk  is  the  principal  point 
of  managing  these  cases,  and  carboliy- 
drate  food  must  be  given  to  make  up  the 
deficiency  in  the  foodstuffs.  After  the 
fourth  month  of  age  this  is  very  easy,  as 
the  child  can  be  fed  on  various  cereal 
preparations  and  also  given  fruit  juice. 
In  later  months  the  albumin  of  eggs  must 
be  avoided,  as  it  is  as  badly  borne  as  the 
milk  proteids.  Whey  mixtures  may  be 
used  in  cases  where  the  child  is  too  yoimg 
to  take  any  other  food  but  some  form  of 
milk.  The  whey  may  be  modified  with 
sugar  and  cereal  gruel,  a  diet  with  which 
Finkelstein  had  great  success  in  the 
treatment  of  cczematous  children.  Freer 
(Miinchener  medizinische  Wochenschrift, 
January  19,  1908;  Medical  Eecord,  Feb- 
ruary 20,  1909). 

FOOD  INTOXICATION  IN  INFANCY. 

The  writer  discusses  the  alimentary 
intoxication  of  infants.  It  is  a  metab- 
olic intoxication  caused  by  the  giving  of 


HEART   IN  TUBERCULOSIS. 


ICHTHYOSIS   AND   THYROID   GLAND.      219 


food  which  produces  toxic  products  of  an 
inadequate  metabolism,  which  may  lead 
to  fatal  consequences,  but  disappears 
when  the  food  is  withheld.  Certain 
foods,  however,  give  rise  to  these  effects, 
and  the  author  insists  on  the  importance 
of  the  fats  and  sugars  in  the  infant's 
food.  The  proteids  he  considers  com- 
paratively harmless.  The  exact  nature 
of  the  toxines  is  unknown.  The  condi- 
tion is  probably  analogous  to  an  acid 
intoxication,  and  the  theory  that  it  is  due 
to  alimentary  rather  than  to  bacterial 
toxines  is  supported  by  the  absence  of 
lesions  in  the  alimentary  canal,  the 
absence  of  any  micro-organism  associated 
with  it,  the  ready  cure  by  withdrawal  of 
food,  the  widely  different  conditions  with 
which  it  is  associated,  and  the  lack  of 
putrefactive  or  fermentative  products 
that  are  caused  by  bacterial  activity 
within  the  intestines.  The  treatment  is, 
therefore,  indicated :  The  withdrawal  of 
food  will  produce  a  normal  temperature 
and  absence  of  evident  intoxication  in 
from  2-i  to  72  hours.  The  child  can  be 
given  plenty  of  water,  sweetened  with 
saccharin,  one  grain  to  the  quart ;  a  little 
barley  water  is  harmless  or  weak  tea  can 
be  given,  as  is  done  so  much  in  German 
clinics.  "When  the  baby  is  no  longer 
toxic  we  can  give  a  little  skim  milk — 
from  5  to  10  ounces  in  tlie  barley  water 
in  the  day's  food.  If  this  is  well  borne 
for  a  day  or  two  one  can  safely  add  a 
small  amount  of  sugar  and  gradually 
increase  it  to  the  amount  for  a  normal 
healthy  child;  but  only  after  weeks  or 
months  can  whole  milk  be  begun  with 
safety  under  careful  control  and  watched. 
The  severer  the  case  the  slower  must  be 
the  progress.  Joseph  Brennemann 
(Journal  American  Medical  Association, 
February  27,  1909). 


HEART  IN  PULMONARY  TUBERCULOSIS. 

Pulmonary  stenosis  is  always  the  pri- 
mary heart  lesion  with  pulmonary  tuber- 
culosis, mitral  insufficiency  and  aortic 
insufficiency  being  usually  secondar)\ 
The  most  frequent  secondary  cardiac 
lesion  in  patients  who  are  able  to  be 
about  is  mitral  stenosis.  Pulmonary 
tuberculosis  occurs  more  frequently  wnth 
patients  who  have  pulmonary  stenosis 
than  in  any  other  form  of  cardiac  disease. 
Mitral  insufficiency  is  associated  with 
pulmonary  tuberculosis  more  frequently 
than  any  other  form  of  valvular  disease, 
but  aortic  insufficiency  is  almost  as  fre- 
quent. Aortic  stenosis  is  rarely  a  com- 
plication of  pulmonary  tuberculosis  and 
involvement  of  several  valves  simulta- 
neously rarely  occurs.  The  treatment  is 
the  same  which  would  be  proper  if  tuber- 
culosis were  not  present.  An  elevation 
of  more  than  2,000  feet  is  inadvisable, 
unless  the  heart  is  well  compensated. 
Overexertion  must  be  avoided,  arsenic, 
strychnine,  ice-bags,  carbonic  acid  baths, 
massage,  rest  at  first  and  careful  exercise 
later,  are  measures  that  will  be  found 
useful.  L.  Brown  (American  Journal  of 
the  Medical  Sciences,  February,  1909). 

ICHTHYOSIS  AND  THE  THYROID  GLAND. 

Certain  cases  of  ichthyosis  coincide 
either  with  thyroid  lesions  or  with  mani- 
festations of  dysthyreoidia,  and  it  is 
logical  to  attribute  the  cutaneous  troubles 
to  these  lesions  as  in  a  number  of  cases 
treatment  directed  to  the  thyroid  has 
caused  myxoedema  and  ichthyosis  to  dis- 
appear. The  writers  also  think  that  cer- 
tain cases  attributed  to  hereditary 
syphilis  should  be  referred  to  thyroid 
lesions,  consecutive  or  not  upon  this  dis- 
ease. It  is  universally  admitted  that  the 
thyroid  gland  presides  over  tlic  nutrition 
of  tlie  subcutaneous  cellular  tissue  and  of 
the  skin,  and  therefore  it  is  logical  to 


220 


INFAJSTL'ILE   SCORBUTUS. 


INFLUENZA  OF  THE   EYELIDS. 


admit  its  intervention  in  the  evolution  of 
ichth3'osis,  E.  Weill  and  G.  Monriquand 
(La  presse  medicale,  February  17,  1909; 
New  York  Medical  Journal,  March  20, 
1909). 

INFANTILE    SCORBITTTIS,    EARLY    DIAG- 
NOSIS OF. 

The  writer  emphasizes  the  importance 
of  early  diagnosis  of  infantile  scorbutus. 
The  picture  of  the  affection,  as  outlined 
in  the  text -books,  is  one  which  applies  to 
cases  in  which  the  disease  has  gained  full 
headway;  the  patient  has  suffered  for 
some  length  of  time  and  has  developed 
the  full  sjTnptomatology  of  the  disease. 
The  disease  follows  invariably  in  the 
wake  of  some  error  of  nutrition,  or,  in 
artificially  fed  infants,  on  an  error  in  the 
composition  of  the  food,  wholesome  or 
othervi^ise,  or  in  its  treatment  after  hav- 
ing been  made  up  for  the  infant.  Cases 
also  occur  in  breast-fed  infants  when  the 
breast  may  have  had  a  denutritional  com- 
position, or  in  infants  partaking  of  raw 
milk,  excellent  in  itself,  but  given  to  the 
infant  in  .a  denutritional  state.  This 
should  always  be  borne  in  mind,  as  the 
physician  is  apt  to  reject  the  possibility 
of  scorbutus  if  the  infant  is  taking  raw 
millc.  Many  infants  taking  sterilized 
food  never  develop  symptoms  of  scorbu- 
tus, and  in  others  sjonptoms  may  be  held 
in  abeyance  by  the  administration  of 
fruit  juices.  It  is  exceedingly  uncom- 
mon to  see  the  disease  in  infants  before 
the  age  of  5  months.  The  writer  be- 
lieves, therefore,  that  scorbutus  may 
develop  in  any  infant  whose  food  is,  or 
has  been  constructed  on  denutritional 
lines. 

The  first  signs  of  latent  or  incipient 
scorbutus  are  a  mild  form  of  anosmia, 
pain  in  the  bones  and  joints  only  elicited 
by  pressure  or  manipulation,  and  the 
appearance  of  blood  in  the  excretions  or 


in  the  vicinity  of  the  bones  or  periosteum. 
It  is  not  an  unconmion  experience  to  see 
scorbutus  in  infants,  at  about  the  sixth 
month  of  life,  who  are  apparently  thriv- 
ing, and  who  give  absolutely  no  symptoms 
such  as  would  lead  one  to  suspect  any 
scorbutic  tendency.  In  such  infants  the 
teeth  may  not  have  erupted.  Deep  pres- 
sure on  the  tibiae  will  cause  these  children 
to  wince,  as  if  there  were  some  tenderness 
of  the  bone.  Fonnerly  this  was  inter- 
preted as  being  due  to  rickets.  Such 
infants  may  be  rachitic,  but  the  tender- 
ness in  question  is  scorbutic.  The  test  of 
the  correctness  of  this  supposition,  in  the 
face  of  the  absence  of  any  s}Tnptoms 
otherwise  of  scorbutus,  is  the  rapid 
response  of  such  infants  to  a  change  in 
the  diet  toward  warding  off  the  full 
development  of  scorbutus.  H.  Koplik 
(Archives  of  Diagnosis,  January,  1909). 

INFLUENZA  AND   (SDEMA  OF   THE   EYE- 
LIDS. 

A   series   of  ten   or  twelve   cases  of    | 
influenza  are  reported  by  the  writer,  in    I 
which    oedema    of    the    eyelids    was    a    j; 
prominent  symptom.     The  usual  history 
was  that  the  patient  went  to  bed  well,  but 
waked  with  marked  oedema.     There  was 
no  redness,  or  at  most  a  faint  pinkish 
tinge.     At  this  stage  there  were  no  gen- 
eral symptoms.     During  the  next  twenty-  ■ 
four  hours   a  bad  headache   developed,  tl 
strictly    localized    to    the    supra-orbital  It 
region.     The  oedema  advanced  till  the  | 
eyes  were  completely  closed,  and  might 
spread  downward  into  the  cheeks.     In 
at  least  half  the  cases  there  was  deep  i 
congestion,  often  accompanied  by  oedema  | 
of  the  conjunctiva,  but  there  was  no  dis-'i 
charge.     The    temperature    never    rose 
above  101°  F.     In  more  than  half  theJ 
cases  the  above  s}anptoms  constituted  alllj 
the  illness ;  but  in  a  fair  proportion,  per-| 
haps  nearly  half,  after  a  few  days,  as  the 


OPIUM  HABIT. 


RHEUMATISM,  ACUTE  AND  SUBACUTE. 


221 


oedema  receded  the  ordinary  symptoms  of 
influenza  set  in,  and  there  were  pains  in 
the  back,  legs,  etc.,  and  great  prostration. 
The  urine  was  normal.  Most  of  the 
cases  occurred  in  women.  There  was 
little  doubt  of  the  influenzal  origin  of  the 
oedema.  About  half  the  patients  had 
other  influenzal  sjonptoms,  and  of  those 
who  did  not,  many  were  found  to  reside 
in  a  house  where  influenza  was  prevalent. 
N"o  cases  were  recorded  apart  from  an 
epidemic  of  influenza.  The  diagnosis 
may  be  hard  or  impossible  in  an  isolated 
case,  and  frontal  sinusitis  or  angioneu- 
rotic cedema  may  be  considered.  The 
presence  of  other  influenzal  symptoms 
will  soon  clear  up  the  difficulty,  however. 
The  prognosis  is  excellent.  The  usual 
lines  of  treatment  for  influenza  should  be 
followed.  Cold  compresses  or  cold  boric 
eye  washes  hasten  the  subsidence  of  the 
oedema.  N.  I.  Spriggs  (British  Medical 
Journal,  December  12,  1908) . 

OPITIM  HABIT. 

The  treatment  should  consist  in 
elimination.  The  patient  must  be  rid  of 
his  stored  toxines,  his  system  disembar- 
rassed of  the  excess,  and  his  manufacture 
of  new  toxines  reduced  to  that  point  at 
which  he  will  need  no  opiate  inhibition 
to  make  him  comfortable.  If  elimina- 
tion is  thus  established  he  will  find  the 
need  for  opiate  lessening  with  each  dis- 
charge of  excretory  material,  and  it  will 
be  merely  a  matter  of  time  when  he  will 
need  none.  The  impacted  colon  should 
be  emptied,  the  masses  of  toxines  stored 
in  the  liver  loosened,  the  renal  action 
kept  up  to  its  highest  level  of  eflficacy,  the 
skin  incited  to  aid  in  throwing  off 
the  toxic  products  whenever  there  is 
evidence  of  their  active  presence  in  the 
blood.  Meanwhile,  a  non-nitrogenous 
diet  should  be  given,  and  the  patient  kept 


at   rest  as  absolutely   as  circumstances 
permit. 

The  means  to  be  employed  to  secure 
these  ends  vary  with  each  case,  and  the 
physician  who  treats  such  maladies  must 
be  qualified  to  fit  his  treatment  to  the 
varying  indications  that  are  present. 
But  time  must  be  allowed  for  the  altered 
conditions  to  be  established,  for  the 
patient  to  learn  to  live  without  drugs,  for 
the  various  organs  to  accustom  them- 
selves to  functionate  independently  of 
drug  control.  It  is  not  too  much  to 
exact  a  year's  absolute  rest,  of  real  play- 
time, after  the  cessation  of  the  habit. 
During  this  period  the  metabolism  is  apt 
to  fall  into  arrears,  and  toxines  tend  to 
acccumulate.  One  of  the  most  signifi- 
cant symptoms  of  this  period  is  a  sub- 
normal temperature.  Another,  usually 
accompanying  it,  is  respiratory  oppres- 
sion. These  demand  instant  action,  in 
emptying  the  bowels,  unloading  the  liver, 
and  stimulating  all  the  vital  functions  by 
the  use  of  that  priceless  vitalizer,  strych- 
nine; juglandin,  and  salines  should  be 
always  at  the  patient's  disposal,  and  he 
himself  should  be  carefully  instructed  in 
their  application,  so  that  he  may  be 
independent  of  the  chance  practitioner, 
who  may  be  of  the  sort  who  look  on  "suf- 
fering as  an  indication  for  morphiue." 
With  a  year  of  rest,  properly  so-called, 
there  is  no  reason  for  any  cured  patient 
relapsing.  W.  F.  Waugh  (Medical 
Record,  December  26,  1908). 

KHEUMATISM,    ACUTE    AND    SUBACUTE, 
EFFECTIVE  TREATMENT  OF. 

The  writer  commends  the  use  of 
sodium  salicylate  in  the  treatment  of 
acute  and  subacute  rheumatism,  but 
says  that  its  employment  has  been  re- 
stricted by  fear  of  cardiac  depression 
and  the  bad  taste  of  the  remedy.  It 
should  be  used  more  freely  and.  con- 


222 


THYMUS  AND  THE  NERVOUS  SYSTEM. 


WHOOPING-COUGH. 


tinued  for  a  longer  time.  The  cardiac 
changes  result  from  the  disease,  how- 
ever, and  not  from  the  remedy.  The 
author  always  finds  dilatation  of  the 
left  ventricle.  As  long  as  the  evening 
temperature  rises  above  normal,  the  dis- 
ease is  still  present,  and  the  remedy 
should  be  continued.  The  addition  of 
bicarbonate  of  sodium  in  an  amount  al- 
ways double  that  of  the  salicylate  is  a 
very  effectual  means  of  diminishing  the 
unpleasant  effects  of  the  latter.  The 
initial  dose  of  sodium  salicylate  may  be 
15  grains  for  an  adult;  for  a  child 
from  seven  to  twelve  years,  10  grains; 
and  below  this  age,  5  grains;  the  daily 
totals  being  150,  100  and  50  grains  re- 
spectively. With  these  larger  doses  the 
pain  rapidly  abates  and  the  joint  swell- 
ings subside.  The  fever  falls,  and  there 
is  little  tendency  to  relapse.  The  im- 
provement in  the  heart  wall  muscle  is 
often  most  striking.  In  bad  cardiac 
cases  and  those  associated  with  pericar- 
dial inflammation,  the  author  com- 
mends the  application  of  ice  to  the 
prfficordium.  The  lower  extremities 
must  be  kept  warm,  and  any  consider- 
able dilatation  of  the  right  auricle  must 
be  relieved  by  leeches  before  the  ice  is 
applied.  The  indications  for  leeches 
are  an  extension  of  the  cardiac  dullness 
in  the  fourth  right  intercostal  space  to 
two  finger-breadths,  rapid  respiration, 
restlessness,  and  some  cyanosis  in  the 
lips  and  face.  D.  B.  Lees  (British  Med- 
ical Journal,  January  16,  1909). 

THYMUS    AND    THE    NERVOUS    SYSTEM, 
RELATIONS  BETWEEN. 

The  writer  has  found  that  removal  of 
the  thymus  of  young  dogs  caused  ex- 
ceptional excitability  of  the  peripheral 
nervous   system,   as   shown   by   electric 


tests.  This  throws  new  light  on  the 
relations  between  the  thymus  and  ner- 
vous system.  Experimental  research 
has  convinced  the  writer  that  the  para- 
thyroid bodies  are  not  exclusively  re- 
sponsible for  the  etiology  of  tetany,  but 
rather  that  a  whole  group  of  allied  or- 
gans are  involved.  Among  these  the 
thymus  takes  a  prominent  place  as  re- 
acting the  most  readily  to  general  dis- 
turbances. In  normal  conditions  the 
thymus  seems  to  be  connected  with  the 
growth  of  the  body  and  the  develop- 
ment of  the  bones  in  early  life,  and  also 
with  a  certain  reaction  of  the  motor 
apparatus  to  the  electric  current.  K. 
Basch  (Jahrbuch  filr  Kinderheilkunde, 
December;  Journal  of  the  American 
Medical  Association,  January  30,  1909). 

WHOOPING-COUGH,  TREATMENT  OF. 

Quinine  and  antipyrine  can  be  de- 
pended on  to  abort  or  attenuate  per- 
tussis, but,  as  usually  given,  the  dislike 
of  the  child  to  take  the  medicine  leads 
to  inadequate  dosage  or  to  its  total 
neglect.  This  can  be  obviated  by  in- 
jecting a  solution  of  the  drug  into  the 
rectum.  The  solubility  of  the  anti- 
pyrine commends  it  for  the  purpose,  and 
the  writer  has  1  Gm.  (15  grains)  dis- 
solved in  25  Gm.  warm  water,  injected 
three  times  a  day,  for  a  child  over 
twelve,  with  smaller  doses  for  younger 
children.  No  ill  effects  have  ever  been 
noticed  on  the  heart,  while,  when  the 
injections  are  commenced  early,  the 
disease  is  frequently  aborted.  It  does  ( 
not  depress  the  appetite  given  in  this 
way,  and  the  therapeutic  effect  seems 
to  be  constant  and  reliable.  Senf  tleben  i 
(Deutsche  medizinische  Wochenschrift, 
January  14,  1909;  Journal  of  the 
American  Medical  Association,  Febru-  | 
ary20,  1909).  ! 


BOOK  REVIEWS.  223 

5ool<  Reviews 


Report  of  CoinnxTEE  ox  Building  of  IIodel  Houses.  By  Gen.  George  M.  Sternberg,  M.D., 
LL.D.,  Chairman  of  the  Committee.  Washington:  The  President's  Homes  Commission, 
1908. 

This  report  is  worthy  of  review  at  some  length,  by  reason  of  the  importance  of  the  sub- 
ject. Lack  of  space,  however,  forbids  more  than  to  call  to  the  attention  of  the  profession  the 
work  of  this  exceedingly  valuable  commission.  No  one  factor  is  of  higher  importance  in  the 
conservation  of  health  than  that  of  suitable  homes  for  the  poor,  especially  in  large  cities. 
Accessibility  to  light  and  air  is  at  all  times  of  primary  significance  in  the  prevention  of  com- 
municable diseases,  especially  tuberculosis.  The  subject  will  be  dealt  with  in  an  editorial  by 
the  reviewer  later. — J.  M.  T. 

Pastobal  SrEDiciJTE:  A  Hand-book  for  the  Catholic  Clergy.  By  Alexander  E.  Sanford,  il.D. 
New  Edition,  Revised  and  Enlarged  by  a  Chapter  on  the  "Jloment  of  Death,"  by  Rev. 
Walter  M.  Drum,  S.J.,  etc.     New  York:    Joseph  Wagner,  1905. 

It  is  interesting  to  note  that,  in  at  least  one  of  the  organized  religious  bodies,  does  the 
subject  of  pastoral  medicine  secure  attention.  Not  only  is  this  particular  text-book,  so  far 
as  the  reviewer  is  able  to  estimate,  given  due  attention  by  the  Roman  Catholic  Church,  but  we 
are  informed  that  there  are  several  other  books,  dealing  with  the  same  subject,  which  are 
used  largely  by  the  priests  as  guides  in  helping  in  matters  of  health  and  personal  hygiene. 
Dr.  Sanford's  book,  since  coming  into  our  possession,  has  been  read  by  several  leading  clergy- 
men whose  opinion  was  solicited  who  testify  uniformly  to  its  excellency,  and  we  can  do  no 
better  than  to  urge  on  all  clergymen  that  they  familiarize  themselves  with  at  least  one  of 
these  books,  so  that  they  may  be  better  qualified  for  complete  fulfilment  of  their  duty  to  their 
flocks.— J.  M.  T. 

The  Semi-Insaxe  and  the  Semi-Respoxsible.  (Demifous  et  Demiresponsables.)  By  Joseph 
Grasset,  Professor  of  Clinical  Medicine  at  the  Montpellier  University;  National  Member 
of  the  French  Academy  of  Medicine,  etc.  Authorized  American  Edition.  Translated  by 
Smith  Ely  JelliflFe,  M.D.,  Ph.D.,  etc.  New  York  and  London:  Funk  &  Wagnalls  Com- 
pany, 1907. 

This  American  edition  of  Grasset's  classical  work,  though  published  in  1907,  came  into 
our  hands  but  recently.  It  is  a  matter  for  regret  that  scanty  space  forbids  discussing  it  at 
length,  but  suffice  it  to  say  that  it  deals  with  a  peculiarly  important  subject,  on  which  most 
physicians,  and  almost  all  clergymen,  are  conspicuously  ignorant.  As  to  lawyers,  it  is  a 
typical  fact  that  in  law  human  beings  are  divided  into  two  sharp-cut  classes:  the  wholly 
responsible  and  the  wholly  irresponsible.  It  has  been  a  favorite  subject  with  the  reviewer  to 
call  attention  to  that  large  group  of  borderland  conditions  which  have  been  entitled  by  Grasset 
the  demifotis  et  dcmiresponsables,  which,  being  interpreted  strictly,  will  be  found  to  include 
over  forty  per  cent,  of  the  population.  It  is  manifest  that  endless  blunders  must  be  made  by 
legislators,  as  well  as  by  physicians  and  clergj^men  in  dealing  with  every-day  problems,  unless 
they  achieve  a  well-rounded  comprehension  of  the  actual  facts  in  respect  to  variations  in 
mental  status. 

While  this  book  is  in  a  sense  technical,  being  written  chiefly  for  physicians,  nevertheless, 
many  of  the  chapters  are  of  such  fascinating  literary  quality  and  so  full  of  information  neces- 
sary for  a  large  group  of  thinking  people,  and  especially  for  those  who  assume  responsibility 
as  guides  to  human  conduct,  that  it  is  well  worthy  of  general  reading.  The  first  chapter  alone, 
entitled  "The  Semi-Insane  in  Literature  and  on  the  Stage,"  will  serve  to  give  a  good  impres- 
sion of  what  it  is  necessary  to  know  to  realize  the  extent  and  importance  of  the  subject. 
Other  chapters  follow,  technical  in  kind;  then  Chapter  IV,  "The  Social  Value  of  the  Serai- 
Insane,"  is  exceedingly  interesting,  citing  instances  of  well-known  individuals  who  have 
enjoyed  wide  influence  and  reached  distinction  in  various  fields,  yet  may  have  incidentally  done 


224  BOOK  REVIEWS. 

vastly  more  harm  than  good,  while  fully  admitting  all  the  good  they  may  have  performed. 
Then,  again,  Chapter  V,  "Rights  and  Duties  of  Society  Toward  the  Semi-Insane,"  is  filled  with 
important  warnings  and  explanations. 

The  reviewer  cannot  too  strongly  urge  that  every  clergyman  should  become  familiar  with 
the  salient  points  of  this  exceedingly  interesting  subject.  Physicians,  many  of  them  at  least, 
doubtless  become  aware — usually  most  vaguely — that  the  conditions  herein  described  exist,  but 
painfully  few  of  them  have  such  accuracy  of  knowledge  as  to  enable  them  to  deal  adequately 
with  the  problems  arising,  and  which  must  arise  frequently  in  the  experience  of  everyone  who 
undertakes  the  responsibility  of  curing  deranged  humanity. — J.  M.  T. 

Disorders  of  the  Bladder.  By  Fallon  Cabot,  M.D.  8vo,  225  Pages.  41  Illustrations,  1 
Colored  Plate.     Prepaid,  $2.00.     New  York:    E.  B.  Treat  &  Co.,  1909. 

This  little  book  is  designed  to  teach  general  practitioners  the  principal  methods  of  diag- 
nosing and  treating  disorders  of  the  urinary  bladder,  and  particularly  the  use  of  the  cysto- 
scope.  It  is  a  record  of  personal  experience  chiefly,  rather  than  a  treatise.  There  are  two 
special  chapters,  one  on  the  "Anatomy  of  Kidneys,  Ureters  Bladder,"  etc.,  by  Dr.  George  W. 
Warner,  and  the  other  on  "Urinalysis,"  by  Professor  H.  T.  Brooks.  No  doubt  this  book  will 
prove  of  excellent  utility. — J.  M.  T. 

Bacteriax  Food  Poisoning:  A  Concise  Exposition  of  the  Etiology,  Bacteriology,  Pathology, 
Symptomatology',  Prophylaxis  and  Treatment  of  So-called  Ptomaine  Poisoning.  By  Pro- 
fessor Dr.  A.  DieudonnS,  Munich.  Authorized  Translation,  edited,  with  additions,  by  Dr. 
Charles  Frederick  Bolduan.  8vo,  128  Pages.  Cloth.  Prepaid,  $1.00  net.  New  York: 
E.  B.  Treat  &  Co.,  1909. 

ITie  subject  of  auto-intoxication  and  allied  toxemias  is  of  much  importance,  and  it  is 
necessary  that  praeitioners  should  have  in  their  hands  authoritative  data,  brought  well  up-to- 
date.  The  subjects  treated  are  poisoning  through  meat,  fish  and  molluscs,  cheese,  ice  cream 
and  puddings,  potatoes,  canned  goods,  and  finally  metallic  poisons.  Through  the  untiring  and 
courageous  efforts  of  Dr.  Harvey  W.  Wiley  and  his  final  triumph  in  the  passage  and  enforce- 
ment of  the  Pure  Food  Act  will  perhaps  make  the  clinical  need  for  such  a  book  as  this  less 
imperative,  nevertheless,  it  must  prove  of  great  service.  We  can  never  expect  the  American 
citizen  to  exercise  sufficient  care  in  selection,  preparation  and  eating  of  food.  This  book  will 
put  the  clinician  in  possession  of  facts  scarcely  otherwise  obtainable. — J.  M.  T. 

Reference  Hand-Book  for  Nurses.     By  Amanda  K.  Beck.     Second  Edition,  Revised.     W.  B. 

Saunders  Company,  1908. 

Of  all  the  books  for  nurses  that  have  come  under  the  reviewer's  notice,  this  seems  the  most 
commendable  for  several  reasons:  it  is  a  succinct,  clear  presentation  of  current  views  on  a 
number  of  subjects  which  a  nurse  may  have  sudden  need  to  know  and  recall  to  mind.  Some 
of  the  chapters  are  written  by  special  contributors  and  signed,  which  adds  to  their  authorita- 
tiveness.  Several  very  good  illustrations  and  diagrams  are  introduced,  and  at  the  end  are 
some  blank  leaves  for  memonranda.  It  is  neatly  gotten  up,  with  rounded  corners  and  flexible 
boards,  and  will  no  doubt  prove  a  great  comfort  to  many  forgetful  nurses. — J.  M.  T. 

Diseases  of  the  Spinal  Coed.     By  R.  T.  Williamson,  M.D.   (London),  F.R.C.P.,  Lecturer  in 

Medicine  at  Victoria  University,  Manchester,  etc.     Seven   Plates   and   136   Illustrations. 

Henry  Frowde,  Oxford  University  Press,  and  Dodder  and  Stoughton,  Warwick  Square, 

E.  C,  1908. 

Dr.  Williamson  has  furnished  an  excellent  review — for  it  claims  to  be  no  more — of  the 
whole  subject  of  spinal  cord  disorders.  It  is  full  enough  for  the  average  physician,  well  illus- 
trated and  admirably  systematic.  The  illustrations  are,  with  one  exception,  from  the  author's 
own  drawings  and  photographs,  or  from  microphotographs  of  his  own  sections  and  unusually 
good.  The  book  is  based  upon  regular  lectures  given  by  the  author  at  the  Manchester  Medical 
School  during  the  past  fifteen  years.  Dr.  Williamson  acknowledegs  his  indebtedness  to  a  large 
number  of  authorities,  more  particularly  the  German,  but  including  some  Americans.  The 
book  is  distinctly  attractive  in  style  and  arrangement,  and  the  reviewer  has  already  enjoyed 
the  reading  of  it. — J.  M.  T.  : 


ONTHLY   Cyclopedia 

AND 

Medical  Bulletin 


(PT7BLISHBD  THB  LAST  OF  EACH  MONTH) 


Medical  Bulletin  Section 


Vol.IL  PHILADELPHIA,  APRIL,  1909.  No.  4. 


Clinical  Lectures 


TINEA  VERSICOLOR. 

By  JOHN  V.  SHOEMAKER,  M.D.,  LL.D., 

Professor  of  Materia  Medica,  Therapeutics,  Clinical  Medicine,  and  Diseases  of  the  Skin, 

in  the  Medico-Chirurgical  College  and  Hospital  of  Philadelphia. 

Gentlemen  :  The  patient  before  you  to-day  confronts  us  with  a  chronic 
parasitic  disease. 

There  are  no  subjective  symptoms  or  internal  physical  signs  present  refer- 
able to  his  present  condition.  He  is  twenty-eight  years  old  and  is  a  machinist 
by  occupation.  His  family  history  is  negative  as  to  the  cause  or  heredity  of 
tliis  disease.  Upon  physical  examination  nothing  abnormal  can  be  elicited 
over  his  abdominal  or  thoracic  organs. 

Present  Illness. — The  patient  states  that  three  years  ago  he  noticed  that 
small,  oval,  er}-thematous,  slightly  elevated  spots  developed  upon  his  abdomen, 
back,  chest,  shoulders,  arms  and  thighs.  In  a  short  time  these  lesions  became 
more  numerous  upon  his  chest  and  abdomen.  As  time  went  on  these  lesions 
increased  in  size  by  peripheral  extension  and  others  frequently  coalesced  to  form 
irregular  patches  with  a  sharp  outline.  The  affected  area  is  covered  with  fine, 
furfuraceous,  mealy  scales.  These  scales  are  loose,  scanty  and  adherent  and 
are  always  less  after  the  patient  has  cleansed  himself.  The  scales  are  very 
easily  scraped  off  due  to  their  fineness.  At  first  they  were  light  yellow  but 
now  they  are  of  a  yellowish-brown  color. 

Sometimes  they  form  a  paste  when  the  patient  perspires  freely,  which 
thus  causes  the  patient  to  feel  very  uncomfortable.  He  says  that  the  itching 
which  he  experiences  is  of  a  mild  character. 

The  patient  does  not  present  any  constitutional  symptoms  and  he  is  other- 
wise in  good  health. 

6  (225) 


226 


TINEA  VERSICOLOR. 


Diagnosis. — From  the  character  and  distribution  of  the  eruption,  its 
location  upon  the  chest  and  abdomen,  the  yellowish  color  of  the  lesions  and  the 
tendenc}^  to  form  scales  we  diagnose  this  case  as  tinea  versicolor. 

In  doubtful  cases  the  microscope  will  decide  the  question  and  leave  little 
doubt  as  to  the  character  of  the  disease. 

Differential  Diagnosis. — The  resemblance  between  tinea  versicolor  and 
the  lesions  of  chloasma,  vitiligo,  lentigo  and  the  macular  sypliilide  is  only 
superficial. 


Tinea  Versicolor. 

1.  AfFects  the  horny  layer. 

2.  Patches   aro   elevated   and   composed  of 

furfuraceous  scales. 

3.  Face  is  rarely  involved. 

Tinea  Versicolor. 

1.  Circumscribed  areas  are  discolored. 

2.  Patches  are  elevated. 

Tinea  Versicolor. 

1.  Patches  rarely  involve  the  face. 

2.  Lesions  are  not  covered  with  scales. 

3.  Patches  are  elevated. 

Tinea  Versicolor. 

1.  Color  of  the  lesions  may  vary  from  a 

light-yellow  to  a  dark-brown. 

2.  Eruption   is   elevated   and   composed  of 

furfuraceous  scales. 

3.  Color  of  patches  varies  from  a  light-yel- 

low to  a  dark-brown. 

4.  No  history  of  infection. 

5.  Lesions   rarely  occur    on   the   face   and 

hands. 

6.  Absence  of  sypliilitic  manifestations. 


Chloasma. 

1.  Consists  of  more  or  less  pigmentation  of 

the  mucous  layer  of  the  epidermis. 

2.  Patches  are  smooth  and  not  elevated. 

3.  Face  is  frequently  involved. 

Vitiligo. 

1.  Circumscribed  areas  are  white. 

2.  Borders  of  the  patches  are  more  or  less 

pigmented  and  smooth. 

Lentigo. 

1.  Patches  frequently  involve  the  face. 

2.  Lesions  are  not  covered  with  scale. 

3.  Patches  are  smooth  and  not  elevated. 

Macular  Syphilidc. 

1.  Color  is  never  a  decided  yellow. 

2.  Eruptions    show    neither    elevation    nor 

desquamation. 

3.  Color  is  a  coppery  hue. 

4.  History  of  infection. 

5.  Lesions  may  occur  on  any  part  of  the 

body. 

6.  Other  manifestations  of  syphilis  present. 


Pathology. — The  parasite  of  tinea  versicolor  does  not  attack  the  hair  and 
nails,  and  only  superficially  involves  the  epidermis. 

The  lesions  are  largely  composed  of  the  spores  and  mycelium  of  the  micro- 
eporon  furfur.  The  corneous  layer  is  pemieated  with  a  luxuriant  growth  of 
myceliimi.     It  does  not  penetrate  the  rete  mucosae. 

If  the  scales  be  detached  from  a  spot  and  placed  in  a  drop  of  liquor  potassa, 
and  then  examined  with  a  microscope;  we  will  see  the  mycelium  composed 
of  short,  angular  threads,  which  frequently  terminate  in  spores.  The  spores 
are  oval,  rounded  and  highly  refractive  bodies.  They  may  be  isolated  or  appear 
in  clusters  varying  in  size  from  .0023  to  .0084  millimeters  in  diameter.  The 
spores  manifest  a  tendency  to  cluster  and  are  found  in  aggregations. 

Etiology.— The  cause  of  tinea  versicolor  is  the  vegetable  parasite  micro- 
sporon  furfur.  The  disease  occurs  more  frequently  in  persons  with  harsh 
skins  than  those  whose  integument  is  soft  and  delicate.     It  attacks  either  sex, 


TINEA  VERSICOLOR.  227 

rich  and  poor,  robust  and  weak  and  also  those  individuals  who  bathe  as  well 
as  those  who  do  not  bathe.  The  disease  is  contagious  to  a  mild  degree  and  it  is 
thought  that  the  spores  are  deposited  in  the  underclothing  of  the  patient  either 
through  the  water  which  was  used  to  wash  the  patient's  clothing  or  through 
the  air.     This  disease  is  especially  liable  to  attack  phthisical  individuals. 

Treatment. — A  radical  cure  of  this  disease  is  not  as  easily  accomplished 
as  might  be  inferred  from  the  light  manner  in  which  many  writers  refer  to 
the  subject. 

Patients  usually  receive  an  apparent  cure  but  soon  the  disease  returns 
because  the  parasite  had  not  been  entirely  destroyed.  Persons  suffering  from 
phthisis,  scrofula  or  angemia  who  are  more  predisposed  will  improve  quicker 
when  constitutional  and  external  remedies  are  both  employed.  The  principal 
treatment  must,  of  course,  be  local  in  order  to  destroy  the  parasite.  Water 
seems  to  increase  the  activity  of  the  fungus  and  promotes  the  spreading  of  the 
involved  areas,  therefore  bathing  the  parts  is  interdicted.  The  parts  should  be 
cleaned  by  a  lotion  containing: 

19  Thymolis   oj. 

Alcoholis    fgij. 

Glycerin!    fgiv. 

Misce.     Signa.    Apply  locally. 

This  lotion  will  keep  the  spots  clean,  remove  all  the  sebaceous  deposits 
from  the  surface  and  act  at  the  same  time  as  a  mild  antiparasitic.  After  this 
treatment  has  been  carried  out  for  a  few  days  and  the  scales  soften  and  become 
detached  so  that  a  stronger  antiparasitic  may  be  applied  in  the  form  of  an 
ointment. 

The  most  effective  remedy  is  the  oleate  of  copper  either  diluted  with  oleic 
acid  or  made  into  an  ointment  ten  to  twenty  per  cent.,  with  lard.  The  salts 
of  copper  possess  marked  antiseptic  and  antiparasitic  properties  of  which  the 
oleate  admits  of  the  most  simple  and  most  thorough  application.  It  not  only 
destroys  the  parasite  on  the  surface  but  by  a  deeply  penetrating  action  arrests 
its  development  in  the  interstices  of  the  epidermic  cells.  No  parasitic  skin 
disease  yields  so  readily  to  any  one  remedy  as  tinea  versicolor  will  to  the  oleate 
of  copper.  I  have  succeeded  in  relieving  and  permanently  curing  many  obstinate 
cases  of  this  disease.  It  is  not  necessary  to  apply  the  oleate  in  large  quantities 
because  it  will  readily  penetrate  the  skin  while  a  large  amount  smeared  upon 
the  skin  will  only  discolor  the  linen  without  being  of  additional  service. 

This  treatment  should  be  continued  until  discoloration  and  scales  are  no 
longer  present  and  a  new  healthy  surface  has  formed. 

I  have  removed  the  patches  by  the  daily  application  of  alcohol  with 
friction,  or  alcohol  with  boric  acid  or  betanaphthol. 

Among  the  remedies  valuable  are  one-per-ccnt.  ointments  of  phenol,  chrysa- 
robin,  picrotoxin;   creolin;   and  a  fiftcen-per-cent.  solution  of  chloral  hydrate. 

Prognosis. — If  this  patient  will  carry  out  our  treatment  faithfully  for  a 
few  weeks  he  will  be  cured  entirely.  If  the  parasite  is  not  absolutely  eradicated, 
the  disease  will  reappear  in  the  course  of  a  few  months. 


230  THE  CANCER  PROBLEM. 

course,  much  stretched  and  one  or  two  patients  said  they  had  felt  cracks  in  it 
whilst  trpng  to  curl  the  tongue  back." 

Dr.  Reckard  has  informed  me  that  his  patient  had  no  signs  of  atrophy 
or  of  dr}-ness  in  the  nasopharjTix. 


Original  Articles 

THE  CANCER  PROBLEM.* 

Bx  JOHN  A.  McGLIISTNT,  A.B.,  M.D., 

PHILADELPHIA. 

Assistant  Professor  of  Gynaecology  in  the  Medico-Cbirurgical  College;    Gynaecologist  to 

St.  Agnes's  Hospital. 

In  the  present  era  of  preventative  medicine  and  educational  methods  in 
vogue  inculcating  the  lessons  of  right  living,  there  are  few  diseases  but  show  a 
decrease  in  their  mortality  rate.  Cancer  is,  perhaps,  of  all  others,  the  one 
disease  which  shows  a  progressive  increase,  and  wliich  is  likely  to  continue 
to  progress,  inasmuch  as  we  know  practically  nothing  definite  of  its  etiology 
and,  consequently,  cannot  in  any  way  lessen  materially  its  frequency.  Few, 
perhaps,  except  those  who  have  studied  its  ravages,  realize  what  a  scourge  this 
most  dreadful  disease  is. 

In  1901,  in  the  registration  area  of  the  United  States  which  represented 
a  population  of  31,293,130,  there  died,  20,171  persons,  of  cancer.  A  mortality 
rate  of  G-4.5  per  100,000  population.  In  1906,  of  a  population  of  40,996,317,  the 
deaths  numbered  29,020,  or  a  rate  of  70.8  per  100,000  population.  This  shows 
an  increase  of  6.3  per  100,000  population  for  six  years.  In  the  registration 
area  of  the  United  States  the  deaths  from  cancer  from  1901  to  1906,  inclusive, 
were  as  follows: 

1901  20,171      1904  23,395 

1902  20,847      1905  24,330 

1903  22,325      190G  29,020 

Total  from  1901  to  1906,  110,088.  These  figures,  large  as  they  are,  are  not 
so  startling  when  compared  with  a  disease  like  tuberculosis,  unless  we  realize  that 
the  latter  disease  kills  at  all  ages  and  that  practically  all  the  deaths  from  cancer 
occur  after  the  age  of  thirty-five. 

Quoting  from  Summersi  "Vital  statistics  show,  that  although  a  much 
greater  percentage  of  the  population  reach  middle  life  than  formerly,  fewer 
people  reach  old  age,  i.e.,  the  saving  of  life  in  modern  times  has  mainly  been 
confined  to  the  pre-cancerous  years  of  existence,  the  death  rates  for  males  over 
thirty-five  and  females  over  forty-five  having  remained  almost  stationary,  while 
the  numbers  attaining  old  age  have  decreased"  (Williams) .  "The  increase  in  the 
death  rate  from  cancer  can  only  in  small  measure  be  accounted  for  by  increased 


Read  before  the  Northern  Medical  Society,  Philadelphia,  March  26,  1909. 


THE  CANCER  PROBLEil.  231 

skill  in  diagnosis  and  more  accurate  vital  statistics.  In  England,  while  the 
population  barely  doubled  (1850-1905),  the  cancer  mortality  increased  more 
than  sixfold  (Williams)  and  all  reliable  vital  statistics  go  to  show  that  this 
increase  in  cancer  mortality  is  universal." 

The  following  table  shows  the  annual  average  death  rate  per  100,000  popula- 
tion from  1901  to  1905,  with  the  increase  or  decrease  between  these  years : 

Country.  Rate.                             Increase.         Decrease. 

Switzerland   129.1                                  3.3 

Netherlands   97.4                                    6.2 

Norway   92.9  to  1004             8.9 

England  and  Wales   86.5                                   4.1 

Scotland   82.8  to  1904             2.8 

German  Empire    76.8  to  1904             5.1 

Victoria.  Australia    74.5                                    8.3 

Austria    73.5  to  1903                                       0. 

Ireland    68.6                                    6.8 

^ew  Zealand   67.4                                                           2.1 

South  Australia    67.2                                                           7.0 

Prussia    65.4                                   7.5 

New  South  Wales 64.2                                   4.4 

Queensland  56.9                                  113 

Tasmania    55.9                                                           7.9 

Italv    54.9                                   3.9 

Japkn    52.3  to  1903             1.3 

West  Australia   44.5                                   9.5 

Spain 44.3                                   3.3 

Hungary   38.8                                   2.2 

Jamaica    16.1                                    4.8 

Ser%'ia   9.7                                      .8 

Cevlon   5.6                                                             -7 

United  States   68.3                                  6.8 

From  these  figures  it  will  be  seen,  that,  with  the  exception  of  Austria, 
Xew  Zealand,  South  Australia,  Tasmania  and  Ceylon,  all  other  countries  show 
a  progressive  increase  in  the  cancer  mortality  rate. 

"In  England,  the  registrar-general's  report  shows  that,  in  1906,  out  of  a 
total  of  141,241  deaths  of  males  over  thirty-five  years  of  age,  12,695  died  from 
cancer;  and  out  of  a  total  of  140,607  deaths  of  females  over  thirty-five  years 
of  age,  17,671  died  from  cancer.  This  means  that  one  man  in  eleven  over 
thirty-five  years  of  age  will  die  of  cancer  and  that  one  woman  in  eight  over 
thirty-five  years  of  age  wiU  die  of  cancer.  In  England  the  cancer  death  rate 
for  1905  was,  for  each  100,000  living  75.6  for  males  and  100.5  for  females; 
the  corresponding  phthisis  rates  being  for  males,  134.7  and  for  females,  95.7. 
This  shows  that  more  women  die  of  cancer  than  of  tuberculosis."  (Summers) 

I  have  been  at  work  for  some  time  studying  American  statistics  and, 
while  definite  conclusions  have  not  been  reached,  I  can  state  that  the  American 
figures  are  nearly  in  accord  with  the  English  statistics. 

The  140,088  deaths  which  occurred  in  the  regi.?tration  area  of  the  United 
States  from  1901  to  1906,  were  distributed  as  follows: 

Cancer  of  the  mouth   4.326 

Cancer  of  stomach  and  liver  51,398 

Cancer  of  the  intestines   ' 14,934 

Cancer  of  female  genitals 20,404 

Cancer  of  the  breast 4,683 

Cancer  of  other  and  unspecified  organs 32,697 


230  THE  CANCER  PROBLEM. 

course,  much  stretched  and  one  or  two  patients  said  they  had  felt  cracks  in  it 
whilst  trying  to  curl  the  tongue  back/' 

Dr.  Eeckard  has  informed  me  that  his  patient  had  no  signs  of  atrophy 
or  of  dryness  in  the  nasopharynx. 


Original  Articles 

THE  CANCER  PROBLEM.* 

By  JOHN  A.  McGLINN,  A.B.,  M.D., 

PHILADELPHIA. 

Assistant  Professor  of  Gynaecology  in  the  Medieo-Chirurgical  College;    Gynaecologist  to 

St.  Agnes's  Hospital. 

In  the  present  era  of  preventative  medicine  and  educational  methods  in 
vogue  inculcating  the  lessons  of  right  living,  there  are  few  diseases  but  show  a 
decrease  in  their  mortality  rate.  Cancer  is,  perhaps,  of  all  others,  the  one 
disease  which  shows  a  progressive  increase,  and  which  is  likely  to  continue 
to  progress,  inasmuch  as  we  know  practically  nothing  definite  of  its  etiology 
and,  consequently,  cannot  in  any  way  lessen  materially  its  frequency.  Few, 
perhaps,  except  those  who  have  studied  its  ravages,  realize  what  a  scourge  this 
most  dreadful  disease  is. 

In  1901,  in  the  registration  area  of  the  United  States  which  represented 
a  population  of  31,292,130,  there  died,  20,171  persons,  of  cancer.  A  mortality 
rate  of  G4.5  per  100,000  population.  In  1906,  of  a  population  of  40,996,317,  the 
deaths  numbered  29,020,  or  a  rate  of  70.8  per  100,000  population.  Tbis  shows 
an  increase  of  6.3  per  100,000  population  for  six  years.  In  the  registration 
area  of  the  United  States  the  deaths  from  cancer  from  1901  to  1906,  inclusive, 
were  as  follows : 

1901  20,171      1904  23,395 

1902  20,847      1905  24,330 

1903  22,325      190G  29,020 

Total  from  1901  to  1906,  140,088.  These  figures,  large  as  they  are,  are  not 
so  startling  when  compared  with  a  disease  like  tuberculosis,  unless  we  realize  that 
the  latter  disease  kills  at  all  ages  and  that  practically  all  the  deaths  from  cancer 
occur  after  the  age  of  thirty-five. 

Quoting  from  Summers^  "Vital  statistics  show,  that  although  a  much 
greater  percentage  of  the  population  reach  middle  life  than  formerly,  fewer 
people  reach  old  age,  i.e.,  the  saving  of  life  in  modern  times  has  mainly  been 
confined  to  the  pre-cancerous  years  of  existence,  the  death  rates  for  males  over 
thirty-five  and  females  over  forty-five  having  remained  almost  stationary,  while 
the  numbers  attaining  old  age  have  decreased"  (Williams) .  "The  increase  in  the 
death  rate  from  cancer  can  only  in  small  measure  be  accounted  for  by  increased 


Read  before  the  Northern  Medical  Society,  Philadelphia,  March  26,  1909. 


THE  CANCER  PROBLEM.  231 

skill  in  diagnosis  and  more  accurate  vital  statistics.  In  England,  while  the 
population  barely  doubled  (1850-1905),  the  cancer  mortality  increased  more 
than  sixfold  (Williams)  and  all  reliable  vital  statistics  go  to  show  that  this 
increase  in  cancer  mortality  is  universal." 

The  following  table  shows  the  annual  average  death  rate  per  100,000  popula- 
tion from  1901  to  1905,  with  the  increase  or  decrease  between  these  years: 

Country.  Rate.                            Increase.        Decrease. 

Switzerland    129.1                                    3.3 

Netherlands   97.4                                    6.2 

Norway   92.9  to  1904             8.9 

England  and  Wales   86.5                                   4.1 

Scotland   82.8  to  1904             2.8 

German  Empire    76.8  to  1904             5.1 

Victoria,  Australia    74.5                                    8.3 

Austria   73.5  to  1903                                       6. 

Ireland    68.6                                    6.8 

JS'ew  Zealand   67.4                                                           2.1 

South  Australia    67.2                                                           7.0 

Prussia    65.4                                   7.5 

New  South  Wales 64.2                                   4.4 

Queensland 56.9                                  11.3 

Tasmania    55.9                                                           7.9 

Italy    54.9                                    3.9 

Japan    52.3  to  1903             1.3 

West  Australia   44.5                                   9.5 

Spain 44.3                                    3.3 

Hungary   38.8                                     2.2 

Jamaica    16.1                                    4.8 

Servia   9.7                                      .8 

Cevlon   5.6                                                             -7 

United  States   68.3                                    6.8 

From  these  figures  it  will  be  seen,  that,  -with  the  exception  of  Austria, 
New  Zealand,  South  Australia,  Tasmania  and  Ceylon,  all  other  countries  show 
a  progressive  increase  in  the  cancer  mortality  rate. 

"In  England,  the  registrar-general's  report  shows  that,  in  1906,  out  of  a 
total  of  141,341  deaths  of  males  over  thirty-five  years  of  age,  13,695  died  from 
cancer;  and  out  of  a  total  of  140,607  deaths  of  females  over  thirty-five  years 
of  age,  17,671  died  from  cancer.  This  means  that  one  man  in  eleven  over 
tliirty-five  years  of  age  will  die  of  cancer  and  that  one  woman  in  eight  over 
thirty-five  years  of  age  will  die  of  cancer.  In  England  the  cancer  death  rate 
for  1905  was,  for  each  100,000  living  75.6  for  males  and  100.5  for  females; 
the  corresponding  phthisis  rates  being  for  males,  134.7  and  for  females,  95.7. 
This  shows  that  more  women  die  of  cancer  than  of  tuberculosis."  (Summers) 

I  have  been  at  work  for  some  time  studying  American  statistics  and, 
while  definite  conclusions  have  not  been  reached,  I  can  state  that  the  American 
figures  are  nearly  in  accord  with  the  English  statistics. 

The  140,088  deaths  which  occurred  in  the  registration  area  of  the  United 
States  from  1901  to  1906,  were  distributed  as  follows: 

Cancer  of  the  mouth   4,326 

Cancer  of  stomach  and  liver   51.398 

Cancer  of  the  intestines   14,934 

Cancer  of  female  genitals 20,404 

Cancer  of  the  breast 4,683 

Cancer  of  other  and  unspecified  organs  32,697 


232  THE  CANCER  PROBLEM, 

Their  order  of  frequency  expressed  in  percentages  being: 

Stomach  and  liver   36.4  per  cent. 

Other  and  unspecified  organs    23.7  per  cent. 

Female  genitals 14.7  per  cent. 

Intestines    10.5  per  cent. 

Breast  8.3  per  cent. 

Skin 3.3  per  cent. 

Mouth   3.0  per  cent. 

During  these  years  increases  in  the  rates  of  death  were  shown  in  cancer  of 
stomach  and  liver,  1.8  per  cent.;  mouth,  .4  per  cent.;  intestines,  .6  per  cent.; 
skin,  .1  per  cent.  Decreases  occurred  in  female  genitals,  .4  per  cent,;  heart, 
.1  per  cent;  other  and  unspecified  organs,  2,4  per  cent.  The  latter  decrease 
being  due  in  part  to  more  exact  specification  of  the  site  of  the  disease. 

In  the  light  of  the  foregoing  figures  it  is  needless  to  enter  into  a  lengthy 
discussion  to  prove  that  in  cancer  we  have  a  problem,  the  solution  of  which  is 
vital  to  the  race  and  one  in  which  the  medical  profession  should  take  an  intense 
interest. 

How  is  this  problem  to  be  solved?  Unquestionably  by  the  painstaking 
work  of  the  army  of  men  who  are  devoting  their  lives  to  the  study  of  the 
disease  in  the  laboratories  and  clinics  throughout  the  world.  Eventually  the 
cause  of  cancer  will  be  discovered  and  then  and  not  till  then  can  we  hope  for 
any  measure  that  will  completely  prevent  its  ravages. 

The  embryonic  theory  of  Colmheim  and  the  inclusion  theory  of  Eibbert 
are  no  longer  tenable.  The  work  of  Gaylord,  Clowes,  Calkins,  Hanan,  Loeb 
and  Ehrlich  in  the  laboratories  of  research  have  been  of  surpassing  interest 
and  value,  but  the  nature  of  the  cause  is  distant  as  ever.  Bashford^  says :  "The 
successful  application  of  the  comparative  and  experimental  methods  appears  to 
be  greatly  narrowing  the  field  of  inquiry  and  dismissing  many  explanations  of 
cause — previously  held  with  good  reason — from  further  serious  consideration. 
Although  this  is  the  case  we  still  know  very  little  as  to  its  etiology  beyond  the 
fact  that  it  manifests  itself  under  the  most  divergent  conditions  and  in  such  a 
way  that  we  may  have  to  entertain  the  possibility  of  several  etiological  factors, 
some  of  which  are  external  and  some  internal  to  the  body.  To  these  factors 
wo  are  only  justified  at  present  in  assigning  an  indirect  and  mediate  etiological 
significance.  The  most  satisfactory  explanation  of  the  causation  of  cancer 
will  probably  be  that  implied  by  the  accurate  description  of  the  nature  of  the 
transformation  of  normal  into  cancer  cells  when  this  advancement  in  knowl- 
edge shall  have  been  attained." 

Cullen,3  discusses  etiology  under  the  following  headings: 

Hereditary, 

Traumatism, 

Embryonic  Cell  Inclusion, 

Eibberts  Theory, 

The  Parasitic  Origin  of  Cancer, 

Cancer  as  a  Primary  Disease  of  the  Epithelium. 

In  conclusion  he  states :  "Summing  up  the  various  analyses  as  to  the 
causation  of  carcinoma,  we  find  that  heredity  seems  to  have  little  influence; 


THE  CANCER  PROBLEM.  233 

trauma  as  produced  by  parturition  apparently  bears  a  causal  relation  to  cancer 
of  the  cervix  but  not  to  that  of  the  body.  jSTeitlier  the  theory  of  Colinheim 
nor  that  of  Eibbert  explain  its  origin;  and  the  weight  of  evidence  is  against 
the  parasitic  origin.  The  result  of  many  investigations,  while  giving  us  an 
increased  knowledge  concerning  the  histological  structure  of  carcinoma,  have 
still  left  its  etiology  an  unsettled  question. 

Anders,  in  a  recent  article^*  says:  "Eecent  personal  observations  joined 
with  certain  theoretical  considerations,  have  led  to  the  conviction  that  all  the 
ascertained  facts  relating  to  gastric  carcinoma  harmonize  with  the  microbic 
origin  of  the  disease.  The  clinical  and  pathological  phenomena  observed  are 
clearly  referable  to  a  common  origin,  a  bacillus  or  parasite.  Indeed  many  ex- 
perimentalists have  taken  cognizance  of  this  truth  and  taken  their  bearings 
accordingly,  so  that  eminently  satisfactory  expositions  of  the  general  subject 
are  to  be  found  in  recent  medical  literature.  Unfortunately,  however,  the 
medical  profession  is  still  confronted  with  a  mass  of  conflicting  views  and 
hypotheses.  "I  would  here  briefly  state  a  series  of  facts,  which  show  that  the 
disease  under  consideration  and  microbic  diseases  as  a  class  are  identical  as  to 
cause  and  operation."  He  then  goes  on  to  record  the  observations  of  Hanan, 
Loeb,  Gaylord,  Ehrlich,  Jensen  and  others. 

Eoger  Williams  in  his  recent  work  "The  Natural  History  of  Cancer," 
bombards  with  shot  and  shell,  the  parasitic  origin  of  cancer. 

Eoswell  Park-'^  states  unhesitatingly  his  belief  in  the  parasitic  origin  of  the 
disease.  "We  may  still  believe  with  Virchow  that  carcinoma  is  an  epithelial 
neoplasm  whose  component  cells  are  not  conforming  themselves  to  normal  habits 
or  appearances.  Aroimd  this  truism  the  orthodox  pathologists  and  histologists 
have  built  a  number  of  theories  endeavoring  to  explain  the  reasons  of  such 
changes.  And  thus,  at  the  autopsy  table  and  in  the  laboratory,  they  continue  to 
gaze  through  brass  tubes  and  bits  of  beautifully  polished  glass,  seeking  in  this 
way  to-day  to  find  the  answer  to  the  most  difficult  problem  in  pathology.  And 
while  doing  all  this  they  have  been  studying  mainly  its  terminal  condition, 
coming  into  little  or  no  personal  contact  with  the  disease  in  its  early  and  living 
forms,  and  having  little,  if  any,  concept  of  it  in  the  living,  while  failing  to  be 
struck  by  the  evidences  of  infectivity  which  every  observant  clinician  cannot 
fail  to  note.  His  belief  is  based  on  clinical  and  experimental  evidences."  Other 
writers,  taking  exactly  the  same  evidence  as  Park,  have  proven,  at  least,  to 
their  own  satisfaction,  the  fallacy  of  the  parasitic  origin. 

While  we  can  be  hopeful  that  the  work  being  done  will  result  in  the  dis- 
covery of  the  cause  and  prevention  of  the  disease,  we  must  realize  that  at  the 
present  we  have  no  knowledge  that  would  enable  us  to  treat  with  the  condition 
from  an  understanding  of  its  full  import  nor  is  there  any  reason  to  believe 
that  the  question  promises  an  early  solution.  We  must  realize  then  that  we  are 
facing  a  vital  problem  and  must  combat  it  with  the  weapons  at  hand. 

How  then,  shall  we  handle  this  problem?  Only  from  the  standpoint  of 
cure  and  in  a  small  part,  at  least,  from  that  of  prevention.  As  to  the  latter, 
I  have  reference  to  the  traumatisms  of  parturition  in  relation  to  cervical  cancer. 


234  THE  CANCER  PROBLEM. 

It  is  now  a  uniyersally  accepted  belief  that  cervical  lacerations  predispose 
to  cancer.  Cullen^  states:  "In  fifty  of  our  cases  of  squamous-cell  carcinoma 
of  the  cervix,  in  which  accurate  data  were  available,'^  49  (98  per  cent.)  had  had 
children,  while  17  of  the  50  had  miscarried." 

"When  one  considers  the  large  nmnber  of  women  who  remain  unmarried, 
and  finds  that  nearly  all  of  the  victims  of  squamous-cell  carcinoma  of  the 
cervix  have  had  children,  one  cannot  but  conclude  that  the  injuries  incidental 
to  labor  have  a  potent  influence  in  the  development  of  this  variety  of  cancer." 
Penrose^  says:  "Cancer  of  the  cervix  is  a  disease  of  the  child-bearing 
woman.  It  is  very  rare  in  the  woman  who  has  never  conceived.  Statistics 
show  that  women  who  develop  cancer  of  the  cervix  have  borne  on  an  average 
five  children. 

Ashton9  states :  "So  far  as  our  present  knowledge  serves  us,  it  is  import- 
ant that  lacerations  of  the  cervix  should  be  viewed  in  the  light  of  a  dangerous 
predisposing  cause," 

"The  obstetrician  before  discharging  a  patient  after  confinement,  should 
examine  the  cervix,  and  if  a  laceration  is  found  to  be  present,  it  should  be 
repaired  in  three  to  four  months.  It  should  also  be  the  duty  of  the  general 
practitioner  to  examine  the  cervix  of  all  women  who  consult  him  for  pelvic 
symptoms  and  urge  a  repair  operation  if  a  laceration  is  found.  And,  finally,  I 
would  urge  as  a  routine  practice,  the  examination  of  every  woman  over  forty 
years  of  age  who  has  borne  children  and  the  iumiediate  repair  of  all  lacerations 
of  the  cervix  that  may  be  discovered." 

As  to  cure.  Can  cancer  be  cured?  Undoubtedly.  How?  By  making 
an  early  diagnosis  and  applying  the  proper  remedy.  I  would  not  state  that 
surgery  is  the  only  remedy,  but  would  say  that  it  is  the  best  and  only  in 
exceptional  cases  should  the  X-ray,  radium  and  cataphoresis  be  more  than 
supplementary. 

There  is  a  time  in  all  cases  of  cancers  when  the  disease  is  strictly  a  local 
condition  and  if  removed  at  that  stage  of  the  disease  the  patient  will  be  per- 
manently cured.  There  will  also  come  a  period  in  all  untreated  cases  when  the 
disease  has  advanced  beyond  the  hope  of  removal  and  cure  by  any  known 
measure. 

Bloodgood  has  shown  that  in  cancer  of  the  breast  when  no  axilliary  gland- 
ular involvement  was  present,  85  per  cent,  of  the  cases  were  well  three  years 
after  operation.  When  involvement  of  the  axillary  glands  had  taken  place, 
30  per  cent,  were  well  after  three  years  and  where  the  glands  of  the  neck  were 
also  involved,  but  10  per  cent,  were  well  after  the  same  period  of  time. 

Cancer  of  the  lip,  on  account  of  its  ease  of  early  diagnosis,  can  be  cured  in 
about  90  per  cent,  of  cases. 

Wertheim  reports  22.5  per  cent,  of  cures  in  all  cases  of  cancer  of  the 
cervix.  Other  Gemian  operators  report  as  high  as  48  per  cent,  of  cures  in 
operable  cases.  In  this  country  the  cures  reported  in  all  cases  of  cancer  of 
the  cervix  vary  from  1.5  per  cent,  to  8  per  cent.  This  remarkable  difference 
in  results  between  the  two  countries  is  readily  explainable. 

These  figures,  while  showing  that  cancer  can  be  cured,  are  not  particularly 


THE  CANCER  PROBLEM.  235 

satisfying.  The  trouble  is  that  even  in  those  cases  that  are  considered  operable 
the  diagnosis  has  been  too  long  delayed  to  give  the  best  results.  Operative 
mortality  cannot  be  held  responsible  for  the  high  death  rate.  Cancer  of  the 
lip  from  an  operative  standpoint  has  practically  no  mortality.  Eodman  has 
shown  that  the  operative  mortality  in  cancer  of  the  breast  is  less  than  1  per 
cent.,  and  hysterectomy  should  not  have  a  death  rate  of  more  than  4  per  cent. 

With  our  present  knowledge,  what  then  is  the  solution  of  the  problem? 
Surely  the  making  of  an  early  diagnosis  and  the  immediate  resort  to  treat- 
ment. 

It  is  not  the  purpose  of  this  paper  to  take  up  in  detail  the  methods  of 
making  an  early  diagnosis  of  the  various  organs  of  the  body  which  are  subject 
to  cancer.  I  only  wish  to  add  my  mite  to  the  campaign  of  education  for  the 
necessity  of  early  diagnosis. 

Three  classes  are  to  be  educated :  the  public,  the  general  practitioner  and 
the  surgeon. 

While  I  have  no  apologies  for  the  profession  for  their  shortcomings,  too 
much  blame  is  frequently  placed  undeservedly  on  the  shoulders  of  the  general 
practitioner  for  his  failure  to  bring  his  case  to  early  operation.  The  blame 
frequently  rests  with  the  patient  in  not  consulting  the  physician  early  enough 
and  refusing  to  follow  his  advice  when  given. 

Taussig  in  an  articleio  entitled  "Kecent  Experiences  in  the  Treatment  of 
Uterine  Cancer"  states :  "The  blame  for  the  late  recognition  of  uterine  cancer 
rests  mostly  on  the  woman  herself.  In  about  90  per  cent,  of  the  cases  she  did 
not  at  once  consult  a  physician.  In  about  one-third  of  the  cases  the  careless- 
ness or  ignorance  of  the  physician  was  partly  or  wholly  responsible  for  the 
delay." 

The  question  of  the  education  of  the  public  presents  many  difficulties. 
Many  plans  of  education  through  the  medium  of  the  public  press  and  popular 
magazines  have  been  proposed  and  vigorously  objected  to.  The  principal 
objection  being  that  a  state  of  cancerphobia  would  be  produced  which  would  be 
more  serious  in  its  results  than  the  disease  itself.  Personally  I  do  not  believe 
that  this  would  be  true  in  relation  to  cancer  any  more  than  it  has  been  in 
appendicitis  and  tuberculosis  and  no  one  can  fail  to  recognize  the  immense 
value  in  life  saving  in  these  two  diseases  as  the  result  of  publicity.  That 
education  of  the  public  in  reference  to  cancer  will  bear  fmit  and  be  free  from 
evil  consequences,  has  been  amply  proven  in  Germany,  where,  as  the  result  of 
Winter's  educational  movement,  the  number  of  cases  of  cancer  of  the  cervix 
coming  to  treatment  has  increased  by  80  per  cent,  since  the  beginning  of  his 
camj)aign.  Llore  tlian  that  the  cases  are  seen  earlier  than  ever  before,  and  no 
cancerphobia  has  developed.  The  family  physician  can  wield  a  potent  power  in 
the  education  of  the  public  by  removing  the  fallacies  for  which  his  bretliren  in 
the  past  have  been  mainly  responsible,  and  instilling  into  their  minds  the  truth 
in  relation  to  the  hopes  of  cure  and  the  safety  of  treatment.  And,  finally,  the 
time  has  come  when  we  should  throw  off  the  sliackles,  not  of  ethics  but  of 
tradition.  We  should  take  the  public  into  our  confidence  and  relieve  medicine 
of  the  shroud  of  mysticism  which  has  so  long  encompassed  it.     In  no  way  can 


236  THE  CANCER  PROBLEM. 

we  do  it  better  than  by  speaking  freely  through  that  best  of  all  educators, 
the  public  press. 

The  physician  himself  needs  to  be  educated.  He  should  realize  the 
importance  of  this  subject  and  familiarize  himself  with  the  methods  of  early 
diagnosis  of  the  disease.  Or,  if  the  diagnosis  requires  special  training,  he 
should  at  least  be  ever  alert  to  refer  his  cases  early  for  an  opinion.  I  do  not 
believe  that  all  the  errors  of  diagnosis  of  cancer  are  due  to  ignorance  on  the 
part  of  the  physician  but  I  do  believe  and  know  that  many  are  due  to  the 
worse  sin  of  carelessness.  Surely  one  cannot  plead  ignorance  in  telling  a 
woman,  during  the  cancer  epoch  of  her  life,  that  her  menorrhagia  or  metor- 
rhagia  is  due  to  the  menopause  and  rest  content  with  that  diagnosis  without 
ever  making  a  vaginal  examination?  And  yet  in  my  experience  that  is  pre- 
cisely what  has  occurred  in  nearly  all  inoperable  cases  of  cancer  of  the 
cervix.  I  have  seen  so  many  sad  cases  of  mothers  condemned  to  a  terrible 
death,  as  the  result,  I  might  almost  sa}^,  of  criminal  negligence,  that  I  believe 
such  a  man  is  a  menace  to  the  community  and  should  forever  be  debarred 
from  the  practice  of  his  profession.  There  is  no  excuse  for  such  conditions  to 
exist;  it  is  not  ignorance  nor  even  stupidity,  it  is  wilful  neglect.  As  to  the 
uterus,  so  the  breast  and  other  organs.  When  we  know  that  80  per  cent,  of 
all  breast  tumors  are  malignant  there  is  no  excuse  in  waiting  imtil  the 
case  is  inoperable  before  making  at  least  a  presumptive  diagnosis  and 
advising  proper  treatment.  Neither  should  a  case  presenting  gastric  sjanp- 
toms  be  treated  indefinitely  for  indigestion  without  an  honest  effort  being 
made  to  discover  the  cause  of  the  symptoms. 

The  great  lesson  which  we  physicians  should  learn  is  that  our  profession 
entails  a  great  responsibility.  Sacred  lives  are  placed  in  our  keeping  and  our 
first  duty  is  to  give  the  best  that  is  in  us  to  the  conservation  of  life  and  happi- 
ness of  our  patients.  If  we  fully  realize  this  we  would  find  time  to  study  our 
cases  and  treat  them  properly. 

In  conclusion  the  surgeon  himself  needs  to  be  educated  in  this  subject  of 
cancer.  Here  is  a  disease  in  which  the  so-called  brilliant  surgeon,  the  rapid 
operator,  may  be  and  often  is,  a  menace.  There  is  little  of  the  theatrical 
brilliancy  in  an  operation  for  cancer.  It  is  the  surgeon  who  is  conscientious, 
patient,  painstaking;  w^io  realizes  his  responsibilities  and  who  has  mastered 
the  pathology  of  the  condition  who  will  achieve  results. 

REFERENCES. 

1  New   York   Medical   Journal,    February   27,    1009. 

2  Lancet,  November  21,  1908. 

3  Cancer  of  Uterus,  p.  647. 

4  "The  Nature  of   Carcinoma   in   General,  etc.,"  New  York  Medical  Journal,  November 

21,  1908. 

5  Surgery,  "Obstetrics  and  Gynsecology,"  November,  1908. 
c  Cancer  of  Uterus,  p.  651. 

T  Idem,  p.  174. 

8  "Text-book  of  Diseases  of  Women,"  p.  177. 

9  "Text-book  of  Gynaecologj-,"  p.  415. 

10  Interstate  Medical  Journal,  St.  Louis,  February,  1909. 


PROPHYLAXIS  OF  GONORRHCEA.  237 

PROPHYLAXIS  OF  GONORRHOEA. 

By  THOS.  W.  ROSS,  M.D., 

ASTOBIA,  OBE. 

This  subject  is  one  of  the  most  important  subjects  in  medicine,  yet  it  is 
coolly  passed  over  in  all  our  text-books. 

The  busy  physician  has  neither  the  time  nor  the  inclination  to  ferret  out 
exactly  how  his  patients  get  infected,  but  busies  himself  with  the  treatment. 

The  gonococcus  is  not  a  motile  germ,  and  certainly  cannot  make  its  way 
from  the  vagina  into  the  male  urethra  during  coitus.  Infecting  a  coccus  free 
urethra  with  gonococci  from  culture  produces  typical  gonorrhoea  in  from 
twenty-four  to  forty-eight  hours.  Infection  after  coitus  rarely  takes  place 
under  five  days,  and,  in  the  majority  of  cases,  between  five  and  seven  days. 

How  can  we  explain  this  discrepancy? 

First,  by  the  lack  of  prophylactic  measures. 

Secondly,  by  the  incomplete  prophylaxis  used. 

By  incomplete  prophylaxis,  we  mean  the  ordinar}'  measures  designated  by 
the  ordinary  physician,  consisting  of  antiseptic,  astringent  or  alcoholic  washes, 
medicated  soaps,  etc.  Also  the  use  of  antiseptic  and  germicidal  injections, 
which  only  serve  to  familiarize  the  patient  with  the  use  of  the  hand  syringe 
for  the  resultant  gonorrhoea. 

Internal  medication  as  a  prophylactic  measure  need  only  be  condemned. 

Lack  of  prophylaxis  results  in  gonorrhoea  in  about  95  per  cent,  of  all  cases. 

During  coitus  the  dorsum  of  the  penis  acts  much  the  same  as  the  examin- 
ing finger,  stroking  out  quantities  of  pus  from  the  female  erethra.  This  pus 
mixing  with  the  residual  pus  in  the  vagina,  and  rendered  more  viscid  by  the 
glandular  secretions  during  sexual  excitement,  is  siphoned  out  by  the  piston- 
like action  of  the  penis  and  deposited  among  the  hairy  portion  of  the  peni- 
pubic  jimction.  The  scrotum,  which  is  in  immediate  contact  with  the  perineum 
receives  the  bulk  of  the  material  siphoned  out. 

After  coitus  the  usual  incomplete  prophylactic  measures  are  resorted  to ; 
the  penis  is  washed  with  any  of  the  numerous  washes,  injections  are  taken  and 
internal  medication  resorted  to.  The  hairy  regions  being  neglected,  the  pus 
cells  (containing  the  gonococci)  and  mucus  are  rubbed  off  onto  the  under- 
wear or  trousers,  from  there  to  the  glans  penis  where  they  gain  entrance  into 
the  urethra. 

This  may  take  a  day  or  days,  owing  to  the  vitality  of  the  germ,  or  the 
amount  of  nourishment  in  the  pus  cell. 

The  non-erectile  condition  of  the  penis  with  the  consequent  resting  of  the 
glans  against  the  hairy  portion  of  the  scrotum  also  leaves  the  way  clear  for  the 
gonococci  to  enter  the  urethra. 

It  can  readily  be  seen  tliat  the  simple  asepsis  of  the  penis  alone,  and  all 
the  other  medication  is  absolutely  useless  unlesB  the  hairy  regions  around  the 
pubes  and  scrotum  are  thoroughly  cleansed.  Asepsis  of  the  entire  sexual 
regions  mil  absolutely  prevent  gonorrhxa. 


238  OBSTETRICS  AND  GYNECOLOGY. 

There  will  always  be  the  patient  who  "thought  he  had  gotten  a  virgin/' 
— "who  was  in  a  bad  place  where  there  was  no  water/'  to  say  nothing  of 
the  unclean,  the  braggart  and  the  drunkard  to  keep  our  surgeons  busy  with 
pus  tubes,  and  our  G.  U.  men  boring  out  strictures  until  eternity.  Instead  of 
fatherly  lectures  on  alcohol  and  tobacco,  lead  your  sons  out  into  the  wood-shed, 
when  they  reach  the  age  of  pubertj^,  and  tell  them  how  to  take  care  of  them- 
selves after  coitus.  Advice  of  this  kind  would  bring  more  grandchildren  into 
the  world  and  less  abdominal  operations  on  our  married  daughters. 

Case  I. — Chester  L ;   age  21 ;  character,  honest  and  truthful. 

History. — Patient  presented  himself  complaining  of  urethral  discharge. 
No  previous  history  of  this  symptom. 

Patient  had  only  had  coitus  once  between  the  dates  of  November  28th 
and  December  26th,  that  date  was  December  26th,  and  used  a  condum.  How- 
ever, urethral  discharge  commenced  January  3d,  a.  m. 

Microscopic  Examination. — Gonococci  found  in  discharge  (Gram  stain 
used) . 

Diagnosis. — Gonorrhoea. 

[N.  B.  I  treated  the  young  lady  from  whom  he  contracted  the  disease 
and  she  had  typical  gonorrhoea.] 

Case  II. — Arthur  E.;   "condum";   gonorrhoea,  9  days. 

Case  III. — Boyd  M.;    "condum";   gonorrhoea,  8  days. 


OBSTETRICS  AND  GYNAFXOLOGY. 

By  E.  S.  McKEE,  M.D., 

CINCINNATI. 
SIR  ARTHUK  VERNON   MA  CAN. 


It  is  with  regret  that  the  writer  records  the  death  of  this  distinguished 
obstetrician.  After  qualifying  himself  in  medicine  at  home,  he  went  abroad, 
spending  several  years  in  study  in  Berlin  and  Vienna.  He  it  was  who  intro- 
duced German  ideas  in  gjna^cology  into  Ireland.  He  was  one  of  a  small 
circle  of  youthful  specialists  who  were  known  in  Dublin  as  "The  German 
Band."  It  was  while  he  was  Master  of  the  Eotunda  Hospital,  in  Dublin,  in 
1887,  that  the  writer  came  under  his  teaching  and  has  ever  since  held  him  in 
the  highest  regard.  Early  years  in  the  Eotunda  were  those  of  the  growth  of 
antiseptic  surgery.  He  did  the  first  successful  case  of  Cesarean  section  known 
to  have  been  done  in  Ireland.  He  instituted  great  reforms  in  the  Eotunda 
Hospital  in  the  nursing  system.  The  obstetric  chair  was  one  of  the  irmova- 
tions  which  he  introduced  into  midwifery  practice  in  Dublin.  He  was  president 
of  the  Obstetric  Section  of  the  British  Medical  Association,  at  Dublin  in  1887, 
at  which  the  writer  was  present.  President  of  the  British  Gynecological 
Society,  Honorary  President  of  the  Obstetrical  Section  of  the  International 
Medical    Congress,    at    Berlin,    in    1890.     He   was    president    of    the    Eoyal 


OBSTETRICS  AND  GYNAECOLOGY.  239 

College  of  Physicians  of  Ireland.  In  1893  he  had  conferred  upon  him  the  honor 
of  Knighthood.  He  was  Icing's  professor  of  midwifery,  Trinity  College,  Dublin 
and  Obstetrician  to  Sir  Patrick  Dunn's  Hospital.  He  was  a  striking  figure  in 
the  Dublin  School  of  Obstetrics.  His  forcible  character  led  to  a  brusqueness 
of  manner  which  covered  a  very  generous  and  kindly  disposition.  ]\Iany 
mourn  his  death  as  they  lose  a  beloved  friend  and  a  distinguished  teacher. 

ABORTION  BY  PARSLEY  STEM  FOLLOWED  BY  FATAL  TETANUS. 

Dr.  Scherb,  of  Algiers,  reports  a  case  in  Journal  de  Med,  et  de  Chirugie 
Pratiques,  where  the  use  of  the  parsley  stem  for  producing  abortion,  as  is  a 
custom  in  Algiers  as  well  as  some  few  other  countries,  was  followed  by  a 
fatal  tetanus.  He  noted  in  the  patient  who  had  been  seized  the  day  before  he 
was  called,  marked  trismus,  laryngeal  spasm,  dysphagia,  dyspnoea  and  tachycar- 
dia. Scherb  was  puzzled  till  he  turned  his  attention  to  the  genital  tract,  when 
the  patient  admitted  that  five  days  previously  a  woman  had  passed  a  parsley 
stem  into  her  uterus  and  succeeded  in  provoking  an  abortion  at  the  third  month. 
Within  two  days  the  ovum  was  easily  expelled  and  without  much  hemorrhage. 
Parsley  grows  abundantly  in  Algiers  on  dung  hills  and  soil  the  fit  abode  for 
Nicolaier  and  Eosenbach's  earth  bacillus.  The  volatile  oil  and  the  apiol  in  a 
piece  of  parsley  could  not  set  up  a  tetanus  of  themselves.  The  patient  insisted 
that  the  stem  had  been  carefully  asepticized  before  it  was  used.  The  probability 
and  possibility  of  this  were  both  doubted  by  the  reporter.  Scherb  employed 
active  measures,  big  doses  of  chloral  and  salicylate  of  eserine,  two  bleedings, 
followed  by  intravenous  saline  injections  and  subcutaneous  injections  of 
carbolic  acid  and  tetanus  antitoxine.  There  had  been  five  days  of  incubation 
and  three  of  evolution.  The  latter  was  practically  without  fever,  whilst 
opisthotonos  and  spasms  of  the  muscles  of  the  extremities  were  not  marked 
and  occurred  at  long  intervals.  The  incubatory  period,  five  days,  was  shorter 
than  usual  in  visceral  infection,  while  on  the  other  hand  the  rapid  evolution 
of  the  tetanic  phenomena,  three  days,  was  in  accordance  with  what  has  been 
noted  in  most  cases  of  this  form  of  infection.  It  seems  to  be  the  first  instance 
of  tetanus  introduced  in  this  way.  The  poison  was,  it  is  true,  not  from  the 
parsley  as  such,  but  from  the  bacillus  introduced  into  the  uterus  with  the  piece 
of  vegetable  matter,  which  in  this  case  happened  to  be  parsley. 

ICHTHYOL   IN   GYNECOLOGICAL   PRACTICE. 

Chesner  contributes  a  valuable  article  in  Quinzaine  Therapeutique  on  the 
uses  of  ichthyol  in  gynaecological  practice.  Latteaux,  of  Paris,  has  found  that 
ichthyol  possesses  very  active  bactericidal  properties  and  will  destroy  all  forms 
of  bacteria  in  a  strength  less  than  that  in  which  it  is  used  therapeutically. 
TJnna  has  shown  that  ichthyol  has  marked  effects  in  relieving  congestion.  For 
these  reasons  ichthyol  has  been  favorably  received  by  gynaecologists  and  is  now 
used  very  widely.  Pozzi  has  used  it  continuously  since  1892,  and  has  had 
excellent  results.  Schauta,  of  Strassburg,  and  Freund,  of  Prague,  have  used 
it  with  unvarying  success  in  uterine  infections.     The  high  percentage  of  sul- 


240  OBSTETRICS  AND  GYNECOLOGY. 

phur  in  ichthyol  which  is  present  in  a  specially  combined  state,  gives  it  the  active 
properties  of  nascent  bodies.  This  is  the  reason  of  the  therapeutic  value  of  the 
remedy.  Impurities  of  ichthyol  are  the  cause  of  blisters  and  eruptions  following 
its  use.  In  gjoiaecology  ichthyol  is  generally  employed  in  a  ten-per-cent.  solution 
in  glycerine.  Tampons  of  cotton  are  saturated  with  this  and  applied  to  the 
place  of  inflammation.  Suppositories  of  ichthyol  and  glycerine  or  saturated 
tampons  inclosed  in  gelatin  capsules  are  more  neat  and  convenient.  Supposi- 
tories of  ichthyol  are  also  valuable  in  rectal  troubles,  as  piles,  fissures  and 
fistula.  It  has  also  proved  of  much  value  in  eczema  and  pruritus  of  the  vulva. 
Barduzzi  recommends  the  following  formula  in  pruritus  vulvae.  Ichthyol  10.00, 
menthol  1.00,  dermatol  5.00,  petrolatum  50.00,  apply  two  or  three  times  daily. 
For  eczema  the  following  ointment  is  recommended:  Ichthyol  10.00,  lanolin 
40.00,  essence  bergamot  q.  s.  Ichthyol  has  been  found  useful  in  gynaecology  in 
the  following  conditions:  Congestions  of  all  kinds,  inflammatory  conditions, 
exudations  in  the  genital  region,  as  in  pelvic  peritonitis,  chronic  parametritis, 
chronic  metritis,  inflammation  of  the  ovary  and  Fallopian  tubes,  erosions  of  the 
cervix.  Fallopian  tubes,  cystitis,  the  various  manifestations  of  gonorrhoea  and 
anal  troubles. 

CANCER  OF  THE  BODY  OF  THE  PANCREAS. 

Chauffard,  at  a  recent  meeting  of  the  Academy  of  Medicine  of  Paris, 
reported  three  cases  of  this  relatively  rare  affection.  The  symptomatology  was 
explained  by  the  anatomical  connections  which  seemed  sufficiently  precise  to 
make  the  clinical  diagnosis  possible.  Pain  of  a  special  character  was  the 
chief  symptom.  In  two  it  started  on  the  left  side  on  a  level  with  costal  margin. 
This  pain  little  by  little,  extended  towards  the  middle  line  and  was  localized  in 
the  epigastrium,  low  down  and  above  the  imibilicus,  often  radiating  towards  the 
back,  the  chest,  the  shoulders  and  took  on  a  very  typical  character.  The 
paroxysms  became  more  frequent,  of  longer  duration  and  very  acute,  producing 
a  corset-like  constriction.  The  patients  adopted  a  characteristic  attitude, 
only  finding  a  little  relief  sitting  bent  slightly  forward  with  the  knees  bent  up, 
thus  relaxing  the  abdominal  muscles  as  much  as  possible.  No  food  could  be 
retained  during  these  crises  and  between  the  crises  no  special  dietary  seemed  to 
have  any  preventative  action.  Intestinal  fullness,  a  false  need  of  going  to  stool, 
was  a  symptom  in  two  cases.  In  the  three  cases  no  tumor  could  be  felt,  but 
in  some  the  existence  of  a  deeply  situated  hard  tumor  can  be  felt,  in  the  middle 
line.  There  was  no  enlargement  of  the  supraclavicular  or  inguinal  lymphatic 
glands  and  no  ascites.  Vomiting  was  rare  and  jaundice  appeared  very  late. 
The  gall-bladder  could  not  be  felt  on  palpation  and  the  liver  was  but  slightly 
enlarged.  The  s}Tnptoms  of  cancer  of  the  body  of  the  pancreas  are  entirely 
different  from  those  of  the  head.  In  two  cases  operated  upon  by  Dr.  Tuffler, 
the  patient  was  given  enormous  relief  and  thought  himself  well.  In  spite  of 
the  amelioration  which  was  extraordinary,  but  of  short  duration,  the  disease 
begins  to  again  progress  rapidly  but  the  patients  did  not  have  any  more  suffering. 


COEDUCATION.  241 

Editorial 


COEDUCATION. 

To  the  last  half  of  the  nineteenth  century  must  be  credited  a  decided  ad- 
vance in  the  estimate  put  on  woman  as  a  student  in  an  equal  class  as  men. 
Previous  to  that  time  the  opinion  of  woman's  inferiority  was  so  deep  rooted, 
that  the  fountains  of  knowledge  had  been  sealed  to  her,  and  her  attaining  equal 
rank  with  man  in  scholastic  pursuit  had  met  with  tardy  recognition.  But  now 
things  have  changed — woman  has  won  for  herself  the  recognition  that  she  is 
capable  for  higher  opportunities  in  education.  This  is  seen  in  the  many  female 
schools,  seminaries  and  colleges  that  have  blossomed  up  with  equipments  equal 
to  the  best  of  those  that  young  men  attend. 

The  admission  of  women  to  our  colleges  and  universities  together  with  men 
is  an  old  question  but  nevertheless  it  is  important  in  the  field  of  education. 

The  separation  of  the  sexes  in  education  has  nothing  to  do  with  any 
difference  in  sphere,  for  we  agree  to  give  women  as  good  an  education  as  men. 
But  the  question  of  allowing  them  to  be  educated  together  is  the  question  to  be 
solved.  A  great  many  people  hesitate  to  accept  coeducation  because  they  believe 
that  the  close  association  of  the  boys  and  girls  will  cause  the  boys  to  imitate 
the  girls  and  the  girls  the  boys,  so  that  each  sex  will  run  the  risk  of  losing  some 
of  its  individuality  and  charm. 

The  college  takes  the  young  man  at  the  most  critical  period  of  his  life  and 
retains  the  entire  control  of  him  for  a  period  long  enough  to  form  his  character 
and  give  his  mind  the  training  so  necessary  for  his  future  success.  The  first 
and  most  essential  view  in  regard  to  this  question  is  the  sexual  question.  The 
constant  personal  contact  would  create  immoral  ideas  and  imaginations  which 
would  tend  to  the  ruin  of  the  individual.  In  the  lower  primary  and  secondary 
schools  the  pupil  is  under  the  direct  care  and  supervision  of  his  teacher  and 
parents.  Home  life  and  the  rigid  discipline  laid  down  by  his  father  and  mother 
are  still  the  main  factors  of  his  life.  But,  however,  in  the  higher  schools  with 
the  coming  of  adolescence,  the  whole  state  of  affairs  change.  The  home  life  and 
discipline  are  now  forgotten  and  they  become  only  memories  and  the  constant 
association  with  the  opposite  sex  exposes  and  promotes  premature  emotional 
development.  It  tends  to  spoil  the  manners  of  the  girls,  making  them  coarse, 
mannish  and  boisterous.  The  real  objection  to  coeducation  would  be  the  ten- 
dency to  marriage  at  an  earlier  period  than  is  desirable  and  agreeable  to  most 
parents. 

It  is  certain  that  the  mental  influences  of  both  sexes  are  quite  different 
and  it  is  clearly  understood  that  these  mental  emotions  are  potent  factors  in  the 
maintenance  of  robust  health,  therefore,  the  possible  evils  resulting  from  con- 
stant association,  would  overbalance  the  desirable  robust  health.  The  young 
lady  at  the  time  of  adolcpcence  should  be  guarded  from  any  disturbance.  Every 
possible  provision  for  sound  physiological  common  sense  should  undoubtedly  be 
made  in  the  whole  structures  of  society  for  the  protection  of  its  women.  The 
6 


242  ADHESIVE  PLASTER  FOR  SWELLING  FEET. 

female  sex,  as  a  nile,  is  unable  to  keep  up  with  the  male  sex  and  should  not  be 
permitted  to  compete  with  the  male  sex  in  an  identical  course  of  education. 
Higher  discretion  should  be  maintained  in  preserving  their  health  owing  to  the 
fact  that  they  are  more  wonderfully  made  and  that  greater  physiological  changes 
and  functions  take  place  during  the  period  of  adolescence.  Woman's  physical 
nature  demands  a  difference  in  treatment  as  regards  the  hours  of  study,  the 
time  of  physical  exercise  and  the  character  of  such  exercise;  also  as  to  the 
regularity  and  uniformity  of  the  task  assigned.  She  does  not  possess  the 
physical  process  to  which  the  mental  process  is  analogous.  A  pugilist  or  a 
wrestler  gains  strength  by  hard  training  and  work,  but  he  must  have  a  great 
deal  of  natural  vigor  to  start  with  and  what  he  docs  is  to  stimulate  the 
separation  of  waste  tissue  and  make  his  muscles  as  strong  as  possible.  Women 
however,  are  not  able  to  stand  such  strain  on  their  physical  or  mental  powers, 
which  all  training  whether  physical  or  mental  involves.  It  is  a  well  Imown 
fact  that  although  women  may  eat  and  drink  as  much  as  men,  take  the  same 
kind  of  exercise  and  live  under  the  same  environments,  they  will  not  be  able  to 
lift  as  much,  walk,  ride  or  swim  as  far.  In  other  words  women  do  not  possess 
the  same  enduring  and  physical  powers  as  men  do  and  are  therefore  unfit  to  be 
educated  with  them.  Very  few  girls  can  cope  with  the  same  amount  of  subjects 
as  the  average  man  without  breaking  down  physically  and  becoming  a  nervous 
wreck.  They  cannot  stand  the  same  amount  of  work  which  their  robust 
brothers  can  easily  undertake.  Even  if  they  could  we  cannot  but  believe  that 
quite  a  different  training  is  required  to  fit  the  members  of  the  different  sexes 
for  the  diverse  work  that  will  necessarily  fall  to  their  lot.  Woman  is  by  her 
nature  fitted  for  certain  functions  and  man  for  certain  other  functions  in  the 
social  economy.  Each  class  of  functions  and  the  inherent  right  of  each  sex 
claims  the  right  to  the  best  that  schools  can  give.  But  it  does  not  follow  that 
each  is  to  bear  the  same  burden.  The  natural  inferences  must  be  that  women 
are  too  weak  morally  to  withstand  the  temptations  of  the  male  society,  the 
excessive  freedom  of  manners,  the  sentimentality  and  tlie  love  making  thus  makes 
coeducation  undesirable  and  impracticable.  Since  the  instinctive  and  heredi- 
tary differences  of  the  two  sexes  do  not  develop  until  the  period  of  adolescence, 
it  is  of  no  harm  to  allow  the  two  sexes  to  have  equal  opportunities  and  be  educated 
together  before  this  period. 


lyiateria  Jlcdica  and  Therapeutics 

ADHESIVE  PLASTER  IN  THE  TREATMENT  The  author  places  the  foot  in  extreme 

OF  SWELLING  FEET.  dorsal  flexion  and  then  alternately  fast- 

Dr.    Stabsarzt   Blecher   discourses   on  ens,  first  one  strip  on  the  inner  side  of 

the  treatment  of  swelling  feet  with  ad-  the  foot,  drawing  it  across  the  sole  of  the 

hesive  strips.     He  employs  eight  strips  foot,  then  across  the  dorsal  surface  of  the 

one  inch  wide  and  two  feet  in  length,  foot  and  upon  the  outer  side  of  the  leg. 


ACUTE  MENTAL  CASES. 


APPENDICITIS. 


243 


This  is  continued  till  all  eight  strips  are 
applied.  The  strips  should  first  be 
warmed  and  applied  with  considerable 
force.  A  flannel  bandage  is  placed  over 
the  strips  up  to  the  knee.  The  adhesive 
plaster  may  be  left  in  place  for  three 
weeks.  Patient  is  at  once  able  to  walk 
and  is  saved  a  long,  tedious  treatment  in 
bed.  (Deutsche  Militarztliche  Zeit- 
schrift.)  

ACUTE  MENTAL  CASES,  TEMPORARY 
TREATMENT  OF. 

Drs.  Damaye  and  Mezie  generalize  the 
therapeutic  treatment  for  acute  mental 
cases.  Instead  of  placing  such  patients 
in  formal  commitment,  the  writers  advise 
some  place,  or  part  of  a  place  to  which 
they  may  be  taken,  voluntarily,  and  if 
recovery  permits,  no  stigma  vrill  follow 
the  patient  as  he  goes  through  life.  The 
treatment  is  not  entirely  psychiatric  but 
also  therapeutic.  For  mania,  chloral; 
for  nervous  and  excitable,  bromide;  for 
fears,  morphine  (never  opium)  in  vari- 
able dosage.  Add  to  this  laxatives, 
organotherapy  in  its  modem  extent. 
Lavage  of  stomach  and  intestines,  so 
difiScult  in  the  home,  in  the  hospital  be- 
comes easy  and  effectual.  Hydrotherapy 
must  be  remembered.  Methods  employed 
to  combat  systemic  infection  are  valuable 
in  mental  cases.  Treatment  must  be 
prompt  and  vigorous  if  it  may  succeed. 
(The  Medical  Times,  March,  1909.) 


AN  EARLY  SYMPTOM  OF  PHTHISIS— EN- 
LARGEMENT OF  THE  HEART  AND  LIVER. 

Dr.  S.  Ton  Unterburger,  of  St.  Peters- 
burg, has  found  that:  (1)  The  phthisi- 
cal process  is  in  the  limgs,  the  danger  in 
the  heart.  (2)  A  small  heart  is  not  a 
symptom  predisposing  to  consumption. 
(3)  The  size  of  the  heart  must  be  deter- 
mined by  percussion  according  to  the 
Eontgen  pictures;    no  other  method  is 


reliable.  (4)  The  relative  dullness  can 
be  determined  only  by  light  percussion. 
(5)  The  rapid  enlargement  of  the  right 
heart  in  phthisis  is  related  to  a  congenital 
anlage  and  is  embryologically  closely  con- 
nected with  congenital  predisposition  to 
tuberculosis  in  general.  (6)  Exciting 
causes  of  the  enlargement  of  the  right 
heart  are:  obstruction  in  the  lesser  cir- 
culation, the  toxines  of  tubercle  bacilli 
and  other  microbes,  and  the  toxins  of 
biologic-chemical  products  of  metabolism. 
(7)  The  liver  is  more  sensitive  than  any 
other  organ  in  its  reaction  to  enlargement 
and  weakness  of  the  heart.  (8)  A  clear 
picture  of  enlargement  of  the  liver,  and 
hence  weakness  of  the  heart,  is  obtained 
not  by  palpation,  but  by  percussion  from 
below  upward  toward  the  border  of  the 
liver.  In  most  cases  a  congested  liver  is 
also  quite  sensitive  to  light  palpation. 
(9)  Enlargement  of  the  heart  and  liver 
forms  a  very  important  link  in  the  chain 
of  early  clinical  symptoms  of  pulmonary 
tuberculosis.  (The  Medical  Times, 
March,  1909.)     

APPENDICITIS,    TREATMENT    OF,    BY    A 
NEW  METHOD. 

Dr.  Jaeger  advocates  this  treatment 
only  in  those  who  have  the  disease  of  a 
mild  or  moderately  severe  type  and  in 
those  cases  who  absolutely  refuse  an 
operation.  He  does  not  intend  that  this 
method  should  substitute  surgical  inter- 
ference. His  method  is  based  on  Bier's 
liypera3mia  and  consists  of  dry  cupping 
the  entire  lower  right  quadrant  once  or 
twice  daily  of  one-half  hour's  duration 
and  repeating  the  procedure  to  the  free 
surfaces  that  have  escaped  the  first  cup- 
ping. No  medication  is  otherwise  re- 
sorted to.  The  patient  is  to  fast  two  or 
three  days,  after  which  time  a  liquid 
diet  is  permissible  and  the  cupping 
resorted  to  but  once  a  day.     The  author 


244 


ATROPIN  IN  ASTHMA. 


CARBUNCLE. 


reports  six  cases  of  appendicitis  treated 
in  this  manner,  all  recovering.  In  five 
cases  the  pain  ceased  entirely  after  the 
second  application,  and  in  one  after  the 
fourth  cupping.  In  no  case  was  there  a 
recurrence  within  two  and  one-half 
months  to  one  and  one-quarter  years. 
In  a  severe  case,  continuous  rectal  injec- 
tions of  normal  saline  solution  were  also 
given.  Jaeger  also  advocates  dry  cup- 
ping of  20  to  25  minutes'  duration  with 
6  to  20  cups  every  three  hours  in  those 
cases  while  the  question  of  operation  is 
being  decided.  (Muenchener  Medical 
Wochenschrift,  No.  6,  1908). 


ATROPIN  IN  ASTHMA. 
Dr.  P.  y.  Terray  protests  against  the 
general  neglect  of  atropin  in  treatment 
of  bronchial  asthma.  As  the  affection  is 
a  neurosis,  atropin  is  theoretically  indi- 
cated, and  he  has  witnessed  excellent 
results  from  it  in  certain  cases,  although 
it  is  by  no  means  a  panacea  in  all  cases. 
In  one  case  he  has  succeeded  not  only  in 
arresting  the  attacks  with  it,  but  the 
patient  was  improved  so  that  there  was 
no  recurrence  of  the  asthma  for  ten 
months,  although  the  man  had  been 
constantly  affected  with  it  for  twenty 
years.  Atropin  can  be  advantageously 
used  as  a  substitute  for  or  to  alternate 
with  morphin.  He  describes  the  cases  of 
seven  patients  with  severe  asthma  treated 
with  atropin,  the  results  quite  encourag- 
ing. He  prescribes  the  atropin  in  pills 
containing  each  0.0005  Gm.  (K20  gr-) 
at  first  one  a  day,  then  after  two  or  three 
days  gradually  increasing  to  a  total  of 
from  four  to  six  pills  a  day,  and  then 
gradually  reducing  the  dosage  to  one  pill 
a  day.  The  atropin  not  only  arrests  an 
attack  but  it  seems  to  prevent  recurrence. 
He  never  saw  any  ill  effects  from  this 
dosage.  (]\redizinische  klinik.,  Berlin, 
January  17,  1909.) 


ATROPIN  TREATMENT  OF  ULCUS 
VENTRICULI. 

Dr.  D.  von  Tabora  obtained  good  re- 
sults in  cases  of  ulcus  ventriculi  com- 
plicated with  hypersecretion  and  mus- 
cular insufficiency.  He  administered 
atropin  internally  by  injecting  one 
milligram  morning  and  evening  hypo- 
dermically,  sometimes  three  milligrams 
daily,  for  four  to  ten  weeks.  He  starts 
his  treatment  with  fasting  for  a  few 
days  and  follows  with  the  diet  of  A^on 
Leube,  while  the  patient  keeps  perfect 
rest.  The  valuable  properties  of  the 
atropin  are  attributed  to  its  antispas- 
modic and  narcotic  action.  In  a  short 
time  the  hypersecretion  ceases,  the 
acidity  diminishes,  the  insufficiency  and 
spasmodic  pylorous  contractions  disap- 
pear. His  patients  stood  the  treatment 
well,  and  suffered  only  from  a  dry  throat 
and  accommodation  paralysis.  The  treat- 
ment never  failed  entirely.  (Miinch. 
Med.  Wochensch.,  1908,  No.  38.) 


CARBUNCLE,  TREATMENT  OF. 
Dr.  Max  Grasmann  reports  the  excel- 
lent results  obtained  by  his  method  of 
treating  carbuncles.  He  states  that  a 
carbuncle  is  one  of  the  most  difficult 
problems  which  the  general  practitioner 
has  to  cope  with.  The  best  and  most 
certain  method  is  excision.  The  opera- 
tion must  be  planned  that  all  the  danger- 
ous area  is  removed,  that  the  general 
health  does  not  suffer  from  the  inter- 
ference, that  not  too  much  healthy  tissue 
be  sacrificed,  and  that  while  the  process  of 
healing  is  rapid,  the  scar  resulting  be- 
comes a  smooth  one.  He  makes  a  deep 
crucial  incision  over  the  carbuncle.  The 
skin  flaps  thus  made  are  dissected  from 
the  muscular  fascia  and  packed  under- 
neath with  gauze.  Hot  boro-salicylic 
acid  solution  applied  on  gauze  is  used 
for  stopping  bleeding  and  for  plugging. 


CEREBELLAR  TUMORS. 


CERIUM   OXALATE. 


245 


The  surrounding  skin  can  be  protected 
from  burning  by  smearing  with  fat. 
The  necrotic  tissue  is  then  removed, 
partly  with  scissors  and  partly  with  for- 
ceps. A  sharp  spoon  should  not  be  used. 
A  hot  boro-salicylic  plug  is  applied  and  a 
large  wet  dressing  covers  the  whole 
wound  after  all  the  inflamed  and 
necrotic  tissue  has  been  gotten  rid  of. 
Within  a  week  the  greater  part  of  the 
necrotic  tissue  is  cast  off  and  healthy 
granulations  appear  in  the  wound.  The 
skin  flaps  are  then  brought  into  position 
by  a  few  sutures,  and  the  woimd  is  ren- 
dered as  small  as  possible.  The  only 
points  in  the  treatment  upon  which  he 
lays  emphasis  are  free  and  early  incision 
from  healthy  tissue  to  healthy  tissue 
across  the  carbuncle,  free  exposure  of  the 
necrotic  tissue  after  the  flaps  have  been 
protected,  and  plugging  with  hot  boro- 
salicylic  acid  solutions.  He  has  obtained 
excellent  results  in  his  cases  with  this 
method.  (Deut.  Med.  Woch.,  October 
15,  1908.)  

CEREBELLAE  TUMOES,  TEEATMENT  OF. 

Dr.  Siemerling  by  personal  observation 
of  7  cases  of  cerebellar  tumor,  four  of 
which  concerned  children,  discusses  the 
diagnostic  significance  of  the  various 
symptoms.  Especial  importance  is  at- 
tached to  the  absence  of  the  corneal  re- 
flexes, as  indicative  of  tumors  of  the 
posterior  cranial  fossa.  Lumbar  punc- 
ture enters  chiefly  in  the  treatment  of 
these  cases.  After  having  been  aban- 
doned up  to  a  certain  degree  in  the 
treatment  of  brain  tumor,  this  method  is 
at  present  winning  new  adherents.  The 
pressure  should  be  relieved,  according  to 
the  author,  by  lumbar  puncture,  or  punc- 
ture of  the  lateral  ventricles,  imder  the 
necessary  precautions.  Ventricular  punc- 
ture is  indicated  more  particularly  in 
those  cases  where  the  efficiency  of  lumbar 


puncture  fails,  and  may,  under  certain 
conditions,  serve  to  render  the  patient  fit 
for  operative  interference.  When  the 
diagnosis  is  positive  and  the  side  occupied 
by  the  tumor  has  been  determined,  which 
is  very  important,  an  operation  is  advis- 
able to  guard  against  a  threatened  loss  of 
vision.  In  these  cases  palliative  trephin- 
ing, at  least,  should  not  be  omitted,  as 
recommended  by  the  author.  (Berliner 
klin.,  Woch.,  No.  14,  1908.) 


CERICTM  OXALATE   FOE   EELIEF   OF 
VOMITING. 

Drs.  G.  Baehr  and  H.  Wessler,  New 
York,  discuss  and  give  in  detail  the  real 
worth  and  use  of  cerium  oxalate.  They 
obtained  the  therapeutic  value  by  carry- 
ing out  experiments  upon  animals,  (a) 
To  determine  the  toxicity  of  cerium 
oxalate  and  the  oxalates  of  lanthanum, 
neodymium,  praseodymium  and  thorium ; 
(b)  to  determine  the  effect  of  commer- 
cial cerium  oxalate  on  vomiting  induced 
with  apomorphin  hydrochlorid  and 
ipecac;  (c)  to  determine  the  effects  of 
cerium  nitrate  on  vomiting  induced  with 
apomorphin  hydrochlorid ;  (d)  to  deter- 
mine the  general  effects  of  cerium  nitrate 
on  the  body  and  also  of  the  paths  of 
excretion  of  cerium  from  the  organism. 
They  arrived  at  the  following  conclu- 
sions : 

1.  Commercial  cerium  oxalate  is  non- 
toxic. 

2.  Cerium  oxalate  has  no  inhibitory 
effect  whatever  on  vomiting  of  central 
origin. 

3.  Cerium  oxalate  may  inhibit  vomit- 
ing due  to  local  irritation  of  gastric 
mucosa,  but  only  if  given  in  large  doses 
for  some  time,  so  as  to  coat  the  stomach 
wall  pretty  generally. 

4.  Cerium  oxalate  is  not  absorbed  from 
the  gastro-intcstinal  tract. 

These  four  propositions  show  the  close 


246 


CONGEALED    CARBON    DIOXIDE. 


OXYGEN    FOR    WOUNDS. 


analogy  between  cerium  oxalate  and  bis- 
muth subnitrate.  Both  are  not  absorbed 
by  the  gastro-intestinal  tract.  Cerium 
oxalate  has  been  used,  in  great  part, 
against  the  reflex  vomiting  of  early  preg- 
nancy. At  tlie  present  time  it  is  being 
used  for  relieving  the  irritability  of  the 
stomach  in  alcoholic  gastritis,  others  for 
allaying  the  gastric  disturbances  that 
occasionally  manifest  themselves  in  the 
course  of  infectious  diseases.  It  is  also 
of  value  in  gastric  ulcer,  in  which  the 
vomiting  is  due  to  local  irritation  of  the 
mucous  membrane.  Cerium  oxalate  ac- 
complishes its  purposes  by  mechanically 
coating  the  wall  of  the  stomach.  It 
ought  to  be  administered  in  doses  com- 
parable to  those  in  v/hich  bismuth  sub- 
nitrate  is  given.  (Archives  of  Internal 
Medicine,  Chicago,  January,  1909.) 


CONGEALED  CARBON  DIOXIDE  IN  THE 
TREATMENT  OF  ANGIOMA. 
Dr.  Sauerbruch  reports  very  favorably 
of  the  results  obtained  from  the  treat- 
ment of  cutaneous  angioma  by  the  direct 
application  of  congealed  car])on  dioxide. 
This  method  which  was  brought  under 
the  author's  notice  by  A.  I.  and  E.  Oxner, 
of  Chicago,  will,  it  is  stated,  be  found 
a  simple  and  efficient  means  of  dealing 
with  both  superficial  navi  and  also  with 
small  cancerous  growths  of  the  face. 
The  following  description  is  given  of  the 
technic  of  the  treatment:  From  a 
cylinder  of  carbon  dioxide,  such  as  is 
used  in  making  frozen  microsections,  a 
fairly  strong  Jet  of  the  gas  is  played  on 
to  a  piece  of  cotton-wool;  the  rajjid 
evaporation  of  the  liquid  dioxide  causes 
intense  chilling,  which  condenses  a  por- 
tion of  the  gas  into  a  snowy  powder  with 
a  temperature  of  — 70°  C.  Some  of  this 
solidified  gas  is  applied  to  the  surface  of 
the  nsevus,  where  it  remains  from  ten  to 
thirty  seconds.     The  intense  cold  causes 


extreme  contraction  of  the  blood-vessels 
and  anemia  of  the  growth.  This  is 
repeated  once  or  twice  at  the  same  sitting, 
the  white  flakes  being  applied  to  different 
parts  of  the  vascular  surface.  No  dress- 
ing is  placed  over  the  seat  of  this  opera- 
tion. The  treatment  is  renewed  at  inter- 
vals of  from  eight  to  ten  days  until  the 
tumor  has  completely  disappeared.  In 
its  cosmetic  results  this  method,  it  is 
stated,  compares  favorably  with  those 
that  are  usually  practiced,  and,  more- 
over, is  free  from  pain.  (Zentralbl. 
1  Chir.,  No.  1,  1909.) 


EFFECT  OF  OXYGEN  UPON  WOUNDS  AND 
INFECTIONS. 

Dr.  Burkhardt  in  a  series  of  experi- 
ments upon  rabbits  and  dogs  tested  the 
efl'ect  of  chemically  pure  oxygen  upon 
wounds  and  infections.  In  his  studies  of 
the  inhibitory  influence  exerted  by  the 
oxygen  upon  the  gi'owth,  or  the  toxicity, 
of  pathogenic  bacteria  the  author  ex- 
amined in  the  first  place  the  ordinary 
pus-producers,  notably  the  staphylococcus 
pyrogenes  aureus.  His  findings  may  be 
summarized  as  follows: 

1.  Contact  with  pure  oxygen  gives  rise 
in  wounds  to  a  well-marked  vascular  in- 
jection, and  there  appears  a  state  of  ar- 
terial hyperajmia.  The  wounds  remain 
more  moist  and  the  formation  of  granula- 
tion tissue  is  stimulated. 

2.  Cultures  of  facultative  serobic  bac- 
teria, or  artificial  nutrient  media,  are 
considerably  retarded  in  their  develop- 
ment when  grown  in  an  atmosphere  of 
pure  concentrated  oxygen,  but  they  are 
not  destroyed. 

3.  In  the  animal  body  even  a  supply  of 
oxygen  in  great  abundance  applied  to  the 
infectious  focus  does  not  seem  to  inhibit 
the  growth  of  the  bacteria  to  a  notable 
extent;  neither  is  this  the  case  in  gen- 
eral infections  when  tiie  entire  body  of 


ERYSIPELAS,  VACCINE  TREATMENT  OF. 


247 


the  laboratory  animal  is  bathed  in  oxy- 
gen. The  animal  experiments  indicate, 
however,  that  there  occurs  a  certain 
slight  diminution  in  the  virulence  of  the 
bacterial  poisons. 

4.  In  the  peritoneum  the  contact  with 
pure  oxygen  produces  a  state  of  mild  in- 
flammatory irritation.  A  rather  con- 
siderable hyperleukocytosis  develops,  es- 
pecially in  the  simultaneous  presence  of 
fluids  in  the  abdominal  cavity;  absorp- 
tion in  the  abdominal  cavity  is  retarded. 

5.  Ozone  seems  to  be  better  adapted 
than  ordinary  oxj^gen  for  the  control  of 
infections,  especially  in  body  cavities, 
which  are  easily  filled  with  the  gas.  It 
certainly  appears  promising  to  continue 
the  experiments  with  ozone  in  septic  in- 
fections. (Medical  Eeview  of  Eeviews, 
February  25, 1909.) 


ERYSIPELAS,  VACCINE  TREATMENT  OF. 
The  results  of  the  use  of  a  vaccine  pre- 
pared from  Fehleisen's  Streptococcus  ery- 
sipelatis  are  reported  and  discussed  by 
Drs.  G.  W.  Eoss  and  W.  J.  Johnson, 
Toronto.  They  employed  the  vaccine  in 
fifty  cases,  and  from  this  experience  they 
firmly  believe  that  when  properly  admin- 
istered it  exercises  a  specific  and  con- 
trolling influence  on  the  course  of  tlie 
disease — preventing  its  spread,  lessening 
its  severity,  and  hastening  recovery.  In 
the  first  sixteen  cases  they  followed  the 
method  of  opsonic  therapy,  but  the  re- 
sults were  so  satisfactory  that  in  the 
remainder  they  felt  justified  in  omitting 
the  usual  opsonic  blood  examinations  and 
had  equal  success  in  the  remaining  cases, 
many  of  which  were  severe.  They  admit, 
however,  that  in  certain  severe  cases  the 
usual  thorough  blood  examination  may  be 
required.  It  is  unnecessary,  they  say,  to 
prepare  a  vaccine  for  each  case,  but  it  is 
advisable  to  have  a  composite  stock  of 
vaccine  from  several  different  strains  and 


as  many  different  cases  and  it  is  probable 
they  think  that  the  more  virulent  the 
case  of  erysipelas  the  more  valuable  will 
its  streptococcus  be  as  a  vaccine.  Their 
method  has  been  in  almost  every  case  to 
inoculate  with  10,000,000  of  dead  strep- 
tococci on  the  first  visit  if  the  case  is  a 
severe  one  and  with  20,000,000  if  the 
case  is  less  severe.  On  the  second,  in  a 
severe  case,  the  patient  gets  10,000,000 
if  there  be  signs  of  improvement.  The 
most  important  of  these  signs  is  a  certain 
clearing  of  the  intellect  and  the  next  are 
the  lessened  tenderness  and  pain.  The 
temperature  is  not  so  valuable,  though  a 
fall  of  two  or  three  degrees  on  the  morn- 
ing following  the  injection  is  a  valuable 
indication  for  a  second  inoculation.  If, 
however,  no  evidence  of  improvement  fol- 
lows in  the  severe  case  and  it  is  impossible 
to  detennine  the  opsonic  power  of  the 
blood,  then  5,000,000  only  should  be 
given  on  the  second  day.  In  less  severe 
cases  improvement  is  almost  always  mani- 
fest on  the  day  after  inoculation  and  the 
patient  sliould  receive  but  half  the  first 
dose;  that  is,  10,000,000.  They  then 
inoculate  with  5,000,000,  10,000,000,  or 
20,000,000  of  streptococci  on  every  sec- 
ond day  until  a  week  after  temperature 
has  reached  normal  and  the  er}i;hema  has 
subsided.  They  arc  guided  as  to  the  dose 
in  each  case  (when  opsonic  investigations 
are  impossible  or  unnecessary)  by  its 
severity  and  the  unsatisfactory  results  as 
shown  by  clinical  observation.  The  rule 
is  "The  more  severe  the  case  and  the  less 
satisfactory  the  clinical  response  the 
smaller  the  dose."  The  site  of  inocula- 
tion has  always  been  chosen  away  from 
the  involved  area.  They  have  been  so 
successful  they  have  not  felt  it  necessary 
to  attempt  inoculation  near  the  site  of 
infection.  Nineteen  cases  observed  by 
them  in  1907  which  were  treated  in  tlie 
ordinary  way  are  tabulated  and  compared 


248 


FIBROLYSIN. 


GENITAL  TUBERCULOSIS. 


with  an  equal  number  treated  in  1908  by 
inoculation  and  the  advantages  of  the 
later  method  in  the  way  of  shortening  the 
duration  of  the  disease,  avoidance  of 
complication,  etc.,  are  very  manifest. 
(Journal  American  Medical  Association, 
March  6,  1909.) 


FIBROLYSIN  IN  PLEURAL  ADHESIONS. 

Dr.  Schniilgen  discusses  the  deposition 
of  fibrin  that  takes  place  after  the  more 
or  less  complete  absorption  of  a  pleural 
effusion.  This  leads  to  adhesions  be- 
tween the  two  layers  of  pleura,  and  thus 
binds  down  the  lung  to  the  chest  wall  or 
the  diaphragm.  The  author  points  out 
that  when  this  affection  is  recurrent,  as  is 
the  case  in  tuberculosis,  an  induration  of 
over  Y2  inch  in  thickness  may  be  formed. 
The  results  of  such  adliesions  and  indura- 
tion on  the  pulmonary  circulation  need 
no  special  description.  The  clinical 
symptoms  of  such  adhesions  are  dimin- 
ished breath  sounds,  loss  of  vocal  fremi- 
tus, and  dullness  on  percussion.  Pain  is 
complained  of.  Subjective  symptoms 
may,  however,  be  very  slight.  The  treat- 
ment usually  adopted  in  such  cases  is 
painting  the  chest  with  iodine,  applying 
iod.  vasogen,  and  lung  gymnastics,  but 
the  results  of  these  forms  of  treatment 
are  rarely  apparent.  When  gymnastics 
are  combined  with  fixation  of  the  healthy 
lung,  by  means  of  pneumatic  apparatus, 
better  effects  are  obtained.  Since  fibro- 
lysin  (thiosinamin  and  sodium  salicy- 
late) has,  within  recent  times,  been 
highly  recommended  for  a  large  variety 
of  internal  and  external  scar  formations, 
the  author  determined  to  try  it  in  pleural 
adhesions.  He  used  Merck's  prepara- 
tion, which  contains  2.3  c.c.  of  fibrolysin 
in  each  capsule,  and  injected  this  dose 
either  locally  or  in  the  gluteal  muscles. 
The  injections  were  repeated  once  or 
twice  every  week  according  to  the  severity 


of  the  case.  In  the  majority  of  the 
cases  the  injections  were  painless,  and  the 
only  undesired  effects  were  occasional 
slight  rises  in  the  temperature,  slight 
feelings  of  tiredness,  and  headache.  The 
objective  and  subjective  symptoms  dimin- 
ished markedly,  and  in  some  cases  with 
extraordinary  clearness.  In  reviewing 
his  cases  he  states  that  fibrolysin  applied 
immediately  after  the  fusion  is  com- 
pletely absorbed,  and  signs  of  beginning 
pleural  adhesions  can  be  made  out,  is 
often  followed  by  good  results,  and 
should  therefore  always  be  tried.  (Brit- 
ish Medical  Journal,  February  27,  1909.) 


GENITAL  TUBERCULOSIS,  TREATMENT 
OF. 

Dr.  F.  J.  McCann  notes  a  growing  ten- 
dency toward  conservative  surgery  in 
the  treatment  of  genital  tuberculosis. 
This  is  destined  to  increase  with  advanc- 
ing knowledge  concerning  the  curability 
of  many  varieties  of  tuberculous  disease. 
If  there  is  no  evidence  of  tubercle  in  the 
ovaries  they  certainly  should  not  be  re- 
moved, and  if  the  infection  is  only  slight 
there  is  still  no  reason  why  they  should 
be  sacrificed,  for  tuberculous  foci  can,  if 
necessary,  be  excised.  The  formation  of 
a  pyosalpinx  is  a  definite  indication  for 
surgical  treatment,  which  is  best  effected 
by  the  abdominal  route.  Aspiration  of 
the  pus  sacs  followed  by  the  employment 
of  an  appropriate  vaccine  would  seem  to 
be  the  ideal  treatment.  When  the  uterus 
is  only  slightly  involved — e.g.,  miliary 
tubercles  being  evident  on  its  peritoneal 
surface — it  should  not  be  removed,  as  it 
is  illogical  and  unscientific  to  remove  this 
organ  while  leaving  undisturbed  a  wide- 
spread infection  of  the  intestine,  omen- 
tum and  mesentery.  (American  Jour- 
nal of  Obstetrics  and  Diseases  of  Women 
and  Children,  February,  1909.) 


HYDROGEN  PEROXIDE. 


INSOMNIA  IN  HEART  DISEASE. 


249 


HYDROGEN  PEROXIDE  IN  MEDICINE. 
Dr.  E.  Friedlander  highly  recommends 
"perhydrol"  formerly  hydrogen,  peroxide 
in  dilution  1 :  9  in  fistulas  and  abscesses  of 
the  antrum  of  Highmore,  and  in  wounds 
and  ulcers  of  the  mouth  in  general. 
Some  authors  use  it  in  the  place  of  abso- 
lute alcohol  to  irrigate  carious  cavities, 
others  in  pyorrhea  alveolaris.  Before 
operating  on  the  mouth  or  teeth,  there  is 
nothing  better  to  sterilize  the  parts  than 
diluted  perhydrol.  Good  results  are  also 
obtained  in  stomatitis,  especially  if  syph- 
ilitic, aphthous  or  ulcerous.  Perhydrol 
should  replace  borax,  potassium  perman- 
ganate and  potassium  chlorate,  as  it  is 
far  superior  to  all  these  drugs  and,  in 
addition,  is  harmless.  A  one-per-cent. 
solution  of  perhydrol  will  usually  kill  all 
germs  in  from  five  to  twenty  minutes. 
The  free  use  of  perhydrol  as  mouth  wash 
will  often  prevent  disease  of  the  upper 
air  passages,  and  sprays  have  recently 
been  recommended  as  the  efficient  means 
of  prophylaxis  in  measles.  The  addition 
of  perhydrol  to  mouth  washes  renders 
them  more  antiseptic.  Finally,  the  drug 
does  good  service  in  hyperesthetic  dentin, 
before  drilling  or  scraping.  This  prep- 
aration of  perhydrol  is  absolutely  pure 
and  is  concentrated  30  per  cent.  (Aerzt. 
Vierteljahrs-Eundsch.,  1908,  No.  3.) 


INFANTILE  MENINGITIS,  TREATMENT 
OF. 
Dr.  Eoque  Macouzet  classifies  menin- 
gitis as  arising  from  (1)  acute  general 
infections,  such  as  influenza,  pneumonia, 
scarletina  or  gastro-intestinal  conditions ; 
(2)  tuberculosis;  (3)  suppurations  of 
the  nose,  throat  or  ear;  (4)  trauma;  (5) 
marasmus  and  inanition.  The  exciting 
cause,  micro-organismal  as  it  may  be, 
coming  upon  selected  soil  produces  the 
disease.  A  specific  form  due  to  the 
menincrococcus  intracellularis  of  Weich- 


selbaum,  may  be  diagnosed  by  its  recov- 
ery through  lumbar  puncture.  Kemig's 
sign  is  esteemed  highly  in  Mexico  and  is, 
by  its  early  recognition  more  valuable. 
In  the  treatment  one  must  determine  any 
cause  of  irritation,  digestive  or  respira- 
tory and  treat  each  secundum  artem. 
Lumbar  puncture,  which  in  babies  is  done 
between  the  third  and  fourth  vertebrae, 
has  not  proven  of  more  than  diagnostic 
value,  except  when  the  tension  of  the 
cephaloracliidian  fluid  indicates  relief. 
Castor  oil  is  administered  with  excellent 
results  in  Mexican  practice.  (The  Medi- 
cal Times,  March,  1909.) 


INSOMNIA  IN  HEART  DISEASE,  TREAT- 
MENT OF. 

Dr.  F.  J.  Wethered  states  that  sleep- 
lessness is  often  one  of  the  most  prom- 
inent causes  of  distress  in  chronic  cardiac 
disease.  Of  all  drugs  he  has  found 
chloralamide  the  most  satisfactory.  It 
may  be  given  at  first  in  doses  of  20  to 
30  grains,  suspended  in  mucilage  or  dis- 
solved in  rectified  spirits.  The  dose  may 
be  increased  until  60  to  70  grains  are 
given  nightly.  The  use  of  the  drug 
should,  however,  be  suspended  at  inter- 
vals, and,  of  course,  if  possible,  the  dose 
should  be  generally  lowered.  The 
author  has  also  found  veronal  (gr.  5) 
also  useful  in  cardiac  cases.  Sulphonal, 
triphonal  and  tetronal  have  not  yielded 
uniform  results  in  the  cases  in  which  he 
has  prescribed  for  them.  Sleep  is  essen- 
tial in  cardiac  cases  and  occasionally  re- 
sort must  be  had  to  opium  or  morphia, 
although  symptoms  giving  rise  to  anxiety 
are  sometimes  manifested,  particularly  if 
there  are  pulmonary  complications.  Ap- 
prehensiveness,  irritability,  restlessness 
are  prominent  symptoms  of  failing  heart. 
The  addition  of  bromide  of  sodium  of 
hydrobromic  acid  to  the  treatment  sug- 


250 


MOVABLE  KIDNEY. 


ORTHOSTATIC  ALBUMINURIA. 


gested  above  will  often  have  a  calming 
effect.     (Folia  Therapeutic-s.) 


MOVABLE  KIDNEY,  TREATMENT  OF. 

Dr.  A.  B.  Bevan  points  out  tliat  in  30 
per  cent,  or  more  of  women  who  come  to 
us  for  a  general  physical  examination,  the 
right  kidney  is  so  movable  that  the  entire 
organ  can  be  palpated.  This  condition 
is  so  common  and  so  seldom  gives  rise  to 
symptoms  that  it  cannot  be  regarded  as 
pathological.  In  spite  of  the  fact,  how- 
ever, many  of  these  cases  are  improperly 
subjected  to  an  operation  to  fix  the  kid- 
ney and  cure  the  patient  of  a  great  train 
of  vague  symptoms  which  have  been  at- 
tributed to  these  slightly  movable  kidneys. 
Experience  has  shown,  however,  that 
these  symptoins  persist  after  these  opera- 
tions, proving  that  they  have  nothing  to 
do  with  the  condition.  Again,  operations 
have  been  too  often  done  to  fix  one  or 
both  kidneys  in  cases  where  the  mova- 
bility  of  the  kidneys  was  but  one  of  the 
evidences  of  a  general  visceroptosis. 
Here  kidney  fixation  does  more  hami 
than  good.  The  operation  of  nephro- 
pexy, or  nephrorrhaphy,  is  an  operation 
of  distinct  value  in  a  limited  number  of 
cases.  These  are  cases  of  extreme  mobil- 
ity with  definite  symptoms,  such  as 
Dietl's  crises,  due  to  temporary  obstruc- 
tion of  the  ureter,  or  distinct  pain  and 
distress  which  can  be  clearly  traced  to 
the  misplacement  of  the  organ.  The 
operation  of  choice  is  the  partial  decap- 
sulation and  stitchiug  of  the  capsule  flaps 
to  the  edges  of  the  wound,  so  that  they 
become  incorporated  in  the  posterior 
linear  scar  as  in  Tuffier's  operation.  In 
well-handled  surgical  clinics  to-day  the 
operation  for  kidney  fixation  is  seldom 
done,  and  then  only  in  well-selected 
cases.    (Ind.  Med.  Jour.,  January,  1909.) 


ORTHOSTATIC  ALBUMINURIA. 
Dr.  Jehle  describes  a  new  etiologic 
factor  which  explains  the  clinical  appear- 
ance of  this  condition.  He  shows  as  a 
result  of  many  experiments,  that  albumin- 
uria is  constantly  absent  when  the  spines 
of  such  patients  are  kept  perfectly 
straight  or  have  only  a  slight  kyphotic 
curve.  When,  however,  the  spine  is 
changed  into  a  position  of  slight  lordosis, 
albumin  will  immediately  appear  in  the 
urine.  He  claims  that  the  cause  of  the 
albuminuria  lies  not  in  the  "orthostatic" 
position  of  the  body,  but  is  the  result  of 
any  position  of  the  body  which  produces  a 
lordosis.  The  albuminuria,  therefore,  is 
not  "orthostatic"  but  "lordotic."  The 
author  had  several  children  with  this  con- 
dition in  whom  albumin  never  appeared 
when  the  spine  was  held  with  a  plaster 
cast  so  that  no  lordosis  of  the  dorsal 
vertebrae  was  possible,  but  when  the  cast 
was  removed  and  the  lordotic  position 
resumed  the  albumin  would  reappear. 
He  argues  that  lordosis  is  the  causative 
factor  of  the  albuminuria  and  that  there 
are  no  pathological  changes  in  the  kidney. 
Albuminuria  was  produced  in  one  case  in 
five  minutes  by  direct  pressure  on  the 
inferior  vena  cava  above  the  entrance  of 
the  renal  veins.  Artificial  lordosis 
caused  the  appearance  of  albumin  in  two- 
thirds  of  the  normal  children  which  as- 
sumed artificial  lordosis.  He  claims  that 
the  albuminuria  is  the  result  of  the  pres- 
sure of  the  spine,  when  in  a  lordotic  posi- 
tion, producing  a  congestion  of  the  renal 
veins. 

His  conclusions  are  as  follows: 
Orthostatic  albuminuria  is  the  result 
of  an  abnormal  position  of  the  body 
which  is  the  result  of  lordosis  of  the  dor- 
sal vertebras.  The  cause  of  lordosis  is  a 
laxness  of  the  ligaments  of  the  vertebrae 
and  a  weakness  of  the  abdominal  muscles 
which  occurs  during  the  period  of  most 


PARALYSIS   OF   SHOXILDER. 


PERNICIOUS   ANEMIA. 


251 


rapid  growth.  The  albmniimria  persists 
as  long  as  an  abnormal  position  of  the 
body  exists.  This  disappears  generally 
when  the  rapid  period  of  growth  is  over. 
Orthostatic  albuminuria  in  adults  is 
due  to  the  same  cause.  (Jahrbuch  fiir 
Kinderheilkimde,  November,  1908.) 


PARALYSIS  OF  THE  SHOULDER,  MECHAN- 
ICAI  TREATMENT. 

Dr.  David  Silver  says  the  disability  of 
paralysis  of  the  shoulder  is  the  result  of 
direct  sinking  of  the  head  away  from  the 
socket,  insecurity  of  the  head,  and  con- 
traction of  unaffected  muscles.  The 
damaged  nerve  cells  may  recover  suffi- 
ciently to  functionate,  but  in  the  mean- 
time the  muscles  be  incapacitated  by 
overstretching  and  atrophy  from  disease, 
is  well  known.  If  these  evils  have  not 
been  avoided  by  timely  measures,  it  is 
still  possible  at  a  later  stage  to  do  some 
good  by  maintaining  the  paralyzed  mus- 
cles in  a  position  of  maximum  relaxation, 
and  thus  permitting  retraction  to  take 
place.  In  the  application  of  this  prin- 
ciple of  treatment  to  the  shoulder  the 
author  makes  use  of  a  modification  of 
]\ronk's  wire  splint,  putting  up  the  arm 
with  hand  supinated,  elbow  flexed  and 
pahn  resting  upon  the  top  of  the  head. 
Three  cases  are  reported  in  which  the 
method  was  followed  by  good  results. 
Since  the  method  is  a  conservative  one, 
its  use  is  recommended  in  all  cases  not 
known  to  be  completely  paralyzed.  While 
in  some  cases  the  paralysis  is  so  extensive 
that  the  remaining  power  will  be  insuffi- 
cient even  when  developed  to  the  highest 
degree  of  efficiency,  to  maintain  contact 
between  the  head  of  the  humerus  and 
the  glenoid,  in  others  it  may  be  sufficient 
to  maintain  contact  and  no  more,  yet 
there  are  still  others  with  a  greater  degree 
of  recovery  of  the  nerve  lesion,  in  which 
a  Tarying  amount  of  active  abduction  will 


be  secured.  The  use  of  the  method  is 
also  recommended  as  a  preliminary 
measure  to  muscle  grafting.  (American 
Journal  of  Orthopedic  Surgery,  Novem- 
ber, 1908.) 

PERNICIOUS  ANEMIA,  TREATMENT  OP, 
Dr.  Byron  Bramwell  reports  a  nimaber 
of  cases  of  pernicious  anaemia.  He  gives 
full  notes  on  one  of  these  cases  with  no 
oral  sepsis  whatever.  There  was  no 
glossitis  and  no  dental  caries.  The 
writer  claims  that  he  has  found  no  oral 
sepsis  in  any  of  his  cases,  and  does  not 
believe  this  has  the  influence  in  the  pro- 
duction of  the  disease  which  some 
authorities  have  suggested.  He  believes 
that  the  glossitis  from  which  many  pa- 
tients who  are  affected  with  pernicious 
anaemia  suffer  as  a  consequence  rather 
than  a  cause;  due  presumably,  to  the 
same  toxin,  whatever  it  may  be,  which  is 
the  cause  of  the  anaemia.  In  treatinsr 
these  cases  a  certain  degree  of  improve- 
ment took  place  under  arsenic,  arrest  of 
the  improvement  occurred,  and  in  which 
the  administration  of  iron  was  attended 
with  very  marked  and  rapid  alteration  for 
the  better.  It  has  long  been  recognized 
that  in  typical  cases  of  pernicious 
anaemia,  in  which  the  color  index  is  above 
the  normal  amount  of  hemoglobin,  the 
administration  of  iron  is  not  usually 
attended  with  benefit,  and  is,  in  many 
cases,  apparently  injurious.  (British 
Medical  Journal,  January  22,  1909.) 


RHEUMATISM,  TREATMENT  OP. 

Dr.  N.  S.  Davis  says  that  there  is  still 
clinical  evidence  that  the  alkaline  treat- 
ment, though  it  can  no  longer  be  regarded 
as  specific,  has  a  beneficial  action  in 
preventing  cardiac  complications.  The 
nearest  to  a  specific  in  rheumatism  are 
the  salicylates,  especially  the  salicylate  of 
sodium,    but    the    known    physiological 


252 


SABROMIN. 


SALINE   INJECTIONS   IN    SCIATICA. 


effects  of  these  remedies,  analgesic  and 
antipyretic  action  in  this  disorder.  They 
are  not  equally  effective  in  other  arthritic 
affections,  and  in  acute  articular  rheiuna- 
tism  they  do  not  lessen  the  liability  to 
cardiac  complications,  another  fact  that 
is  not  readily  explainable.  The  most 
reliable  of  the  salicylates  in  the  author's 
opinion  is  the  salicylate  of  sodium  and 
the  stomach,  in  his  experience,  has 
tolerated  best  that  form  of  salicylate  of 
sodium  which  is  made  from  oil  of  winter- 
green.  All  the  salicylates  are  most 
agi'eeably  administered  in  capsules.  Half 
a  gram  of  salicylate  of  sodium  can  be 
given  in  this  way,  and  two  capsules  will 
make  an  average  dose.  A  sufficient  quan- 
tity of  water  should  be  taken  with  the 
capsules  to  ensure  the  prompt  solution 
and  dilution  in  the  stomach.  A  charged 
solution  of  bicarbonate  of  sodium  or 
effervescing  sodium  and  potassium  citrate 
may  be  drunk  instead  of  water,  thus  com- 
bining the  salicylate  and  alkaline  treat- 
ments. Other  drugs  may  be  substituted 
for  the  salicylates  in  rheumatism,  but 
they  have  their  disadvantages.  Anti- 
pyrin  may  be  effective,  but  it  increases 
the  anoemia,  and  the  convalescence  is 
prolonged.  Other  coal-tar  preparations 
are  open  to  similar  objections,  and  if 
given  in  sufficient  doses  may  be  dan- 
gerous. Consequently,  they  should  be 
adapted  for  very  mild  cases  of  short  dura- 
tion. (Journal  of  the  American  Medical 
Association.) 


SABROMIN,  A  NEW  BROMIDE  PREP- 
ARATION. 

Dr.  V.  Mering  has  investigated  the 
action  of  sabromin,  the  dibrombehenate 
of  calcium,  so  called  from  its  analogous 
composition  to  that  of  sajodin,  the 
monoiodbehenate  of  calcium.  The  for- 
mula of  sabromin  is  (C22H4i02Br2)2Ca, 
and  it  contains  29  to  30  per  cent,  of 


bromide.  It  is  a  colorless,  odorless,  and, 
in  contrast  to  the  alkaline  bromides, 
tasteless  powder,  well  borne  by  the 
stomach,  where  it  is  converted  into 
dibrombehenic  acid,  a  substance  which 
has  no  action  upon  the  stomach,  and  only 
becomes  absorbed  when  it  has  passed  into 
the  intestine.  The  author  finds  the 
action  of  sabromin  to  be  less  prompt,  but 
more  lasting,  than  that  of  the  alkaline 
bromides.  He  considers  the  drug  espec- 
ially suitable  for  hysteria,  neurasthenia, 
nervous  excitation,  palpitation,  sense  of 
anxiety  and  nervous  insomnia.  V.  Mer- 
ing usually  prescribes  1  gram  two  or 
three  times  daily,  but  he  has  given  as 
much  as  6  grams  daily  over  a  long 
period.  Potassium  bromide  contains  67 
per  cent,  of  bromide,  while  sabromin  only 
contains  30  per  cent.,  and  since  the  thera- 
peutic effect  of  the  latter  equals  that  of 
the  former,  wliile  the  dose  is  about  the 
same,  it  follows  that  a  smaller  quantity 
of  bromide  is  required  when  the  sabromin 
is  administered.  This  may  partly  account 
for  the  fact  that  signs  of  bromism  have 
never  been  observed  from  the  use  of 
sabromin,  even  in  animals  to  whom  very 
large  doses  have  been  experimentally 
administered.  (Mediz.  klinik.,  Septem- 
ber 20,  1908.) 


SALINE  INJECTIONS  IN  THE  TREATMENT 
OF  SCIATICA. 

Dr.  J.  Flesch  reports  eight  cases  of 
sciatica  in  which  he  applied  Lange's 
method  of  local  injection  of  salt  solution 
imder  pressure.  Lange  himself  has  re- 
ported 60  per  cent,  of  cures,  and  Flesch 
also  found  that  the  affection  was  refrac- 
tory in  some  of  his  cases,  although  the 
effects  were  ideal  in  others.  According 
to  his  experience,  the  loss  of  the  Achilles 
tendon  reflex  on  the  affected  side  is  a  sign 
that  the  injections  will  prove  useful. 
Without  the  loss  of  this  reflex,  none  of 


WHOOPING-COUGH. 


ZINC   PEEJMANGANATE. 


253 


the  other  signs,  tender  points  or  Lasegue 
sign  is  decisive.  The  presence  of  the 
knee-jerk  excludes  tabetic  sciatica.  Ex- 
cellent results  can  be  confidently  an- 
ticipated in  suitable  cases.  (Medizinische 
klinik.,  Berlin,  January  3,  1909.) 


WHOOPING-COUGH,  TREATMENT  OF. 
Dr.  Czemy  remarks  that  the  nervous 
element  in  whooping-cough  has  been  too 
long    disregarded    and    the    treatment 
should   be   directed   principally   against 
this.     A  change  from   drugs  to  hydro- 
therapy, inhalations  or  irrigation  of  the 
nose  often  proves  effectual.     The  treat- 
ment need  not  be  directed  to  the  organs 
specially  involved  in  the  pertussis  process. 
The  isolation  of  a  child  with  the  whoop- 
ing-cough   is    the    more    efficient,    the 
greater   the   change   from   its    ordinary 
surroundings.     It  should  not  be  allowed 
to   see   or   hear   other  children   with   a 
cough.     He  believes  that  the  child  can  be 
safely  isolated  by  transferring  it  to   a 
ward  where  there  are  no  other  children 
vrith    whooping-cough.     His    experience 
has  demonstrated,  he  says,  that  the  dis- 
ease is  never  transmitted  from  a  child 
kept  in  bed  to  the  neighboring  beds.     It 
requires  more  skill  on  the  part  of  the 
physician  to  treat  whooping-cough  with 
suggestion,    instead    of    drugs,    but   the 
results  will  be  much  more  satisfactory 
except  in  infants  unable  to  be  influenced 
by  the  physician's  words.     Only  excep- 
tionally    will     threatening     conditions 
require  a  sedative;    then  comparatively 
large  doses  must  be  given.   (Journal  of 
the  American  Medical  Association,  Janu- 
ary 23,  1909.) 


bread  in  which  ground  wood,  commonly 
known  as  excelsior,  has  been  added,  in  the 
proportion  of  fifty  grammes  to  seven 
hundred  and  fifty  grammes  of  dough. 
Birch  is  the  best  wood  for  this  purpose. 
The  bread  will  not  differ  in  appearance 
and  taste  from  ordinary  bread.  The 
mechanical  irritation  from  the  cellulose 
and  the  chemical  stimulus  of  the  gases, 
formed  by  the  wood  in  the  intestines,  did 
much  to  cure  the  constipation.  Excel- 
lent results  were  reported  in  eighty  cases. 
Constipation  can  be  cured  by  removing 
the  cause,  and  the  chief  causes  of  chronic 
constipation  are  lack  of  exercise,  diet 
poor  in  residue,  and  habitual  suppression, 
resulting  eventually  in  a  motor  and 
nervous  insufficiency  of  the  intestines. 
(Med.  Fortnightly,  January  11,  1909). 


WOOD    CURE    FOR    CHRONIC    CONSTIPA- 
TION. 
Dr.  Bluemland  Ulrich  (Klin.  Therap. 
Woch.)  recommends  very  highly  a  wheat 


ZINC  PERMANGANATE. 

Drs.  W.  A.  Puckner  and  W.  S.  Hil- 
pert  have  reported  the  results  of  a  recent 
investigation  of  the  tablets  and  various 
brands  of  zinc  permanganate.  After 
mentioning  the  various  tests  employed, 
they  claim  that  the  purity  of  the  per- 
manganate now  on  the  market  varies 
from  72.76  to  97.05  per  cent.,  a  differ- 
ence of  20.29  per  cent.  They  remark 
that  it  is  commendable  that  since  1881 
(when  Biehl  found  as  low  as  seven  per 
cent,  of  the  claimed  content  in  some 
brands  of  the  solution  and  only  G2  per 
cent,  of  the  soluble  salt  in  the  crystalline 
products)  manufacturers  have  so  im- 
proved their  methods  as  to  bring  it  to  the 
comparative  uniformity  of  the  present- 
day  product.  The  authors  offer  a 
description  of  a  proposed  standard  of 
purity  of  the  drug,  of  not  less  than  90 
per  cent.,  almost  completely  soluble  in 
water,  its  appearance,  tests  of  purity,  etc., 
and  with  a  dosage  of  1  part  to  4,000 
(1  grain  in  8  fluidounces),  1.3  Gm.  zinc 


254  BOOK  REVIEWS. 

permanganate.  It  resembles  the  potas-  an  injection  or  urethral  douche  in 
siimi  salt  in  its  oxidizing  properties,  but  urethritis.  (Journal  of  the  American 
is  more  astringent,  and  its  chief  use  is  as     Medical  Association,  February  6,  1909.) 


5ool<  I^e views 

Tbansactio>^s  of  the  Tenth  Annu.«iX  Meeting  of  the  American  Proctologic  Societt, 
held  at  Chicago,  111.,  June  1  and  2,  1908. 

The  contents  of  this  volume  show  articles  of  considerable  interest  to  the  progressive 
physician.  The  articles  are  well  and  exceptionally  prepared,  and  therefore  furnish  a  very 
useful  work  for  the  pliysician.  The  papers  cover  quite  thoroughly  all  their  subjects  from 
a  surgical  and  anatomical  standpoint. 

Among  some  of  the  interesting  and  instructive  articles  are:  "Amcebiasis;"  "Dysentery," 
"Surgery  of  Specific  Diseases  of  the  Rectum;"  "The  Treatment  of  Rectal  Prolapse  by  a  New 
and  Simple  Procedure;"    "The  Choice  of  an  Anesthetic  in  Rectal  Surgery,"  etc. 

A  very  interesting  and  illustrated  paper  is  that  by  Adler  on  "Rectal  Diseases:"  A  report 
of  three  cases — Condyloma,  Lipoma  and  Foreign  Body.  The  treatment  outlined  is  excep- 
tionally good. 

Transactions  or  The  Medical  Society  of  London,  Volume  31.  Edited  bv  Frederick  J. 
Poynton,  M.D.,  F.R.C.P.,  and  Thomas  H.  Kellock,  M.A.,  F.R.C.S.  London:  Printed  for 
the  Society  by  Harrison  &  Sons.  St.  Martin's  Lane,  Printers  in  Ordinary  to  His 
Majesty,  1908. 

The  articles  in  this  volume  are  each  written  by  a  competent  observer,  and  each  one 
deals  with  an  interesting  and  important  phase  of  medicine. 

Among  the  important  articles  and  discussions  are:  "On  the  Use  of  Chemicals  in  Aseptic 
Surgery;"  "Nervous  Phenomena  in  Pneumonia."  The  Lettsomian  lectures:  "On  Tuber- 
culosis of  the  Kidney  and  Malignant  Disease  of  the  Caecum;"  "The  Pneumococcus  Infec- 
tions;"   "Malta  Fever." 

All  the  material  in  this  volume  comprises  the  Transactions  of  the  Society  during  its 
one  hundred  and  thirty-fifth  session,  from  October  14,  1907,  to  May  18.  1908. 

The  papers  cover  their  subjects  in  a  plain  and  entertaining  manner,  and  are  illustrated 
by  cuts,  diagrams  and  colored  plates. 

The  volume  concludes  with  a  large  chapter  called  "Clinical  Evenings,"  in  which  the  his- 
tories, symptoms  and  treatment  of  many  cases  are  presented. 

Parcimony  in  Nutrition.  By  Sir  James  Crichton-Brov^'ne,  M.D.,  LL.D.,  F.R.S.,  Lord 
Chancellor's  Visitor  in  Lunacy,  London.  London  and  New  York:  Funk  &  Wagnalls 
Company,  1909. 

The  author  in  this  small  volume  formulates  and  presents  in  an  attractive  manner  some 
good  and  common  sense  ideas  as  to  what  and  how  much  the  average  human  being  should  eat. 
The  book  consists  of  six  chapters: 

I.  The  Up-Keep  of  the  Body. 

II.  Proteid   Foods. 

III.  Prison  Experiences. 

IV.  Public  Health. 

V.  The  Study  of  Animal  Function. 

VI.  The  Voice  Nature. 

The  theories  concerning  the  intake  of  food  of  Mr.  Horace  Fletcher  and  Professor  Chit- 
tenden, of  Yale,  are  very  keenly  and  cleverly  attacked.  The  author  states  that  tlie  science 
of  dietetics  is  not  based  on  physiological  data,  nor  on  laboratory  experiments,  but  it  is  based 
upon  common  observation,  hereditary  customs  and  habits  of  mankind.  He  also  states  that 
all  the  successful  races  have  consumed  proteid  far  in  excess  of  the  Chittenden  standard,  and 
far  in  excess  of  what  was  required  for  tissue  repair. 

In  conclusion  tlie  author  says:  "We  should  not  aim  at  a  parcimony  in  nutrition,  but 
scatter  plenty  o'er  a  smiling  land." 

This  is  not  only  a  valuable  little  book,  but  it  is  also  written  in  the  most  interesting  and 
entertaining  manner. 


BOOK  REVIEWS.  255 

Pbimaey  Studies  foe  Nurses:  A  Text-Book  for  First- Year  Pupil  Nurses.  By  Charlotte  A. 
Aikens,  formerly  Superintendent  of  Columbia  Hospital,  Pittsburg,  and  of  the  Iowa 
Methodist  Hospital,  Dea  Moines.  12mo  of  435  Pages,  Illustrated.  Philadelphia  and 
London:    W.  B.  Saunders  Company,  1909.     Cloth,  $1.75  net. 

The  writer  states  in  the  preface  that  the  purpose  of  this  book  is  "designed  to  assist  in 
securing  graded  instruction  in  training  schools  for  nurses;  to  promote  unifoi-mity  in  the 
teaching  of  the  subjects  allied  to  nursing;  to  eliminate  non-essential  instruction  of  a  medical 
character  from  the  nursing  course,  and  to  save  time  and  labor  for  both  pupils  and  teacher." 

The  book  certainly  fulfils  this  purpose,  and  is  admirably  fitted  for  the  needs  of  the 
nurse.  The  author  has  presented  plainly  and  concisely  the  essentials  of  anatomy,  physiology, 
hygiene,  bacteriology,  therapeutics,  materia  medica,  dietetics  and  invalid  cookery  in  the  most 
useful  and  available  form.  In  the  chapter  on  "Therapeutics  and  Materia  Medica"  very 
important  information  concerning  the  various  methods  of  administering  medicines  and  the 
different  classes  of  drugs,  together  with  their  antidotes,  are  given.  Another  feature  of  the 
book  is  the  chapter  on  "Dietetics  and  Invalid  Cookery." 

Everything  possible  has  been  incorporated  in  this  volume  of  428  pages  to  make  it  a  mint 
of  information  aud  of  the  utmost  value  to  the  nurse. 

The  Climbeb.  By  E.  F.  Benson,  author  of  "Sheaves,"  "The  Angel  of  Pain,"  "Tlie  Image  in 
the  Sand,"  etc.     With  Frontispiece.     New  York:    Doubleday,  Page  &  Company,   1909. 

In  this  work  the  author  has  taken  for  his  central  character  Lucia  Crimson,  a  very 
ambitioiis  person,  who  is  striving  for  social  leadership.  At  last  she  reaches  her  goal,  the 
height  of  her  ambition,  but  finally  she  pays  dearly  for  it.  It  is  a  good  tale,  full  of  action 
and  incident,  with  a  steady  progress  of  the  main  theme  and  the  constant  growth  of  the 
character.  The  light  and  shade  are  cleverly  put  in,  and  the  author  succeeds  in  portraying  to 
the  reader  life's  contrasts.  We  recommend  this  book  unhesitatingly  as  a  fine  piece  of  literary 
workmanship,  as  well  as  an  entertaining  novel. 

Saundebs'  Pocket  Medical  Foemulaby.  New  (Ninth)  Edition,  Adapted  to  the  1905  Phar- 
macopoeia. By  William  M.  Powell,  M.D.,  author  of  "Essentials  of  Diseases  of  Children." 
Containing  1831  formulas  from  the  best-knowTi  authorities.  With  an  Appendix  contain- 
ing Posologic  Tables,  Formulas  and  Doses  for  Hypodermic  Medication,  Poisons  and  Their 
Antidotes,  Diameters  of  the  Female  Pelvis  and"  Fetal  Head,  Obstetric  Table,  Diet-lists, 
Materials  and  Drugs  used  in  Antiseptic  Surgery,  Treatment  of  Asphyxia  from  Drowning, 
Surgical  Remembrancer,  Tables  of  Incompatibles,  Eruptive  Fevers,  etc.,  etc.  Philadel- 
phia and  London:  W.  B.  Saunders  Company,  1909.  In  Flexible  Morocco,  with  Side 
Index,  Wallet  and  Flap,  $1.75  net. 

The  author  has  certainly  brought  this  edition  up  to  the  level  of  our  latest  knowledge  by 
inserting  in  it  formulae  from  the  foremost  authorities.  Many  of  the  prescriptions  contain 
the  more  important  remedies  and  newly  discovered  drugs.  The  appendix  is  a  distinguishing 
feature  of  this  small  book,  and  its  contents  will  prove  of  the  greatest  value  to  the  physician. 
Scattered  throughout  the  book  are  blank  pages  for  the  insertion  of  any  additional  formulae 
or  notes.  The  book  is  made  up  of  flexible  morocco,  with  side  index,  wallet  and  flap,  which 
add  very  much  to  its  attractiveness,  and  make  it  very  convenient  to  carry  around.  The  press 
work  is  well  executed. 

A  Text-Book  of  Medical  Chemistet  and  Toxicology,  By  James  W.  Holland,  M.D.,  Pro- 
fessor of  Medical  Chemistry  and  Toxicology,  Jefferson  Medical  College,  Philadelphia. 
(New)  Second  Revised  Edition.  Octavo  of  655  Pages.  Fully  Illustrated.  Philadelphia 
and  London:    W.  B.  Saunders  Company,  1908.     Cloth,  $3.00  net. 

Dr.  J.  W.  Holland  in  this  book  lias  produced  a  work  which  is  understandingly  readable 
and  has  presented  his  subject  in  such  a  manner  as  to  please  the  most  scientific  reader.  The 
introductory  chapter  is  very  good  and  covers  the  essential  principles  of  physics  which  a 
medical  student  is  expected  to  have  when  he  enters  college.  The  author's  repiitation  for  his 
ability  in  this  field  of  medicine  is  well  established,  and  the  book  will  certainly  prove  its 
worth  and  usefulness.  In  addition  to  the  good  descriptive  text  and  colored  plates,  the  author 
has  inserted  numerous  illustrations  and  diagrams  to  illustrate  the  various  experiments  and 
apparatus  used  in  the  generation  of  the  various  gases  and  the  performaneo  of  the  diflforent 
tests.  The  contents,  of  this  volume  have  been  thoroughly  revised  and  made  to  accord  with 
the  recent  edition  of  the  United  States  Pharmacopoeia  and  the  advances  in  physiologic  chem- 
istry. This  work  is  arranged  systematically,  covering:  "The  Cliemical  Elements,"  ""Organic 
and  Physiologic  Chemistry,"  and  "Energy  of  Foods."  The  chapter  devoted  to  the  urine  is 
especially  valuable,  owing  to  the  fact  that  it  contains  the  latest  improvements  in  urinary 
tests.  The  attractive  type,  on  a  fine  grade  of  paper,  add  much  to  the  plea.sure  of  reading. 
A  good  index  is  appended,  and  to  good  advantage. 


256  EOOI^  REVIEWS. 

Constipation  and  Intestinal  Obstruction.  By  Samuel  G.  Gant,  ]\I.D.,  LL.D.,  Professor  of 
Diseases  of  the  Rectum  and  Anus  in  the  New  York  Post-Graduate  Medical  School  and 
Hospital.  Octavo  of  559  Pages,  with  250  Original  Illustrations.  Philadelphia  and  Lon- 
don:   W.  B.   Saunders  Company,   1909.     Cloth,  $fl.00  net;    Half-Morocco,  $7.50  net. 

This  is  one  of  the  most  important  and  recent  books  on  the  subject  of  constipation  and 
intestinal  obstruction  (obstipation).  The  book  is  a  large  one,  and  the  subjects  are  very 
extensively  treated.  The  first  part  of  the  book  is  concerned  with  a  simple  and  plain  exposi- 
tion of  the  anatomy  and  physiology  of  the  stomach  and  intestines.  Then  follow  chapters  on 
the  Etiology,  Pathology,  Symptoms,  Diagnosis  and  Treatment  of  the  various  forms  of  Con- 
stipation and  Obstipation.  The  great  feature  of  this  volume  is  the  treatment.  This  feature 
occupies  a  considerable  space,  covering  the  psychic  (moral)  and  dietetic  (foods  permitted 
and  foods  prohibited)  treatments,  exercise,  internal  and  external  hydrotherapy,  massage, 
mechanical  vibration,  electricity  and  other  physical  therapeutic  procedures  and  the  medical 
treatment.  Following  this  is  a  chapter  devoted  entirely  to  formulas,  which  will  prove  of 
great  value  to  the  practitioner.  The  author  discusses  in  detail  the  various  non-medical  and 
surgical  means  at  hand  which  have  proved  of  value,  and  are  based  upon  the  results  obtained 
from  personal  experience.     The  latter  part  of  the  book  considers  the  surgical  treatment. 

The  real  merits  of  this  volume  lie  in  its  description  of  operative  technic,  and  every  step 
is  treated  thoroughly.  We  regard  this  book  as  a  valuable  addition  to  medical  literature,  and 
we  bespeak  for  it  a  cordial  reception.  The  author  has  dealt  with  every  phase  of  the  subject 
in  a  thoroughlv  scientific  manner,  and  the  entire  subject  is  adequately  and  judiciously  con- 
sidered. The  typography  and  binding  are  excellent,  but  especial  mention  should  be  made  of 
the  illustrations,  which  "are  very  striking  and  elucidative. 

Transactions  of  the  American  Climatologicai.  Association  for  the  Year  1908,  Volume 

XXIV.     Philadelphia:    Printed  for  the  Association,   1908. 

This  volume  of  the  Transactions  is  exceptionally  interesting.  The  contributions  are  very 
good,  and  among  the  interesting  and  instructive  are:  "EflFect  of  Climatic  Conditions  in 
Tuberculosis;"  "Climate  and  Hay  Fever;"  "Calmette  and  von  Pirquet  Tuberculin  Tests  in 
Children;"  "Pulmonary  Actinomycosis;"  "Cardiac  Dangers  in  High  Altitudes;"  "Medical 
Gymnastics  in  Early  Myocardial  Incompetence;"  "High  Frequency  Electricity  in  the  Treat- 
ment of  Cardiac  Diseases;"  "Aneurism  of  the  Aorta  and  Pulmonary  Artery;"  "Endo- 
carditis," etc.  The  papers  give  trustworthy  expositions  of  everything  that  is  new  and  inter- 
esting. '  It  is  full  of  practical  hints  and  useful  information. 

The  Death  of  Lincoln:  The  Story  of  Booth's  Plot,  His  Deed  and  the  Penalty.  By  Clara 
E.  Laughlin.  Illustrated  from  Photographs.  New  York:  .Doubleday,  Page  &  Co.,  1909. 
Miss  Laughlin  has  succeeded  in  unearthing  a  great  quantity  of  valuable  information  in 
connection  with  this  terrible  tragedy.  The  authoress  shows  not  only  a  large  storehouse  oi 
facts,  but  a  clever  talent  for  weaving  them  into  readable  form.  The  plot  is  traced  from  its 
birth  in  the  brain  of  the  clever  but  misled  asssassin  to  the  trial  and  execution  of  the  con- 
spirators. The  writer  has  covered  the  ground  in  the  most  careful  and  painstaking  manner. 
Many  details  which  have  hitherto  been  overlooked  are  given  here  and  every  elTort  has  been 
made  to  substantiate  all.  The  horror  and  consternation  which  seized  the  whole  country  after 
the  perpetration  of  this  terrible  crime  is  graphically  pictured;  an  extended  account  of  the 
trial  in  which  it  was  so  dillicult  for  justice  to  be  meted  out  to  the  accused,  is  given.  With 
forty  odd  years  shedding  their  light  on  these  scenes  we  cannot  but  feel  a  wave  of  pity  sweep 
over  us  as  we  consider  the  unnecessary  severity  of  the  treatment  received  by  the  prisoners. 
The  great  noble  heart  lying  cold  and  still  in  Springfield  would  have  been  the  first  to  plead 
mercy  for  the  criminals.  Among  the  many  things  which  impress  the  reader  is  the  broad 
impartial  treatment  of  the  entire  subject.  The  authoress  has  evidently  made  a  study  of 
human  nature.  She  sees  with  such  a  clear  vision  its  weakness  and  its  strength,  and  through 
her  whole  study  runs  a  deep  love  and  a  strong  true  sympathy.  Wliile  in  no  degree  mmimiz- 
Ing  the  fearful  crime,  the  writer  has  succeeded  in  arousing  much  pity  for  the  handsome 
brtlliant  misguided  youth  whose  hand  fired  the  fatal  shot,  and  not  for  him  alone,  but  also 
for  those  who  were,  by  the  magnetic  personality  of  the  actor,  drawn  into  the  plot  and  who 

shared  his  fate.  .    .    ,    .     i 

It  is  a  book  that  is  of  great  interest,  not  only  from  a  historical  viewpoint,  but  also  as  a 
character  study.  It  should  help  the  friends  and  enemies  of  the  martyred  President  to  a 
better  understanding. 


ONTHLY      CYCLOPiEDIA 

AND 

EDicAL   Bulletin 


Published  the  Last  of  Each  Month 


MontMy  Cyclopaedia  Section 


Vol.  II.  PHILADELPHIA,  MAY,  1909.  No.  5. 


Original  Articles 


Department  in  charge  of  J.  MADISON  TAYLOR,  A.M.,  M.D. 


EXTRA-UTERINE  PREGNANCY.* 

By  JOHN  B.  DEAVER,  M.D.,  LL.D., 

PHILADELPHIA. 

A  BRIEF  review  of  the  history  of  this  important  subject  ought  to  possess 
for  us  more  than  ordiaary  interest  because  of  the  important  role  played  in  its 
development  by  one  ahnost  of  our  own  number  and  generation  in  whom  we  may 
take  a  pardonable  local  pride.  I  refer  to  the  illustrious  and  lamented  John  S. 
Parry.  He  was  not  the  first  to  write  upon  the  subject.  Indeed  Albucasis,  the 
Arabian,  in  the  eleventh  century  recognized  and  described  a  case  of  extra- 
uterine pregnancy.  Nor  was  he  the  first  to  grasp  the  possibilities  of  operative 
treatment  in  the  emergency  of  rupture.  That  was  proposed  by  Harbert,  of 
New  York,  in  1849.  The  merit  of  Parry  consisted  not  only  in  grasping  the 
significance  of  the  catastrophe  and  the  correct  mode  of  meeting  the  emergency, 
but  in  applying  his  philosophical  mind  and  scholarly  attainments  to  the  produc- 
tion of  a  monograph  which  by  its  masterly  marshaling  of  facts  and  lucidity  of 
deduction  should  have  quieted  the  doubts  of  Thomas.  He  was  able  to  collect 
for  his  book,  which  was  published  in  187G,  500  cases  reported  in  the  literature. 
Of  499,  in  which  the  result  was  stated,  36G  died  and  1G3  recovered.  Of  the 
deaths,  174  had  been  from  rupture.  Of  these  deaths  81  had  died  witliin  24 
hours.  These  figures  were  his  text.  He  began  his  sermon  with  this  sentence: 
"From  the  middle  of  the  eleventh  century  when  Albucasis  described  the  first 
known  case  of  extra-uterine  pregnancy,  men  have  doubtless  watched  the  life  ebb 
rapidly  from  the  pale  victim  of  this  accident  but  have  never  raised  a  hand  to 


•Read  before  the  Northorn  Medical  Association  of  Pliiladolpliia,  February  20,  1909. 

3  (2r,7) 


258  EXTRA-UTERINE  PREGNANCY. 

lielp  her."  Tlien,  tliough  not  himself  a  surgeon,  he  points  out  the  phiin  surgical 
indications.  In  the  same  year  as  the  publication  of  his  monograph  he  died, 
doubtless  depriving  the  world  of  one  who  was  destined  to  become  one  of  its 
greatest  figures  in  the  advancement  of  medicine.  Parry  was  a  pupil  of  my 
father,  who  often  used  to  speak  of  his  studious  habits  and  scholarly  grasp.  He 
was  by  nature  fitted  for  mental  leadership. 

The  honor  of  performing  the  first  operation  for  this  emergency  went  to 
Lawson  Tait  in  1883.  lie  had  been  earnestly  solicited  to  operate  for  this  condi- 
tion in  1881  by  a  physician  who  had  correctly  diagnosed  a  case  of  rupture  with 
internal  haemorrhage.  He  refused,  and  the  patient  died  shortly  after.  Unfor- 
tunately the  first  patient  operated  on  died  also,  but  his  change  of  heart  was 
complete,  and,  correctly  attributing  his  failure  in  the  first  case  to  faulty 
technic,  he  altered  his  method  and  continued  to  operate  all  such  cases.  Of  the 
next  40  cases  only  one  died.  Truly  a  brilliant  record  which  was  not  long  in 
converting  the  medical  fraternity. 

The  original  microscopical  preparations  of  Tait  in  which  he  demonstrated 
his  ideas  on  extra-uterine  pregnancy  and  pelvic  hematocele,  which,  before  him, 
were  in  a  very  confused  state,  are  still  to  be  seen  in  the  museum  of  the  Eoyal 
College  of  Physicians  in  London. 

There  are  many  other  names  of  more  or  less  importance  in  connection  with 
the  development  of  the  siibject,  but  these  two  are  central  and  all  we  have  time 
to  consider  to-night. 

In  attempting  to  get  a  clear  idea  concerning  the  causation  of  extra-uterine 
pregnancy,  one  is  quite  awed  and  overcome  by  the  vast  number  of  hypotheses 
which  have  been  advanced  to  account  for  this  curious  anomaly.  It  reminds  us 
of  the  wealth  of  therapeutic  suggestions  with  which  v/e  are  favored  in  the  case 
of  diseases  as  yet  resistant  to  all  modes  of  treatment.  It  is  not  surprising 
that  there  is  still  considerable  obscurity  in  the  etiology.  A  correct  under- 
standing of  the  pathology  of  any  condition  presupposes  a  fairly  exact  laiowledge 
of  the  normal  physiology  of  the  parts.  There  still  exist  many  problems  con- 
nected with  maturation,  ovulation,  impregnation,  implantation  and  develop- 
ment. Some  of  these  problems  carry  us  well  back  into  the  shadowy  realms  of 
the  beginnings  of  life  itself,  that  Ultima  Thule  of  the  biologist. 

The  incompleteness  of  our  information  concerning  these  abstruse  secrets 
of  Nature  forces  us  here,  as  in  so  many  other  medical  problems  to  resort  to 
the  methods  of  induction  and  experience  and  if  we  have  not  yet  arrived  at 
the  point  where  we  may  safely  take  the  inductive  hazard  it  is  because  we  may 
not  yet  have  appreciated  fully  the  saying  of  old  Ambroise  Pare  that  "such 
matters  cannot  be  determined  by  sitting  do\^Ti  and  thinking  but  by  hard 
unremitting  toil." 

Gradually,  however,  our  knowledge  of  the  normal  functions  of  procreation 
has  been  expanding  and  a  sufficient  number  of  cases  have  been  observed,  recorded 
and  analyzed  to  enable  us  to  recognize  certain  factors  which  evidently  play  an 
important  part  in  the  etiology. 

Lawson  Tait  origimilly  thought  that  the  ciliary  current  of  the  mucous 
membrane  of  the  tubes  and  that  of  the  uterus  was  in  opposite  directions,  that 


EXTRA-UTERINE  PREGNANCY.  259 

of  the  tubes  being  directed  towards  the  uterus  and  that  of  the  uterus  moving 
upwards  thus  forming  a  natural  meeting  place  of  sperm  and  o\aim  at  the 
fundus.  He  considered  it  abnormal  for  spermatozoa  to  gain  an  entrance  into 
the  tubes  and  held  that  impregnation  occurring  in  the  tubes  through  this 
accidental  invasion  of  the  spermatozoon  was  very  likely  to  give  rise  to  tubal 
pregnancy.  This  beautifully  simple  conception  has  yielded  to  the  iconoclastic 
power  of  observed  facts.  We  now  know  that  the  ciliary  current  of  the  uterus 
as  well  as  that  in  the  tubes  is  downward.  We  know  that  the  spermatozoa  can 
readily  stem  this  current,  their  rate  of  speed  being  calculated  by  Ilenle  as  1  cm. 
in  three  minutes. 

We  know  that  they  quite  regularly  obtain  entrance  into  the  tubes  and 
swarm  up  its  lumen  and  it  seems  quite  probable,  if  not  certain  that  impregna- 
tion in  the  tube  is  common,  if  not  the  regular  method.  Once  fertilization  has 
taken  place  development  begins  at  once.  The  ovum,  comparable  in  many 
respects  to  a  parasite,  rapidly  throws  out  the  chorionic  villi  which  lay  hold  on 
the  maternal  tissues  and  by  erosion  secure  anchorage  and  open  up  the  inter- 
villous blood  spaces.  Just  how  soon  the  ovum  displays  these  grasping  ten- 
dencies is  unknown.  The  youngest  ovum  of  which  we  know  was  discovered  by 
Peters  in  the  uterus  of  a  woman  who  committed  suicide  three  days  after 
missing  her  period.  It  measured  .6  x  .8  x  1.3  millimeters  and  was  firmly 
implanted  with  numerous  projecting  villi  in  the  process  of  formation.  Certainly 
this  oTom  was  less  than  a  week  old.  Just  what  condition  must  be  met  by  the 
maternal  tissues  to  permit  of  implantation  is  uncertain.  Webster  is  quite 
certain  that  there  must  be  a  decidual  reaction  and  a  number  of  observers  have 
reported  having  seen  decidual  formation  in  the  tubes.  Normally  the  oosperm  is 
swept  down  into  the  uterus  before  it  effects  a  lodgment.  The  forces  which 
accomplish  this  movement  are  the  peristalsis  of  the  tube  and  the  action  of  the 
cilia.  Whatever  delays  the  ovum  in  transit  permitting  it  to  put  out  tlie 
anchoring  villi,  in  the  presence  of  a  suitable  soil  renders  imminent  the  occur- 
rence of  an  extra-uterine  gestation.  Concerning  the  nature  of  the  soil  required 
by  the  ovum  we  are  not  so  certain.  Concerning  the  influence  of  delay  which 
is  governed  by  mechanical  causes  everyone  is  agreed. 

These  causes  may  be  classified  as : 

1.  Malformation:  as,  diverticula,  accessory  ostia,  and  persistence  of  the 
greatly  convoluted  fcetal  contour  of  the  tubes. 

2.  Obstruction  from  within :   as  in  tubal  polypi  and  torsion  of  the  tube. 

3.  Obstruction  from  without:  as  in  myoma  and  peritoneal  bands  and 
adhesions. 

4.  Inflammation,  which  acts  by  destroying  the  motor  power  of  cilia  and 
musculature  and,  secondarily,  by  tlie  formation  of  diirerent  types  of  ol)Ptruction. 

5.  Excessive  size  of  the  o\'um  itself  as  in  the  delay  which  occurs  in  external 
migration  of  the  ovum. 

The  importance  of  tlic  inflammatory  factor  in  the  etiology  of  ectopic 
gestation  is  becoming  more  and  more  appreciated  and  is  even  of  use  in  the 
diagnosis,  a  history  indicating  more  or  less  pronoiinced  salpingitis  tending  to 


260  EXTRA-UTERINE  PREGNANCY. 

arouse  our  suspicions  of  the  greater  possibility  of  an  extra-uterine  pregnancy  in 
a  doubtful  case. 

According  to  the  site  of  implantation  we  recognize  several  varieties; 

1.  The  interstitial,  located  in  that  part  of  the  tube  which  pierces  the 
uterine  wall. 

2.  The  isthmial. 

3.  The  ampullar. 

4.  The  infundibular. 

5.  The  ovarian. 

These  are  the  primary  forms.  Later  the  gestation  sac  by  reason  of  rupture 
or  growth  may  change  its  position  giving  rise  to  the  secondary  forms. 

Thus  the  interstitial  form  may  be  converted  into  an  intra-uterine  by 
rupture  into  the  cavity  of  the  uterus,  into  an  abdominal  by  rupture  into  the 
general  cavity  or  into  an  intraligamentary  by  escape  between  the  layers  of  the 
broad  ligament.  The  isthmial  and  ampullar  forms  similarly  may  become 
tubo-abdominal,  tubo-ovarian,  abdominal  or  intraligamentary.  An  infundi- 
bular or  ovarian  pregnancy  always  tends  to  become  abdominal.  The  last  named 
condition  is  one  of  the  greatest  curiosities  of  abdominal  pathology.  All  the 
undoubted  cases  of  ovarian  pregnancy  so  far  observed  can  be  numbered  on 
the  fingers.  The  interstitial  and  infundibular  forms  are  almost  as  great 
rarities  so  that  for  practical  purposes  we  have  to  do  only  with  cases  primarily 
isthmial  or  ampullar,  of  which  the  latter  are  most  nimierous,  and  with  the  forms 
secondary  to  these  primary  varieties. 

The  natural  outcome  of  extra-uterine  pregnancy  is  early  interruption 
whether  by  reasons  of  insufficient  blood  supply  or  imfavorable  mechanical  condi- 
tions for  the  continued  development  of  the  foetus. 

The  most  common  event  is  the  formation  of  a  tubal  mole  from  the  slow 
leakage  of  blood  about  the  sac.  Tliis  soon  results  in  the  death  of  the  foetus 
and  cessation  of  growth.  In  this  way  spontaneous  recovery  may  occur.  I 
have  several  times  in  the  course  of  pelvic  operations  encountered  old  tubal 
hasmatomata  which  were  clearly  the  result  of  a  previous  tubal  pregnancy  which 
had  terminated  itself  and  retrogressed  without  giving  the  patient  any  great 
inconvenience.  That  this  is  not  a  frequent  occurrence  our  clinical  experience 
and  the  infrequency  of  such  operative  findings  testify.  There  is  evidence  to 
show  that  even  after  the  death  of  the  fo3tus  the  chorionic  villi  may  continue 
to  grow  and  exert  an  erosive  action  on  the  wall  of  the  tube  which  coupled  with 
the  distention  due  to  lucmorrhage  may  bring  about  a  rupture.  More  common 
than  this  is  the  gradual  extrusion  of  the  mole  from  the  fimbriated  extremity, 
a  process  known  as  tubal  abortion.  Kupture  of  tlie  tube  and  tubal  abortion 
may  take  place  rapidly  without  the  previous  formation  of  a  mole.  These 
arc  apt  to  be  the  fulminating  cases. 

Haemorrhage  is  more  free  in  case  of  rupture  than  in  abortion  as  a  rule: 
more  free  in  rupture  into  the  general  abdominal  cavity  than  in  rupture  into 
the  broad  ligament,  more  free  when  the  site  of  rupture  involves  the  placental 
attachment,  and  more  free  at  the  comual  end  of  the  tube  than  at  the  ampullar 
end.    This  latter  tendency  was  tersely  expressed  by  Formad  who  used  to  say. 


EXTRA-UTERINE  PREGNANCY.  261 

''Euptured  comual  cases  belong  to  the  coroner,  ruptured  ampullar  to  the  sur- 
geon." Surgery  in  its  march  has  modified  this  statement  but  it  still  serves  to 
point  out  the  relative  dangers.  Haemorrhage  is  the  outcome  of  extra-uterine 
pregnancy  which  chiefly  concerns  us  from  a  practical  standpoint.  It  is  prob- 
able that  no  case  of  ectopic  gestation  occurs  which  is  not  accompanied  by 
haamorrhage  at  some  time.  It  may,  however,  be  early  or  lat«,  slow,  or  rapid, 
slight  in  amount  or  profuse. 

It  is  the  chief,  though  not  the  only  factor  in  the  production  of  so-called 
shock,  and  is  the  main  agent  in  a  fatal  outcome.  I  shall  have  more  to  say 
concerning  hfemorrhage  under  the  question  of  treatment. 

If  the  patient  be  fortunate  enough  to  survive  the  primary  rupture  and  the 
foetus  live,  she  still  has  to  face  the  possibility  of  a  second  rupture  of  the  gesta- 
tion sac  in  its  new  position.  Occasionally  an  extra-uterine  pregnancy  may 
progress  to  t^rm.  Usually  this  is  rendered  possible  by  the  escape  of  the  foetus 
within  its  amniotic  sac  into  the  general  abdominal  cavity,  the  placenta  remain- 
ing attached  at  the  primary  site.  In  this  event,  after  a  spurious  labor  at  term, 
the  foetus  dies  and  offers  an  inviting  site  for  infection.  Operation  is  here 
indicated  on  the  same  principle  as  in  the  case  of  any  foreign  body  which 
threatens  the  host.  This  holds  true  in  spite  of  the  well-known  fact  that  in 
some  instances  the  foetus  has  caused  little  harm,  being  converted  into  a  litho- 
paedion  or  adipocere.  Such  a  late  terminal  event  presupposes  a  series  of 
diagnostic  failures  which  we  trust,  now  that  the  condition  is  so  well  known 
and  understood,  may  not  come  to  pass. 

The  symptoms  of  extra-uterine  pregnancy  include  those  due  solely  to  the 
condition  of  pregnancy  and  those  which  arise  only  from  its  abnormal  situation. 
Inasmuch  as  the  majority  of  cases  terminate  within  three  months  at  which  the 
ordinary  signs  of  pregnancy  are  not  usually  pronounced,  we  do  not  often  get 
much  help  from  the  symptoms  belonging  to  the  first  group.  Yet  such  symp- 
toms and  signs  as  enlargement  of  the  breasts,  the  presence  of  colostrum,  cessa- 
tion of  menstruation,  increased  vascularity  of  the  genitalia,  softening  of  the 
cer\'ix  and  body  of  the  uterus  with  slight  enlargement,  disturbances  of  the 
bowels  or  bladder,  morning  nausea,  and  the  abnormal  appetite,  cravings  or 
sensations  which  the  multipara  sometimes  recognizes,  are  occasionally  of  con- 
firmatory value. 

It  would  be  desirable  to  make  the  diagnosis  before  rupture  were  it  possible 
to  do  so.  Unfortunately  a  large  percentage  of  cases  give  such  trifling  evidence 
of  the  true  condition,  if  indeed  there  be  any  prodromal  symptoms  at  all,  that 
no  suspicion  is  aroused.  Still  it  is  occasionally  possible  to  make  the  diagnosis 
and  it  should  be  our  effort  to  do  so.  One  operator.  Dr.  Baldwin,  of  Columbus, 
Ohio,  has  reported  11  such  cases. 

The  diagnosis  in  these  cases  rests  upon :  first,  a  consideration  of  the  his- 
tory. Important  points  for  consideration  are  the  age  of  the  patient,  exposure 
to  pregnancy  and  the  presumptive  signs  and  symptoms,  a  history  indicative  of 
an  antecedent  tubal  inflammation,  a  previous  period  of  sterility  usually  of  some 
years.  This  last  point  has  been  observed  by  all  students  of  the  condition  and 
Parry  remarks  on  what  he  calls  "the  previous  inaptitude  for  conception"  of 
these  patients. 


262  EXTRA-UTERINE  PREGNANCY. 

Amenorrhcea  of  shorter  or  longer  duration  is  a  fairly  constant  feature  and 
is  followed  in  tlie  majority  of  instances  by  irregular  bleeding  from  the  uterus, 
sometimes  profuse,  sometimes  a  'mere  staining.  The  history  of  passing  bits 
of  tissue  or  the  demonstration  of  decidua  in  the  discharge  is  important. 

Pain  if  felt  before  rupture  consists  frequently  in  vague  uneasy  sensations 
in  the  pelvis.  Sometimes  it  is  more  severe,  colicky  in  type  and  accompanied 
by  nausea. 

In  cases  which  show  any  of  these  suspicious  symptoms  an  internal  examina- 
tion should  not  be  neglected.  The  demonstration  of  a  pelvic  mass  lying 
outside  of  the  uterus,  in  the  presence  of  a  probable  pregnancy  is  a  very  sus- 
picious circumstance.  If  this  mass  should  correspond  in  size  vvdth  the  duration 
of  pregnancy,  if  it  should  be  located  in  the  course  of  the  tube,  if  it  be  mova])le, 
moderately  soft  and  very  tender,  we  may  fairly  conclude  we  are  dealing  with 
a  case  of  extra-uterine  pregnancy.  It  must  be  remembered  that  it  is  some- 
times easy  to  mistake  a  retroflexed  pregnant  uterus  for  an  extra-uterine  preg- 
nancy. 

Often  before  a  diagnosis  can  be  made,  usually  before  the  diagnosis  is 
made,  rupture  of  the  tu1)e  or  extensive  separation  and  htemorrhage  from  the 
placental  site  supervenes.  It  was  formerly  thought  that  rupture  was  the  most 
conunon  outcome  of  tubal  pregnancy.  ]\Iore  careful  examination  of  the 
specimens,  however,  has  shown  us  that  in  many  cases  of  supposed  rupture 
we  are  dealing  with  a  case  of  tubal  abortion  with  hfemorrhage  from  the  site 
of  implantation.  Moreover,  haemorrhage  from  this  source  while  less  violent  as 
a  rule  than  in  rupture,  may  be  very  severe  and  even  fatal.  Frequently,  how- 
ever, it  is  comparatively  slow  and  by  slow  leakage  is  responsible  for  the  majority 
of .  hfematoceles  which  we  find.  Recent  statistics  indicate  that  these  tubal 
abortions  occur  more  frequently  than  does  rupture.  The  tragic  stage,  however, 
may  follow  either  process. 

Comfort  not  yourselves  with  the  idea  that  rupture  is  not  so  frequent  as 
has  been  supposed  and  therefore  an  extra-uterine  pregnancy  is  not  so  dangerous 
a  condition.  Had  operation  not  been  urgently  indicated  these  specimens  of 
tubal  abortion  would  never  have  been  removed  for  examination.  In  short  it  is  a 
matter  of  common  knowledge  that  tubal  abortion  may  give  rise  to  a  condition 
as  serious  as  any  of  the  accidents  of  ectopic  pregnancy.  I  should  not  feel  it 
necessary  to  insist  on  this  fact  were  it  not  for  an  impression  which  is  going 
abroad  in  regard  to  treatment,  which  I  shall  consider  later. 

Rupture  is  the  most  serious  accident  of  ectopic  gestation.  It  may  take 
place  very  early  nnd  be  the  first  symptom.  Cases  have  been  reported  of  rupture 
in  the  first  or  second  weeks  of  pregnancy.  Usually  it  occurs  in  the  second  or 
third  months,  but  occasionally  may  be  delayed  into  the  later  months. 
Secondary  rupture  may  occur  at  any  time  after  primary  rupture  up  to  term. 
Rupture  is  usually  ushered  in  by  severe  lancinating  pain  in  the  hypogastrium, 
accompanied  by  shock,  sometimes  by  syncope  and  frequently  by  nausea  or 
vomiting.  Following  this  the  symptoms  of  internal  hemorrhage  make  their 
appearance.  Increasing  pallor,  rapid  and  weak  pulse,  sighing  and  labored 
respiration  and  air  hunger,  dimming  of  vision,  with  increasing  but  slight  dis- 


EXTRA-UTERINE  PREGNANCY.  263 

tcntion  of  the  abdoinen,  signs  of  fluid  in  the  flanks,  general  abdoniiuai  tender- 
ness most  marked  in  the  hypogastrium  and  a  peculiar  doughy  feel  of  the 
abdomen  which  is  readily  distinguished  from  the  usual  rigidity  of  inflamma- 
tion of  the  peritoneum. 

There  are  the  symptoms  of  rupture  and  of  haemorrhage  per  se.  They  are 
not  always  so  frank  and  outspoken  and  in  order  to  be  sure  of  our  ground  it  is 
frequently  necessary  to  bring  to  our  aid  the  history  and  the  internal  examina- 
tion. In  this  condition  as  in  so  many  others,  the  classical  picture  in  toto  is 
rarely  seen  and  it  has  happened,  paradoxically  enough,  as  Douglas  remarks  that 
many  more  diagnoses  are  made  nowadays  since  the  integrity  of  all  the  classical 
sjTiiptoms  have  been  repeatedly  attacked  than  when  a  clear  average  picture  had 
been  drawn  and  accepted.  It  will  do  then  to  know  that  the  three  cardinal 
s}Tirptoms  are  pain,  menstrual  irregularities  and  tumor  if  we  appreciate  their 
variability. 

The  question  of  great  and  timely  interest  in  connection  with  the  treatment 
of  extra-uterine  pregnancy  has  to  do  with  the  management  of  the  case  at  the 
time  of  rupture,  with  associated  haemorrhage  and  shock,  and  it  is  to  the  con- 
sideration of  this  phase  of  the  subject  that  I  wish  to  devote  most  of  my  time 
to-night.  Before  discussing  this  important  question,  however,  I  wish  to  direct 
your  attention  to  the  complications  which  may  arise  in  such  cases  as  escape  the 
most  imminent  peril  of  shock  and  haemorrhage.  Thanks  to  the  early  operation 
these  complications  are  rare  nowadays,  but  I  greatly  fear,  if  the  advocates  of 
delayed  treatment  secure  a  following  in  the  profession,  that  these  cases  may 
occur  more  frequently,  and  that  cases  which  would  be  noted  in  the  statistics  of 
extreme  conservatives  as  cures,  will  later  succumb  to  a  condition  which  is  the 
direct  result  of  the  Fabian  policy.  I  have  already  pointed  out  that  spontaneous 
cures  may  occur  without  leaving  a  dangerous  condition  behind  and  have 
remarked  on  the  rarity  of  such  a  favorable  outcome.  More  usual  is  it  for  a 
collection  of  blood,  often  very  large,  to  be  left  as  a  foreign  body  in  the 
peritoneum. 

These  collections,  or  hsematoceles  excite  a  reactive  peritonitis  which  serves 
to  glue  together  the  intestines  and  encapsulate  the  mass  of  clots.  Absorption 
and  organization  of  such  a  clot  may  take  place,  but  is  usually  very  slow.  In 
the  meantime  not  infrequently  infection  occurs.  The  danger  of  this  is  apparent 
when  we  realize  that  an  hsematocele  is  nothing  but  a  most  inviting  medium  for 
bacterial  growth,  situated  about  the  rectum  or  lower  bowel  which  harbors  the 
most  virulent  bacteria.  An  infected  ha?matocele  is  a  serious  condition  and 
demands  prompt  evacuation  and  drainage.  This  is  best  done  by  way  of  the 
vagina,  if  possible.  At  times  it  is  necessary  to  attack  it  by  the  abdominal 
route  accepting  the  danger  of  a  subsequent  peritonitis. 

Obstruction  of  the  bowel  is  mentioned  by  Parry  as  the  cause  of  death  in 
a  number  of  instances.  The  mechanism  of  this  is  by  the  peritoneal  adhesions 
set  up  by  the  old  extravasation  of  blood  or  a  degenerated  foetus  in  neglected 
cases. 

A  pregnancy  which  is  allowed  after  rupture  to  develop  free  in  the  abdomen 
or  in  the  broad  ligament  later  furnishes  a  very  difficult  problem  to  tlic  surgeon 


264  EXTRA-UTERINE  PREGNANCY. 

owing  to  the  danger  in  dealing  with  the  placental  site,  and  the  mortality  in  such 
cases  is  much  higher  than  in  the  early  cases.  Left  entirely  to  itself  the  foetus 
often  becomes  infected,  and  the  earliest  records  we  have  of  extra-uterine  preg- 
nancies are  of  cases  in  which  this  occurred,  the  resulting  abscess  later  sponta- 
neously discharging  through  the  abdominal  walls,  when  its  nature  was  surmised 
by  the  appearance  of  degenerated  foetal  parts  in  the  discharge.  Sepsis,  ex- 
haustion and  death  were  noted  in  54  of  Parry's  cases. 

With  this  brief  review  of  the  late  complications  of  extra-uterine  preg- 
nancy I  will  proceed  to  a  discussion  of  the  immediate  considerations  concerning 
an  active  versus  expectant  mode  of  treatment  in  cases  of  rupture. 

It  has  long  been  my  practice  to  operate  every  acute  case  of  extra-uterine 
pregnancy  without  delay  and  my  results  have  been  so  unifonnly  good  that  it 
would  never  have  occurred  to  me  to  reopen  the  question.  Eobb  in  1907  came 
forward  with  the  assertion  that  surgeons  were  losing  many  of  their  desperate 
cases  from  overhaste  in  operating  during  shock.  He  believes  that  shock  is 
mainly  due  to  the  effect  of  the  accident  of  rupture  upon  the  nervous  system,  that 
it  would  bo  a  great  rarity  for  a  patient  to  bleed  to  death  and  that  cases  in 
which  the  loss  of  blood  in  itself  would  be  sufficient  to  bring  about  a  fatal 
termination  would  seldom  be  seen  in  time  to  save  the  patient.  He  bolsters  his 
position  by  animal  experiments,  having  observed  that  dogs  do  not  die  of 
haimorrhage  even  after  section  of  the  uterine  and  ovarian  vessels. 

Just  what  he  considers  the  cause  of  death  in  these  cases  is  not  clear.  The 
coroner's  statistics  of  Dr.  Formad,  though  he  admits  that  it  is  on  record  that  in 
certain  instances  the  amount  of  blood  which  was  found  was  enough  to  fill  the 
abdominal  cavity,  he  dismisses  by  saying  that  "such  statements  are  entirely 
too  meagre  to  give  us  any  definite  knowledge,  nor  can  they  be  entirely  depended 
on."  He  also  says  in  this  regard  that  "in  a  given  fatal  case  it  must  also  be 
proven  that  there  were  no  other  and  possibly  equally  important  factors  in  the 
causation  of  the  fatal  result."  Such  sublime  confidence  in  one's  opinions  it  is 
rarely  vouchsafed  us  to  see.  He  not  only  doubts  that  the  coroner  saw  the  blood 
but  he  invites  us  to  prove  that  the  patient  did  not  die  of  cerebral  apoplexy 
instead  of  abdominal  haemorrhage.  As  for  the  animal  experiments  I  can  only 
say  that  if  he  has  not  seen  a  woman  die  from  hemorrhage  from  a  uterine 
arterj',  he  has  been  more  fortunate  than  I  have  been,  and  that  I  therefore  still 
resort  to  the  old-fashioned  expedient  of  tying  as  secure  a  knot  about  that  vessel 
as  I  am  able. 

Formerly  it  was  not  such  an  uncommon  thing  for  these  patients  to  bleed 
to  death.  Of  the  500  cases  reported  by  Parry  there  were  336  deaths,  174  of 
which  were  from  rupture  and  hasmorrhage.  Of  113  of  these  in  which  the 
time  of  death  was  stated  81  had  died  at  the  end  of  24  hours  and  at  the  end  of 
48  hours  only  15  were  left  alive. 

Of  course  this  gives  a  greatly  exaggerated  idea  of  the  danger  because  in 
those  days  only  the  evident  and  severe  cases  were  noted.  Still  it  serves  to 
show  that  without  operation,  death,  which  was  shown  by  autopsy  to  be  associated 
with  excessive  haemorrhage,  was  not  so  uncommon  a  sequel.  If  these  deaths 
were  not  due  to  haemorrhage,  what  did  cause  them  ? 


EXTRA-UTERINE  PREGNANCY.  265 

Has  anyone  seen  a  death  from  shock  of  rupture  with  an  insignificant  or 
even  a  moderate  amount  of  blood  in  the  peritoneal  cavity  ?  In  the  cases  which 
I  have  seen  in  this  so-called  state  of  shock,  the  condition  of  the  patient  bore  a 
striking  parallelism  with  the  amount  of  blood  found  in  the  abdominal  cavity. 
I  wish  to  enter  a  strong  protest  against  the  loose  use  of  the  term  shock  in  this 
condition  as  well  as  the  vicious  tendency  of  such  flashy  phrases  as  "adding 
shock  to  shock."  The  great  danger  in  these  cases  is  not  from  the  shock  of 
rupture  but  from  the  subsequent  haemorrhage.  Or  to  be  very  conservative, 
severe  haemorrhage  is  necessary  to  produce  the  fatal  outcome.  Let  us  consider 
for  a  moment  this  factor  shock.  It  is  known  that  any  acute  lesion  of  the 
peritoneum  produces  through  shock  to  the  gi-eat  abdominal  nerve  centres  a 
certain  train  of  symptoms,  whether  the  lesion  be  due  to  rupture  of  the  appendix, 
twisted  pedicle  of  an  ovarian  tumor,  passage  of  gall-stones,  acute  strangulation 
of  the  intestine,  or  rupture  of  an  extra-uterine  pregnancy  and  to  this  train  of 
symptoms  Giibler  has  given  the  name  'peritonism.'  These  symptoms  are 
independent  of  inflammation  or  of  septic  intoxication.  They  are:  pain,  pro- 
found exhaustion,  distressful  anxiety,  pallor,  soft  quick  pulse,  cold  extremities, 
shallow  respiration,  nausea  and  vomiting.  These  vary  in  degree  and  are 
common  in  some  degree  to  all  cases  in  which  there  has  been  a  wide  and  abrupt 
impression  upon  the  nerve  centres  of  the  abdomen.  This  is  the  train  of  symp- 
toms which  follow  immediately  upon  an  acute  rupture  of  the  gestation  sac 
and  gives  the  picture  properly  denominated  as  shock.  This  shock  as  such  is 
practically  never  fatal.  Clinical  evidence  is  conclusive  on  this  point.  We  do 
not  find  our  patients  di'opping  over  dead  from  acute  strangulation,  twisted 
pedicles  or  tubal  ruptures.  The  shock  exerts  its  maximum  influence  at  the 
moment  of  the  tearing  injury  to  the  peritoneum  and  sympathetic  trunks  and 
practically  ceases  at  once  with  the  release  of  tension  after  the  laceration  has 
been  clfected.  This  factor  is  sudden,  momentaiy,  expends  its  energy  ajid 
ceases.  Reaction  begins,  or  would  begin  at  once,  either  spontaneously  or  witli 
the  aid  of  stimulants.  This  sudden  insult  to  the  peritoneum  and  the  great 
sympathetic  centres  is  not  what  places  the  patient's  life  in  jeopardy  and  holds 
her  hovering  in  the  balance  for  hours. 

This  is  but  the  advance  agent  of  the  real  executioner,  haemorrhage.  Let 
me  read  you  the  symptoms  of  shock  in  the  same  order  as  before  leaving  oil  the 
pain  in  the  beginning  and  behold  we  have  the  symptomatology  of  haemorrhage. 
Profound  exhaustion,  distressful  anxiety,  pallor,  soft  quick  pulse,  cold  extremi- 
ties, shallow  respiration,  air  hunger,  nausea  or  vomiting.  Who  is  that  man 
who  will  tell  us  in  these  cases  where  shock  leaves  off  and  haemorrhage  begins  to 
play  the  leading  role?  Find  him  and  let  him  be  our  king  and  rule  over  us 
for  we  know  not  how  to  do  these  things. 

I  feel  most  strongly  that  we  are  dealing  here  with  a  wrong  use  of  words, 
that  there  is  a  sophistical  "nigger  in  the  woodpile."  I  do  not  believe  that  the 
patients  reported  by  the  advocates  of  the  expectant  treatment  as  suffering  from 
shock  were  suffering  from  primary  shock,  but  instead  from  shock  plus  haemor- 
rhage and  that  by  the  time  they  were  seen  by  the  surgeon,  that  haemorrhage 
was  playing  by  far  the  chief  role.    Those  patients  who  are  fortunate  enough  to 


266  EXTRA-UTERINE  PREGNANCY. 

lose  but  a  small  quantity  of  blood  at  the  time  of  rupture  react  from  the  shock 
with  considerable  promptitude.  By  the  time  proper  surgical  intervention  can 
be  brought  to  bear  their  condition  is  such  as  to  give  the  surgeon  little  immediate 
anxiety  as  far  as  the  shock  of  operation  is  concerned.  These  patients  should  be 
operated  at  once  on  account  of  the  danger  of  secondary  rupture  or  a  renewal  of 
bleeding.     They  should  all  get  well. 

An  immediate  operation  detracts  nothing  from  their  chances  but  guards 
against  imminent  danger.  Those  patients,  who,  when  seen  an  hour  or  several 
hours  after  rupture  (I  am  speaking  of  conditions  as  we  find  them,  for  patients 
do  not  come  to  a  hospital  or  doctor's  office  to  be  handy  at  the  time  of  rupture), 
these  patients,  I  say,  who  are  hanging  in  the  balance  with  the  symptoms  some 
are  pleased  to  call  shock,  are  not  suffering  from  shock,  but  rather  of  shock 
plus  haemorrhage,  shock  in  small  type,  haemorrhage  in  large  red  capitals  and  the 
examples  which  these  gentlemen  adduce  of  reaction  are  not  proofs  of  the  wisdom 
of  waiting  but  of  the  fact  that  many  desperate  cases  will  stop  just  short  of 
bleeding  to  death  if  left  to  themselves,  a  fact  wliich  has  for  years  been  patent 
to  all. 

There  are  certain  factors  which  would  favor  the  cessation  of  bleeding  such 
as  a  long  and  voluminous  sigmoid  or  omentum  wedging  down  in  the  pelvis,  but 
as  we  are  not  often  furnished  with  a  diagram  of  interior  arrangements  in  these 
cases,  we  do  not  know  whether  these  staunch  allies  are  on  tlie  ground.  The 
character  of  the  rent  and  the  coagulability  of  the  blood  we  cannot  estimate. 
If  we  are  going  to  treat  these  patients  expectantly  let  us  rob  Justice  of  her 
blindfold  and  wrap  it  about  the  brows  of  Aesculapius. 

As  sure  as  there  are  immutable  laws  of  hydrostatics  and  of  the  circulation 
of  the  blood,  these  patients  have  died  in  the  past  in  considerable  numbers  from 
hemorrhage  and  occasionally  die  to-day  from  that  cause,  and  the  only  reason 
more  do  not  die  of  it  is  because  of  the  early  operation  practiced  by  clinical 
surgeons. 

I  am  willing  to  grant  that  a  patient  should  not  have  a  "penknife"  opera- 
tion done  on  her  before  she  has  recovered  from  her  first  faint.  There  is 
reason  in  all  things.  It  is  equally  true  that  a  patient  in  articulo  mortis  should 
not  be  subjected  to  operation..  "The  resources  of  surgery  are  rarely  successful 
when  practiced  on  the  dying.  Tbesc  principles,  however,  should  not  be  made 
use  of  to  attack  a  mode  of  treatment  which  has  been  crowned  with  the  highest 
success." 

My  position  then  is  this:  A  continuance  of  the  collapsed  condition,  com- 
monly, and  as  I  believe  erroneously,  termed  shock,  for  a  longer  time  than  one 
hour  indicates  that  a  considerable  hemorrhage  has  occurred  and  may  be  con- 
tinuing. The  surgical  indications  are  clear — stop  the  bleeding;  stimulate. 
Let  us  not  revert  to  the  dark  ages  in  the  ranks  of  those  who  "watched  the 
life  ebb  rapidly  from  the  pale  victim  of  this  accident  but  never  raised  a  hand 
to  help  her." 

Since  1900  1  have  had  110  cases  of  extra-uterine  pregnancy,  many  of  them 
of  the  acute  type,  without  a  death. 


Tubal  Pregnancy.      (J.  B.  Deaver.) 


EXTRA-UTERINE  PREGNANCY.  267 

My  procedure  in  these  urgent  cases  is  as  follows :  If  the  condition  be  very 
low  stimulation  is  begun  on  admission  by  hypodermoclysis  and  strychnia.  If 
there  is  extreme  restlessness,  morphia  is  a  valuable  adjunct. 

They  are  placed  on  the  table  with  as  little  disturbance  as  possible  and  a 
light  quick  etherization  given.  Preparation  is  rapidly  completed  and  intra- 
venous transfusion  of  normal  saline  solution  started  as  the  abdominal  incision 
is  made.  "Get  in  quickly,  get  out  quicker"  applies  here  as  forcibly  as  anywhere 
in  surgery.  The  offending  tube  and  ovary  are  removed.  The  clots  are  scooped 
out,  and  if  the  condition  of  the  patient  warrants,  the  abdomen  is  flushed  out 
and  filled  with  normal  saline  before  closure. 

I  have  frequently  seen  the  patient  go  off  the  table  with  a  far  stronger  pulse 
and  in  better  condition  than  before  the  operation,  a  sufiicient  refutation  of  the 
charge  of  "adding  shock  to  shock."  I  have  rather  refused  to  allow  haemorrhage 
to  be  added  to  haemorrhage,  and  now  I  am  not  afraid  to  fill  her  vessels  with 
sufficient  fluid  to  satisfy  the  mechanical  needs  of  the  circulation. 

My  last  case,  about  two  weeks  ago,  happened  to  be  most  appropriate  to 
this  discussion  and  with  your  permission  I  will  give  it  in  brief : 

A  young  woman,  aged  24,  married  three  years,  with  nothing  of  note  in  her 
past  history.  She  had  had  one  child  nine  months  ago,  which  died  in  January. 
No   miscarriages. 

Menstruation  had  always  been  regular  and  normal  up  to  her  January 
period  which  she  missed.  At  the  February  period  she  bled  quite  profusely  and 
for  a  longer  time  than  usual.     No  staining  since. 

Suddenly  at  6  a.m.  on  February  12th,  during  coitus  she  had  an  acute 
pain  in  the  lower  left  side  of  the  abdomen,  followed  in  a  few  minutes  by 
syncope.  Soon  she  recovered,  but  fainted  several  times  in  the  course  of  the 
morning  and  vomited  several  times.  Gradually  grew  weaker  and  grew  short  of 
breath. 

On  examination  she  did  not  have  a  particle  of  color  in  her  skin  or  lips. 
Expression  was  anxious :  she  was  restless  and  dyspnoeic.  The  pulse  was  about 
180  and  barely  perceptible.  Her  abdomen  was  moderately  distended  and  tender 
in  left  side  low  down.  Vaginal  examination  was  negative  except  for  tender- 
ness in  the  left  lateral  fornix. 

She  was  taken  to  the  operating  room  and  subcutaneous  infusion  started 
with  the  ether. 

Preparation  having  been  quickly  accomplished,  the  operation  and  intra- 
venous transfusion  were  started  together.  A  left  sided  tubal  pregnancy  (See 
Plate)  the  size  of  a  hickory  nut  was  found  in  the  isthmial  portion  about  2  cm. 
from  the  comual  extremity.  Through  the  tube  was  a  perforation  only  about 
as  large  as  a  pin  head.  No  time  was  wasted  in  determining  whether  there  was 
any  active  bleeding.  Tube  and  ovary  were  removed.  As  the  patient's  condi- 
tion was  improving  on  the  table,  I  washed  out  the  blood,  of  which  there  was  a 
large  quantity  and  filled  tlie  abdomen  before  closure  with  salt  solution. 

Her  pulse,  which  before  the  operation  was  180,  at  the  end  of  tlie  opera- 
tion was  140  and  much  improved  in  quality.  She  was  put  back  in  bed  and 
continuous  proctoclysis  started. 


268  POSTOPERATIVE  TREATMENT  IN  RECTAL  OPERATIONS. 

I  wisli  to  call  attention  to  the  value  or  rather  necessity  of  filling  the  empty- 
blood-vessels  with  saline  in  these  depleted  cases.  Note  the  amount  used  in  this 
case.  By  hypodermoelysis  at  the  beginning,  1000  c.c.  Intravenous  transfusion 
during  the  operation  2000  c.c.  Left  in  the  abdomen  at  least  1500  c.c.  Then 
in  the  twelve  houra  after  operation  her  thirsty  vessels  absorbed  by  way  of  the 
large  bowel  4000  c.c.  additional.  Nearly  nine  liters  of  saline,  over  two  gallons 
of  fluid  to  meet  the  mechanical  needs  of  the  circulation.  Without  this  saline 
my  patient  would  have  run  grave  danger  of  dying  on  the  table.  As  the 
intra-abdominal  pressure  is  released  by  incision  the  blood  flows  into  the 
"splanchnic  tank"  and  from  the  great  depletion  due  to  haemorrhage  nothing  is 
left  in  the  great  vessels  for  the  heart  to  pump.  The  medullary  vessels  are 
asphyxiated  and  death  results.  This  restoration  of  the  fluid  volume  of  the 
blood  is  a  most  important  point  and  will  eliminate  what  is,  I  suspect,  the 
most  potent  factor  in  that  additional  shock  so  feared  by  the  misguided  advocates 
of  erpectancy. 

THE  IMPORTANCE  OF  CAREFUL  POSTOPERATIVE  TREATMENT  IN 
RECTAL  OPERATIONS.* 

By  HERMAN  A.  BRAV,  M.D., 

PHILADELPHIA, 

Proctologist  to  the  American  Hospital  for  Diseases  of  the  Stomach,  and  Surgeon  to  the 
Lebanon  Hospital  of  Philadelphia. 

The  ultimate  success  of  rectal  operations  depends  more  upon  the  care 
which  is  exercised  in  the  after-treatment  than  it  does  upon  the  technic  during 
the  operation.  The  surgeon's  responsibility  does  not  end  with  the  completion  of 
the  operation,  but  continues  until  healing  is  complete.  Many  brilliant  opera- 
tions turn  out  to  be  failures  because  the  proper  after-treatment  was  not  carried 
out.  The  object  of  the  after-treatment  is  to  discover  complications  early,  and 
if  found  to  treat  them  so  intelligently  as  to  give  the  patient  the  best  chance 
for  recovery  and  the  best  final  result. 

In  the  short  time  allotted  to  me  I  wish  to  confine  myseK  to  only  the  most 
common  operations  of  the  rectum,  namely,  operations  for  fistulas  in  ano  and 
hajmorrhoids.  After  the  operation  for  fistulse  in  ano  has  been  completed,  the 
wound  must  be  packed  tightly  to  prevent  hemorrhage.  The  dressing  should  be 
retained  m  sliu  by  a  well-fitting  T  bandage.  The  initial  dressing  should  be 
removed  on  the  second  day.  It  is  well  to  moisten  the  dressing  with  a  mild 
bichloride  solution  in  order  to  facilitate  its  removal.  The  wound  must  be  kept 
as  clean  and  aseptic  as  possible  by  daily  irrigations  with  the  bichloride  of 
mercury  1-2000.  Immediately  after  the  irrigation  a  strip  of  iodoform-gauze  is 
placed  between  the  cut  surfaces  and  part  of  it  pushed  down  to  the  bottom 
with  a  probe  so  as  to  ensure  healing  up  from  the  bottom.  Such  a  dressing,  if 
carefully  carried  out,  will  prevent  the  bridging  over  which  may  be  the  cause 
of  the  development  of  secondary  fistula3.     On  the  fourth  day  after  the  operation 

•Read    before   the   North    Branch   of  the  Philadelphia    County   Medical    Society, 
March  16,  1909. 


POSTOPERATIVE  TREATMENT  IN  RECTAL  OPERATIONS.  269 

the  bowels  should  be  made  to  move  freely  by  administering  a  purgative  and 
henceforth  a  free  action  should  be  obtained  daily  during  the  entire  treatment. 

If  any  union  of  the  granulations  of  the  two  sides  is  noticed  it  should  be 
broken  up  at  once.  The  bichloride  irrigation  should  be  kept  up  for  several  days, 
and  each  time  the  woimd  is  dressed  a  careful  search  for  pus  pockets  should  be 
made,  and  if  pocketing  of  the  tissues  is  discovered  they  must  be  laid  open. 
After  a  week  or  ten  days  and  at  the  time  when  all  evidences  of  suppuration  are 
absent  and  healthy  granulation  has  been  established  the  bichloride  irrigations 
can  be  replaced  by  a  creolin  solution  of  one  dram  to  the  pint.  While  it  is 
advisable  to  keep  the  patient  under  observation  until  the  wound  has  completely 
healed  up  it  is  not  necessaiy  to  keep  him  in  bed  for  a  long  time.  This  applies 
especially  to  tuberculous  patients  who  ought  to  be  allowed  to  be  up  and  about  as 
soon  as  possible  and  live  in  the  fresh  air  and  sunshine.  It  should  be  borne  in 
mind  that  the  constitutional  treatment  is  of  paramoimt  importance.  A  nutri- 
tious and  easily  assimilated  diet  should  be  ordered. 

Stimulants,  tonics  and  constructives  are  extremely  useful  for  promoting 
repair.  The  dressing  of  wounds  made  in  operating  for  fistula  in  ano  should 
never  be  left  to  the  young  resident  or  as  is  often  done  to  the  nurse,  but  should 
be  done  by  the  surgeon  himself  until  a  cure  is  effected.  The  novice  can  not  be 
expected  to  differentiate  between  a  normal,  sluggish  and  exuberant  granulation. 
It  therefore,  requires  the  experience  of  a  surgeon  to  know  when  to  stimulate 
and  when  to  destroy  granulations.  I  have  only  recently  seen  a  case  that  has 
been  operated  upon  by  an  eminent  surgeon  who  kept  llie  patient  two  months 
in  the  hospital  confined  to  bed  and  at  the  end  of  that  time  told  him  he  had  to 
undergo  another  operation  for  another  fistulas.  An  examination  showed  a 
large  cicatrized  area  one  end  of  which  did  not  heal  up  and  the  oozing  of  pus 
from  it  was  continuous.  The  patient  informed  me  that  the  surgeon  never 
looked  at  him  after  the  operation,  and  the  dressing  of  the  wound  was  done  by 
tlie  resident  and  nurse  alternately.  This  case  is  a  striking  example  of  failure 
due  to  careless  and  improper  management  of  the  wound  after  the  operation. 
I  could  cite  a  large  number  of  similar  cases  but  this  one  will  suffice  to  demon- 
strate the  result  of  careless  after-treatment  of  wounds  following  operations  for 
fistnlae  in  ano.  Failures  following  operations  for  internal  haemorrhoids  are 
likewise  caused  by  lack  of  attention  to  the  postoperative  treatment.  It  is  not 
enough  to  excise,  bum  or  ligate  off  piles  and  then  leave  the  healing  up  of  the 
wounds  to  nature.  Such  a  procedure  often  leads  to  a  strictured  condition  of 
the  anal  canal  or  ulceration  thereof.  It  should  not  be  forgotten  that  the  re- 
moval of  a  ha^morrhoidal  tumor,  by  whatever  method,  leaves  behind  an  ulcerated 
surface.  The  healing  of  these  ulcers  must  be  carefully  watched  and  treated  in 
order  to  prevent  excessive  granulation  which  tends  to  produce  partial  or  com- 
plete stricture  of  the  rectum. 

Sometimes  one  of  these  ulcers  fails  to  heal  up,  especially  in  a  debilitated 
patient,  and  the  irritation  produced  by  such  an  ulcer  makes  the  patient  more 
miserable  than  he  was  before  the  operation.  These  complications  can  be  pre- 
vented by  intelligent  postoperative  treatment.  After  a  hnRmorrhoidal  operation 
the  patient  should  be  kept  as  quiet  as  possible  in  order  to  prevent  possible 


270  THE  IMPORTANCE  OF  THE  JOINTS  OF  THE  PELVIC  GIRDLE. 

hasmorrhage.  The  anal  canal  should  be  irrigated  twice  daily  with  a  creolin  or 
any  other  mild  antiseptic  solution.  The  irrigation  of  the  anal  canal  is  best 
accomplished  by  asking  the  patient  to  force  down  the  anus  and  while  doing  so 
the  ulcerated  area  is  irrigated  or  bathed  as  it  were.  Thirty-six  hours  after  the 
operation  the  patient  is  given  fractional  doses  of  calomel  followed  by  a  saturated 
solution  of  magnesium  sulphate  to  secure  a  thorough  evacuation  of  the  bowels. 
If  this  does  not  produce  the  desired  result  an  enema  should  be  given  to  supplant 
the  cathartic. 

It  is  desirable  to  ensure  a  daily  movement  and  immediately  after  the 
movement  the  anal  region  and  the  ulcerated  area  should  be  irrigated  with  a 
creolin  solution,  one  dram,  to  the  pint.  The  wound  should  be  inspected  at  each 
dressing  and  if  found  to  heal  sluggishly  it  should  be  stimulated  with  silver 
nitrate  or  balsam  of  Peru  from  time  to  time.  Exuberant  granulation  which 
eventually  leads  to  the  development  of  cicatrical  contraction  must  be  checked. 
A  good  method  to  prevent  narrowing  of  the  anal  canal  after  a  hemorrhoidal 
operation  is  the  passage  of  a  rectal  bougie.  Commencing  about  a  week  after  the 
operation  and  continuing  it  during  the  process  of  healing  of  the  wound  the 
daily  passage  of  a  smooth  glass  rectal  bougie  or  dilator  about  one-half  inch  in 
diameter  will  invariably  prevent  the  occurrence  of  cicatricial  contraction. 
The  bougie  should  be  kept  in  the  rectum  for  five  or  ten  minutes. 

The  patient  need  not  be  confined  to  bed  longer  than  a  week  or  ten  days 
but  should  be  under  observation  for  at  least  four  weeks.  I  do  not  wait  until 
symptoms  of  contraction  appear  but  make  it  a  routine  practice  to  pass  bougies 
daily  at  the  end  of  the  first  week  after  the  operation.  Patients  may,  after  two 
weeks,  follow  their  usual  occupation  and  call  at  the  office  or  hospital  for  this 
treatment.  If  this  treatment  has  been  carefully  carried  out,  the  patient  can 
safely  be  discharged  at  the  end  of  four  weeks.  I  have  employed  this  method 
for  several  years  with  excellent  results  and  I  have  yet  to  see  a  case  of  stricture 
following  this  mode  of  postoperative  treatment.  It  must  be  admitted  that  con- 
striction of  the  upper  part  of  the  anal  canal  is  apt  to  follow  a  free  removal  of 
piles  in  spite  of  the  best  surgical  technic. 

Since  it  is  difficult  to  foretell  which  one  of  the  cases  will  be  followed  by 
this  complication,  it  is  best  to  resort  to  the  passage  of  the  bougie  in  every  case. 
The  introduction  of  the  bongie  while  the  patient  is  straining  as  much  as 
possible  is  not  attended  by  any  discomfort  and  is  cheerfully  tolerated  by  patients. 
In  conclusion  I  would  like  to  reiterate  that  a  successful  issue  in  most  rectal 
operations  depends  more  upon  the  after  treatment  than  upon  the  operation. 


THE  IMPORTANCE  OF  THE  JOINTS  OF  THE  PELVIC  GIRDLE. 

By  JOEL  E.   GOLDTHWAIT,  M.D., 

BOSTON,  MASS. 

Since  the  first  article  upon  the  pelvic  articulations  was  published  by  the 
writer  in  Boston  Medical  and  Surgical  Journal  (May  25,  June  1,  1905), 
the  importance  of  these  structures,  both  as  regards  their  own  tone  and  as  regards 


THE  IMPORTANCE  OF  THE  JOINTS  OF  THE  PELVIC  GIRDLE.  271 

the  functions  of  other  portions  of  the  body,  has  been  increasingly  evident.  It 
has  been  demonstrated  beyond  question  that  the  pelvic  bones  are  joined  together 
with  three  true  joints  which  are  made  up  of  all  the  structures  peculiar  to  a 
joint,  and  that  motion  is  a  natural  part  of  their  function.  The  age  and  sex 
are  of  no  importance  in  this  except  that,  naturally,  in  childhood  the  stability  of 
the  joints  is  apt  to  be  less  than  in  adult  life  and  except  that  with  women  the 
stability  is  less  than  with  men  because  of  the  possibility  of  childbearing.  It  has 
been  clearly  shown  that,  with  women,  under  certain  conditions  the  stability  of 
these  joints  is  naturally  greater  than  at  other  times.  As  a  physiological  part  of 
pregnancy  they  are  rehixed,  at  times  to  quite  an  extreme  degree,  but  practically 
always  enough  so  that  if  the  mechanism  of  the  possible  motion  is  understood  the 
character  of  the  labor  can  be  very  greatly  modified.  It  is  also  true  that  at  each 
menstrual  period  there  is  a  physiological  relaxation  of  the  pelvic  joints,  men- 
struation being  simply  a  miniature  pregnancy,  from  the  physiological  point  of 
view,  and  that  this  explains  many  of  the  backaches  so  commonly  supposed 
to  be  due  to  pelvic  organ  disease  there  can  be  no  question.  Not  only  are  these 
facts  true,  but  if  there  be  any  disturbance  of  the  circulation  of  the  pelvic  organs, 
there  may  be  a  reflex  relaxation  of  the  joints  and  instability  result  from  this, 
facts  of  much  importance  in  deciding  the  nature  of  the  treatment  from  either 
the  point  of  view  of  the  joints  or  the  pelvic  viscera. 

The  planes  of  the  articulation  of  the  pelvic  joints  are  such  that  the  support 
of  these  joints  and  their  stability  must  depend  almost  entirely  upon  the  tone 
of  the  muscles  and  ligaments.  The  joint  at  the  symphysis  pubis  is  vertical. 
The  sacro-iliac  joints  are  oblique,  inclining  only  a  few  degrees  from  the  vertical, 
Avith  flat  surfaces  and  with  no  element  of  support  other  than  that  represented  by 
the  soft  structures.  The  pelvic  girdle,  representing  as  it  does  the  structural 
base  of  the  body  to  which  all  of  the  trunk  muscles  are  attaclied  and  to  which 
practically  all  of  the  thigh  muscles  are  attached,  is  naturally  of  great  importance 
in  the  matter  of  proper  use  of  the  body.  If  the  joints  are  weak  it  is  naturally 
impossible  for  the  patient  to  use  the  body  rightly,  to  maintain  the  proper  poise, 
or  to  withstand  strains  of  any  form,  because  the  muscles  which  are  attached 
to  the  pelvic  girdle  cannot  act  rightly  if  the  base  to  which  they  are  attached  is 
insecure.  Not  only  this,  but  it  is  useless  to  attempt  to  strengthen  the  muscles 
of  the  trunk  or  thighs  if  the  base  to  which  these  muscles  arc  attached  is  weak. 
Eecognizing  the  fact  that  the  joints  depend  upon  the  muscles  for  their  support 
it  is  at  once  apparent  that  use  which  overtires  these  muscles  must  take  away 
from  their  support  and  consequently  be  harmful.  Attitudes  or  occupations  that 
keep  the  body  flexed  for  long,  since  under  these  conditions  the  spinal  muscles 
must  be  strained,  are  distinctly  undesirable. 

The  affect  upon  the  body  which  lack  of  stability  of  the  pelvic  joints 
occasions  is  shown  partly  by  the  limitation  in  activities,  partly  by  peculiarities 
in  gait — the  weakness  at  times  making  locomotion  almost  if  Jiot  entirely  impos- 
sible, and  making  it  impossible  to  use  the  body  in  the  erect  position. 

The  importance  of  the  erect  position  has  been  shown  to  be  far  greater 
than  simply  the  aesthetic  importance,  since  if  the  body  is  used  in  tlie  drooped  or 
flexed  position,  not  only  arc  the  muscles  and  joints  still  further  strained,  Init 


272  TUBERCULIN  THERAPY. 

the  support  which  the  viscera  should  receive  from  the  abdominal  muscles  and 
from  the  various  fossae  in  which  they  should  be  held  by  the  muscles  no  longer 
exists,  and  displacement  or  malposition  of  the  viscera  or  interference  with  their 
function  is  a  necessary  result. 


TUBERCULIN  THERAPY.* 

By  H.  B.  weaver,  M.D., 

ASnEVIIXE,   N.   O., 

Ex-Presidcnt  of  the  Medical  Society  of  the  State  of  North  Carolina;    ex-Member  of  the 
State  Board  of  Medical  Examiners. 

The  renev/ed  interest  in  tuberculin  as  a  curative  agent  in  the  treatment 
of  tuberculosis  has  become  so  manifest  and  my  personal  experience  with  it  for 
the  last  eight  years,  especially  with  a  certain  method  of  its  use,  has  been  found 
of  such  supreme  value,  that  it  seems  worth  while  again  to  call  attention  to  this 
subject.  And  I  am  more  emboldened  to  do  so  from  the  fact  that  the  history 
of  tuberculin  since  its  discovery  in  1890,  teaches  that  its  scope  as  regards  its 
action  and  dosage  has  never  been  properly  understood  by  the  profession  at 
large,  and  also  by  the  favorable  reports  of  reliable  clinicians  the  world  over, 
who  have  lately  given  this  method  of  treatment  their  unqualified  endorsement. 

The  causes  of  failure  of  tuberculin  therapy  in  its  first  epoch,  and  the 
negative  results  that  followed  can  be  accounted  for  in  two  ways :  (1)  the  remedy, 
with  few  exceptions,  was  employed  in  a  faulty  manner,  and  (2)  the  pathological 
findings  were  falsely  interpreted  by  the  profession. 

Notwithstanding  Koch's  guarded  announcement  as  to  the  limitations  of 
the  remedy,  it  was  received  with  enthusiasm,  and  too  much  tuberculin  was 
given  in  too  short  a  time,  producing  thereby  a  condition  of  excessive  intoxica- 
tion, the  organism  being  overloaded  with  toxins.  For  example,  one  of  Eut- 
meyer's  patients  received  eleven  injections  in  eleven  days ;  in  spite  of  this  fact, 
his  temperature  rose  to  104,  and  he  lost  eleven  pounds  in  weight;  on  the  sixth 
day  he  received  30  mg.,  and  7  days  later  he  died  of  acute  tubercular  meningitis. 
No  human  organism  could  indefinitely  stand  such  heroic  poisoning.  Such  a 
method  to-day  would  be  branded  as  malpractice.  In  view  of  such  disastrous 
results,  there  is  little  wonder  at  the  revulsion  of  feeling  against  the  remedy,  to 
the  extent  that  it  was  criticised,  condemned  and  almost  abandoned.  But  a 
decade  passed,  interest  revived,  and  like  all  truths,  though  wounded  and 
"crushed  to  earth,  shall  rise  again."  To-day,  thanks  to  such  men  as  Wasser- 
man,  Wright,  Trudeau  and  Baldwin,  we  have  the  renaissance  of  an  almost  for- 
gotten method,  which  illumined  by  their  splendid  geniuses,  bids  fair  indeed,  to 
become  one  of  our  most  valuable  assets  in  medicine. 

Varieties  of  Tuberculin. — For  practical  purposes,  it  is  necessary  to  men- 
tion only  four  preparations  of  tuberculin : 

•  Read  before  the  Medical  Association  of  the  Carolinas  and  Virginia,  Charleston, 
S.  C,  February  16,  17,  1909. 


TUBERCULIN  THERAPY.  273 

1.  Tuberculin  "0",  or  old  tuberculin,  is  a  liquid,  or  bouillon  upon  whicli 
has  been  grown  tubercle  bacilli,  which,  killed  by  heat,  are  filtered  out,  leaving  a 
clear  filtrate  to  which  is  added  five  per  cent,  of  glycerine.  This,  by  evaporation, 
is  reduced  to  1/10  of  its  volume. 

2.  Denys's  tuberculin  is  a  germ  free  filtrate  from  bouillon  cultures  of  the 
tubercle  bacillus,  and  contains  the  same  soluble  products  elaborated  by  the 
bacilli  as  are  found  in  old  tuberculin,  and  differs  in  no  particular  from  the 
latter,  except  it  is  made  without  heat. 

3.  The  new  tuberculins  "T.  E."  and  bacillin  emulsion  consist  of  the  pul- 
verized bodies  of  the  live,  virulent,  crushed,  tubercle  bacilli.  These  are  more 
toxic,  and  if  any  of  the  undissolved  fragments  of  the  bacilli  of  the  emulsion 
should  by  mishap  enter  the  system,  they  would  set  up  a  new  process.  They, 
however,  are  more  antibacterial,  while  old  tuberculin,  and  Denys's  are  more 
antitoxic  and  therefore  more  active  in  the  production  of  immunity.  Old  tuber- 
culin has  the  advantage  over  all  others  in  that  it  is  prepared  by  addition  of 
heat,  which  removes  the  possibility  of  re-infection. 

4.  Von  Eucfs  watery  extract,  consists  of  the  pure  solution  of  the  germs 
only,  into  which  no  culture  fluids  enter,  and  being  filtered  through  porcelain, 
is  absolutely  free  from  any  germs,  or  fragments  thereof.  He  claims  that  the 
superiority  of  his  method  over  all  others  consists  in  the  fact  that  he  has  suc- 
ceeded in  extracting  the  fats  from  the  bodies  of  the  bacilli  with  sulphuric  ether, 
and  that  this  leaves  a  perfectly  soluble  proteid,  tlie  essence,  as  it  were,  of  the 
bacillus. 

The  Action  of  Tuberculin. — The  mode  of  action  of  tuberculin  is  not  fully 
understood,  and  the  limits  of  this  paper  will  not  allow  a  full  discussion  of  the 
different  theories  advanced  by  investigators  in  the  elucidation  of  this  question. 
They  are  all  based  on  the  principles  of  active  immunization.  Koch's  idea  was 
that  of  a  local  action  on  diseased  areas;  Ehrlich  ascribes  it  to  the  union  with 
receptors  of  the  tissue  cells;  Metchnikoff,  to  phagocytosis;  Wright,  to  the 
increase  of  opsonins  in  the  blood,  and  Sajous,  to  its  power  of  stimulating  the 
"test  organ"  of  the  pituitary  body,  the  latter  being  the  nerve  centre  which  con- 
trols the  functional  activity  of  the  thyroid  and  adrenals  and  through  these 
organs,  the  immunizing  power  of  the  blood. 

From  the  best  evidence  obtainable,  it  seems  that  parts  of  all  of  these 
theories  are  correct. 

Metchnikoff's  demonstrations  of  the  phagocytic  properties  of  the  leucocytes 
are  now  established  on  a  firm  basis.  Perhaps  the  most  important  discovery  is 
that  by  Wright  of  the  opsonic  power  of  the  blood  by  which  bacteria  are  sensi- 
tized and  prepared  for  ingestion  by  the  leucocytes.  As  Wright  says,  "increased 
opsonic  phagocytic  response  is  associated  with  successful  immunization,  or  cure, 
and  this  increased  phagocytic  response  is  dependent  on  the  opsonic  power  of  the 
blood  fluids  and  not  on  the  increased  capacity  for  spontaneous  phagocytosis  on 
the  part  of  the  white  blood-cells.  But  Wright  has  failed  to  show  the  origin 
of  the  "opsonins,"  and  also  whether  they  contain  all  the  elements,  with  the 
leucocytes,  necessary  for  complete  immunization;  for  as  Trudeau  well  says, 
"w6,  as  yet,  are  unable  to  say  how  reliable  a  criterion  of  immunity  the  opsonic 
4 


274 


TUBERCULIN  THERAPY. 


power  of  the  blood  really  is,  because  opsonins  after  all,  constitute  but  one  of 
the  antibodies  produced  in  immunity  reactions."  This  is  where  Sajous's  labors 
come  in. 

In  his  recent  work  on  the  "Internal  Secretions,"  in  the  manner  of  a 
master  only,  Sajous  has  pointed  out  that  the  blood's  immunizing  properties 
are  found  in  the  secretions  of  the  ductless  glands,  and  makes  this  postulate; 
"the  power  of  the  system  to  antagonize  the  constitutional  effects  of  the 
pathogenic  germs,  is  directly  proportionate  to  the  functional  eflBciency  of  the 
adrenal  system,"  the  latter  being  composed  of  the  pituitary  body  as  governing 
center,  the  thyroid  glands,  and  the  adrenals.  -According  to  this  view,  it  is  by 
and  through  the  adrenal  system  that  all  the  immunizing  substances  are  manu- 
factured, and  instead  of  having  a  multiplicity  of  antibodies  he  resolves  them 
into  two  groups,  both  caused  to  appear  in  the- blood  by  the  exciting  action 
of  the  tubercular  toxin  on  the  adrenal  center:  the  preparatory  group  (opsonin, 
agglutinin)  composed,  as  shown  by  correspondence  of  chemical  tests,  of  the 
thyro-parathyroid  secretion,  which  sensitizes  bacteria  and  toxin,  and  the  hac- 
teriohjiic  or  antitoxic  group  (amboceptor  and  complement  in  plasma  and  phago- 
cytes) composed,  as  also  shown  by  chemical  correspondence,  of  the  adrenal 
secretion,  a  trypsic  ferment,  and  nucleoproteid  granulations  of  certain  leuco- 
cytes. 

Gruber,  Wright  and  others  had  expressed  the  view  that  the  antibodies 
were  internal  secretions  of  the  tissues  of  the  body  and  the  opinion  prevails  that 
they  are  physiological  products  of  tissue  cells,  but  Sajous  has  shown  that  while 
they  are  present  more  or  less  in  all  tissues,  their  original  source  is  the  thyroid 
adrenals  and  pancreas,  since  removal  of  either  of  these  organs  inhibits  the 
immunizing  power  of  the  body  and  of  all  cells.  In  the  blood,  the  antibodies 
act  chemically  (by  hydrolytic  digestion)  upon  the  bacteria  and  their  toxins,  m 
his  opinion,  these  pathogenic  substances  being  thus  converted  into  benign  and 
eliminable  products. 

Sajous's  work  in  this  connection  is  too  recent,  however  (1907),  to  have 
received  the  benefit  of  much  experimental  and  clinical  study  by  others,  but 
what  has  appeared  so  far,  has  sustained  him.  Fassin,  of  the  Bacteriological 
Institute  of  Liege,  Belgium,  found  since  that  "the  bacteriolytic  and  hasmolytic 
alexins  were  increased  when  thyroid  preparations  were  given  in  any  form," 
while  Marbe,  of  the  Pasteur  Institute,  found  that  this  applied  to  opsonins,  "the 
phagocytic  activity  of  leucocytes  for  various  bacteria,  including  the  tubercle 
bacillus  and  the  bacillus  coli,  being  markedly  increased,"  under  the  influence  of 
thyroid.  Conversely,  removal  of  the  thyroid  gland  reduced  greatly  the  opsonic 
power  of  the  blood.^ 

Now  the  pathological  side.  As  tuberculosis  is  both  a  bacillary  and  anti- 
toxic disease,  we  have  two  processes  going  on  in  the  tubercular  area;  "one, 
sclerosis,  encapsulation  (conservative  and  healing)  ;  the  other,  caseation, 
softening,  destructive  and  dangerous."2  Therefore,  the  rational  application  of 
tuberculin  can  be  had  only  in  strictly  localized  processes,  and  in  early  pulmonary 

1  Pratiqiie  MC-dicale,  October,  1908. 

2  Osier. 


TUBERCULIN  THERAPY.  275 

tuberculosis,  where  the  focus  of  infection  is  cut  off  from  the  blood-stream. 
"In  this  class  of  cases,"  says  Douglas,  "'the  'opsonic  index'  is  persistently  low, 
owing  to  the  absence  of  the  immunizing  stimuli."  In  the  formation  of  tubercle, 
there  is  lowered  vitality  in  the  focus  of  infection,  caused  by  the  absorption  of 
the  '^acteriotropic"  substance  by  the  tubercle  bacilli;  and  because  there  is  a 
deficit  of  autobacterial  substances  in  the  foci,  is  owing  to  the  fact  that  their 
conveyance  through  the  lymph-vessels  is  greatly  hindered  by  the  barriers  in 
the  form  of  fibrous  capsule  around  the  tubercle.  Under  these  conditions,  it  is 
evident,  therefore,  that  tuberculin  can  act  on  the  bacilli,  only  in  an  indirect 
way;  and  this  consists  in  raising  the  nutritive  power  of  the  cells  in  and  around 
the  infected  focus,  where  we  get  encapsulation  of  the  tubercle,  and  at  the  same 
time,  revitalize  the  tissues,  making  them  uninhabitable  for  the  bacilli.  But 
the  bacillus  still  retains  its  poisonous  properties,  and  at  some  future  time  will 
become  dangerous  to  the  organism  through  diminished  cell  resistance.  There- 
fore we  must  seek  such  agents  as  tuberculin,  which  are  specific  in  their  nature, 
under  whose  influence  the  body  will  secrete  protective  substances — the  opsonins, 
antibodies,  etc.,  in  sufficient  amounts  to  diminish  or  destroy  the  vitality  of  the 
bacilli  or  neutralize  their  toxins. 

Therapeutic  Use  of  Tuberculin. — The  efficiency  of  tuberculin  as  a  curative, 
as  well  as,  a  diagnostic  agent,  has  been  proven  to  such  a  degree  that  it  has 
passed  beyond  the  pale  of  controversy.  As  proof  of  this  Trudeau  states  that 
after  15  years  of  treatment  with  the  remedy,  he  obtained  permanent  results  in 
18  to  25  per  cent,  of  cases.  It  is  proven  by  Wright  that  after  injection  of  a 
dose  of  tuberculin  there  occurs  a  decline  of  "negative  phase"  which  lasts  from 
two  to  fourteen  days,  according  to  the  dose.  This  corresponds  to  a  decline  in 
the  antibacterial  power  of  the  blood.  Then  there  occurs  a  rise  or  "positive 
phase,"  which  clinically,  is  characterized  by  general  improvement,  dependent  on 
the  amount  of  antibodies  produced.  This  may  be  maintained  by  repeated 
injections  of  sufficient  doses  at  proper  intervals;  and  in  this  consists  the 
essence  of  the  method;  that  the  dose  be  so  regulated  as  to  quantity  and  time 
that  no  reactions  of  a  serious  nature,  shall  occur,  and  the  patient's  opsonic  power 
shall  be  kept  at  "high  tide." 

I  believe  that  moderate  reactions  of  99°  to  100°  F.  of  fever  with  slight 
physical  symptoms,  are  conservative  and  do  good  to  the  patient.  When  tuber- 
culin was  first  introduced  it  was  believed  that  strong  febrile  reactions  were 
necessary.  "Experience  has  proven  this  to  be  incorrect.  While  an  occasional 
reaction  may  unavoidably  occur,  we  should  take  every  precaution  to  avoid  them. 
When  the  reactions  are  violent  and  frequent,  it  is  an  indication  that  the  tuber- 
culin is  having  a  bad  effect  and  should  be  discontinued."  These  violent  reactions 
are  due  to  over-stimulation.  The  curative  action  of  the  tuberculin  is  due  not 
only  to  the  reaction  in  the  local  area  of  infection,  but  it  has  a  stimulating  effect 
on  the  body  cells,  "a  stimulation"  says  Trudeau,  "which  results,  in  the  produc- 
tion of  some  sort  of  antibodies  in  these  cells,  as  well  as  possibly  an  increased 
activity  of  the  phagocytes.  For  these  reasons  a  small  dose,  very  gradually 
increased  and  continued  a  long  time  is  the  best  method  of  treatment  possible." 


276  TUBERCULIN  THERAPY. 

Indications. — The  type  of  cases  most  desirable  and,  which,  in  my  experience 
has  yielded  almost  invariably  good  results,  are: 

First:  The  incipient  and  moderately  advanced  cases,  which  are  mostly 
afebrile,  with  a  temperature  ranging  at  times  not  over  100°  F.  and  whose  nutri- 
tion is  good. 

Second:  Uncomplicated  first  and  second  class  cases  with  fever,  although 
bacilli  are  found  in  the  sputum. 

Tliird:    Fibroid  cases  without  febrile  reactions. 

Fourth :  Cases  where  fever  is  due  solely  to  the  toxin  of  bacilli  and  will  not 
abate  under  rest  and  hygienic  treatment ;  small  tentative  doses  may  do  good. 

Contraindications. — 1.  Acute  miliary  cases. 

2.  All  third  stage  cases  with  mixed  infection. 

3.  Second  stage  cases  with  bad  nutrition  and  mixed  infection. 

4.  Haemoptysis.  When  hemorrhage  occurs,  it  is  a  signal  to  stop  the  use 
of  tuberculin  temporarily,  until  all  signs  of  danger  from  hgemorrhagic  lesions 
have  gone. 

5.  Heart  disease.  Where  we  fear  that  compensation  might  be  lost  by 
active  stimulation  from  tuberculin. 

6.  Where  the  frequency  and  weakness  of  the  pulse  are  present  without  any 
recognizable  heart  lesions. 

7.  Weak  and  greatly  emaciated  patients  with  a  feeble  and  fast  heart  action. 

8.  All  complications  of  internal  organs,  and  nervous  diseases  (Einger). 

A  daily  record  of  temperature  for  three  days  should  be  kept  before  begin- 
ning treatment.  The  injection  should  be  given  in  the  morning.  The  patient 
should  not  exercise  during  the  day.  He  should  keep  a  two  hours'  record  of 
temperature  each  day,  until  next  injection. 

Alcohol  and  all  intemperance  must  be  sedulously  avoided. 

Eeactions. — Eeactions  are  a  combination  of  symptoms  which  are  indicative 
of  over-stimulation  by  tuberculin,  and  may  be  of  all  grades: 

First:  Systemic  reaction.  This  is  the  most  important,  and  makes  itself 
felt  and  known  in  from  six  to  twentj^-four  hours  after  the  injection  of  tuber- 
culin, with  rise  of  fever  from  100*^  F.  to  as  high  as  105°  F.  Then  comes 
chilliness,  with  aching  limbs,  and  back  with  a  tormenting  headache,  general 
malaise  and  nausea. 

Second:  Local  reaction,  (a)  In  the  lungs.  There  may  be  increased 
cough  and  expectoration,  with  mucus  tinged  with  blood.  The  physical  signs  are 
more  or  less  increased,  especially  the  r&les  become  more  moist,  and  respiration 
prolonged.  All  these  are  indicative  of  hypersemia  of  tissues  surrounding  the 
local  process,  (b)  In  the  larynx,  the  mucous  membranes  become  red  and  con- 
gested; the  ulcers  are  reddened,  and  there  is  an  hyperasmic  condition  of  the 
surrounding  tissues,  and  increased  hoarseness  may  occur,  (c)  The  skin.  In 
from  6  to  10  hours  after  injection  there  appears  a  red  hypergemic  circle  the 
size  of  a  silver  dollar  around  the  site  of  the  injection.  It  is  tender,  painful  on 
pressure,  and  slightly  oedematous.  It  lasts  from  two  days  to  a  week,  and 
gradually  disappears. 


TUBERCULIN  THERAPY.  277 

Dosage. — The  most  important  feature  in  tuberculin  therapy,  and  one  on 
which  success  or  failure  depends,  is  the  question  of  dosage.  Whether  w©  adopt 
the  opsonic  index  aa  a  guide,  or  rely  on  clinical  symptoms,  the  one  important 
thing  is,  the  correct  dose. 

Therefore  to  be  on  the  uafe  side,  we  should: 

Eirst:   Begin  with  an  infinitesimal  dose. 

Second:  Do  not  shorten  the  time  by  increasing  the  doses  too  rapidly,  or 
decreasing  the  intervals.  As  all  tuberculins  have  the  same  reaction,  and  their 
eflects  are  identical,  it  is  a  matter  of  personal  choice  which  preparation  one 
should  use.  I  have  used  only  two ;  old  tuberculin,  and  the  watery  extract.  In 
using  old  tuberculin,  we  should  prepare  five  serial  dilutions  in  5  vials,  each 
dilution  being  10  times  stronger  than  the  preceding  one.    The  initial  dose  of  No. 

1  is  1/1000  of  a  mg.,  and  No.  2,  1/100  and  so  on,  until  No.  5  is  reached,  which 
contains  10  milligrams  to  the  dose.  The  beginning  of  each  dilution  is  2 
minims.  We  begin  with  2  minims  and  progressively  increase  until  20  minims 
are  injected.  Then  begin  the  next  series.  Injections  should  be  given  twice  a 
week.     Having  a  graduated  syringe  holdiug  1  c.c,  I  begin  with  2/10,  or  about 

2  drops,  and  increase  by  tenths  untH  20  minims  are  given.  We  then  change  to 
the  next  dilution  No.  2,  and  then  proceed  in  the  same  way,  and  so  on  until 
the  highest  series  is  reached,  remembering  all  the  time  that  we  are  proceeding 
under  the  decimal  system,  and  that  each  series  is  ten  times  stronger  than  the 
former.  If  reaction  appears  at  any  stage,  then  we  should  discontinue  until 
three  days  after  normal  temperature  has  been  reached.  Then  begin  with  half  of 
the  original  dose,  and  proceed  cautiously  lengthening  the  intervals. 

The  main  principle  is  so  to  regulate  the  dose  and  interval  that  the  maximum 
dose  may  be  reached  with  as  Httle  disturbance  as  possible.  The  intervals  should 
be  lengthened  gradually,  as  the  highest  doses  are  reached,  and  extended  to  two 
weeks  between  the  last  few  injections.  The  treatment  should  last  from  six 
months  to  two  years. 

Results. — To  quote  Trudeau  and  Denys,  the  principal  faults  leading  to 
failures  are: 

First:   "Beginning  the  treatment  with  too  large  amounts." 
Second:    "Eaising  the  dose  too  rapidly,  or  at  too  short  intervals." 
Third:   "Injecting  again  before  the  effects  of  reaction  both  constitutional 
and  local  have  passed  away." 

Fourth:  "Increasing  the  dose  after  reaction  has  occurred." 
Hence  the  failure  in,  or  danger  of,  tuberculin  treatment  lies  principally  in 
the  faulty  and  reckless  manner  of  administration  of  the  remedy.  The  crucial 
test  after  all,  of  the  efficiency  of  this  method  of  treatment  of  tuberculosis,  lies 
in  the  comparison  with  that  of  sanatorium  methods  alone.  The  best  evidence 
of  this  comparison  is  found  in  Trudeau's  experience  of  15  years  which  shows 
that  there  were  from  18  to  25  per  cent,  letter  results  from  tuberculin  treatment 
than  sanatorium  treatment  alone.  Puttenger's  statistics  confirm  this  statement, 
in  that  the  results  are  20  per  cent,  in  favor  of  the  tuberculin-treated  cases. 

All  this  speaks  well  for  the  future  of  tuberculin  treatment,  which  bids  fair 
to  become  one  of  the  most  effective  methods  of  warfare  against  "The  Captain 


278  THE  ADRENAL  PRINCIPLE  IN  ANIMAL  EXTRACTS. 

of  the  Hosts  of  Death."  At  no  time,  and  under  no  circumstances,  however,  do 
we  consider  tuberculin  treatment  superior  to  the  dietetic  and  hygienic  and  open 
air  treatment,  it  is  only  an  adjunct. 


THE  ADRENAL  PRINCIPLE  AS  THE  MAIN  ACTIVE  AGENT  IN 
PITUITARY,  TESTICULAR,  OVARIAN  AND  OTHER 
ANIMAL  EXTRACTS.* 

By  CHARLES  E.  de  M.  SAJOUS,  M.D., 

PHILADELPHIA. 

Pehmit  me,  Mr.  President  and  gentlemen,  to  thank  you  for  the  honor  you 
have  bestowed  upon  me  in  inviting  me  to  address  you  on  the  subject  of  opo- 
therapy. What  work,  e^•perimental  and  clinical,  I  have  done  in  that  direction 
has  had  for  its  purpose  to  ascertain  if  possible  the  limitations  of  this  branch  of 
therapeutics  and  to  do  what  I  could  to  place  the  whole  subject  on  a  higher  plane 
than  it  has  occupied.  The  question  taken  up  in  this  paper  is  quite  in  keeping 
with  this  purpose  since  it  aims  to  determine  the  active  factor  in  some  of  the 
agents  to  which  virtues  innumerable  have  been  ascribed,  and  thus  to  enable  us 
to  employ  them,  not  empirically  as  they  are  now  used,  but  with  scientific 
accuracy. 

Those  of  you  who  happen  to  be  familiar  with  a  work  on  the  internal 
secretions,  published  recently,  may  have  noticed  that  I  do  not  refer  to  animal 
extracts  other  than  those  obtained  from  the  thyroid,  parathyroids  and  adrenals. 
This  was  because  the  physiological  action  of  these  products  seemed  to  me  to 
correspond  to  such  a  degree  vvith  the  effects  of  extracts  derived  from  certain  other 
organs  that  I  began  to  suspect  that  the  agents  which  produced  them  had  a 
common  source.  Further  study  of  the  subject  strengthened  this  impression ;  it 
suggested  in  fact,  that  such  a  relationship  actually  existed,  and  that  the  effects 
of  ovarian,  testicular,  and  pituitary  extracts,  for  example,  should  not  be 
ascribed  to  any  internal  secretion  specific  to  each  of  these  different  organs,  but 
to  substances  which  they  contained  in  common.  It  is  a  brief  review  of  the 
line  of  evidence  which  points  to  this  fact  that  I  am  about  to  submit  to  you. 

Before  doing  so,  however,  I  must  briefly  review  the  functions  of  the  adre- 
nals as  my  researches  have  led  me  to  interpret  them. 

Over  ten  years  ago  efforts  were  made  to  compensate  for  the  destruction  of 
the  adrenals  in  Addison's  disease,  by  grafting  two  of  these  organs,  obtained 
from  dogs,  into  the  abdominal  tissues  of  each  case.  The  patients  died  promptly. 
Courmont,  referring  to  a  patient  personally  observed  whose  death  occurred 
twenty-four  hours  after  the  operation,  states  that,  although  there  had  been  no 
infection  of  the  wound,  death  was  preceded  by  what  he  termed  a  "formidable 
hyperthermia."  How  account  for  this  excessive  temperature?  Text-books  of 
physiology  or  of  pharmacology  afford  no  clue  to  the  manner  in  which  this 

*Read  ])y  invitation  before  the  Medical  Society  of  Kings  Connly,  Brooklyn,  April 
20.  1909. 


THE  ADRENAL  PRINCIPLE  IN  ANIMAL  EXTRACTS.  279 

phenomenon  could  be  produced.  Viewed  from  my  standpoint,  it  represents  the 
fundamental  expression  of  the  action  of  adrenal  preparations.  Six  years  ago, 
I  advanced  the  opinion,  based  on  considerable  experimental  and  clinical  evidence, 
that  the  adrenal  secretion  took  up  the  oxygen  of  the  air  in  the  pulmonary 
alveoli  to  become  that  constituent  of  hajmoglobin  which,  stored  in  the  red  cor- 
puscles, distributes  oxygen  to  the  tissue  cells  to  sustain  oxidation  and  meta- 
bolism. When  we  recall  that  Keid  Hunt^  noted  that  less  than  six  million tlis 
of  a  gram  of  epinephrin  per  kilo  of  bodyweight  sufficed  to  cause  a  rise  of  blood- 
pressure  of  G6  mm.  Hg.  and  that  Lepine^  found  that  this  phenomenon  was 
always  followed  by  a  rise  of  temperature,  the  cause  of  the  untoward  effects  of 
grafting  of  two  adrenals  becomes  self-evident  when  the  functions  I  have 
attributed  to  the  adrenals  are  taken  into  account :  Un governed  by  nerves,  as 
they  are  normally,  the  artificial  organs  introduced  into  the  circulation  a  quantity 
of  adrenal  principle  representing  thousands  of  doses;  these  caused  excessive 
tissue  oxidation  and  the  "formidable  hyperthermia"  to  which  Courmont  refers. 

The  morbid  effects  of  grafting  is  not  the  only  phenomenon  explained  by 
the  influence  on  oxidation  and  metabolism  I  attribute  to  the  adrenal  secretion. 
It  may,  in  fact,  be  regarded  as  the  one  function  which  enables  us  to  explain  all 
the  therapeutic  effects  of  adrenal  preparations.  Thus  Crile*^,  by  means  of 
adrenalin  largely  diluted  in  saline  solution,  and  simultaneous  artificial  respira- 
tion, resuscitated  animals  fifteen  minutes  after  all  signs  of  life  had  ceased 
and  kept  a  decapitated  dog  alive  over  ten  hours.  With  the  adrenal  principle  as 
the  active  factor  in  metabolism,  i.e.,  in  the  vital  process  itself,  these  wonderful 
results  are  readily  accounted  for.  This  applies  as  well  to  shock  in  which,  as 
shown  by  Kinnaman*  the  fall  of  temperature  is  the  most  uniform  and  progres- 
sive factor,  and  also  to  Addison's  disease  in  which  the  activity  of  the  vital 
process  is  so  reduced  that,  as  observed  by  Eolleston^  the  cases  sometimes  emit  a 
cadaverous  odor.  Such  disorders  as  asthma,  migraine,  hay-fever,  often  bene- 
fitted by  adrenal  extract,  are  generally  ascribed  to  deficient  nuclein  catabolism, 
itself  due  to  imperfect  oxidation.  Its  beneficial  use  in  neurasthenia  is  obviously 
due  to  the  improved  oxidation  and  nutrition  of  the  nervous  system  it  insures — 
an  explanation  which  applies  equally  well  to  myasthenia  and  vasculocardiac 
atony,  in  which  the  muscular  elements  are  relaxed  because  of  inadequate  cel- 
lular metabolism  and  nutrition.  Even  the  local  effects  of  adrenal  extractives, 
suprarenalin,  adrenalin,  epinephrin  aud  others,  are  explained  by  the  same 
process,  the  intense  vascular  contraction  which  arrests  haemorrhage  or  causes 
blanching  of  the  mucosa  being  due  to  the  intense  metabolic  activity  these 
agents  awaken  in  the  muscular  coats  of  the  arterioles  over  which  the  solution 
is  applied. 

The  clinical  indications  of  adrenal  preparations  thus  harmonize  perfectly 
witli  the  functions  I  attributed  to  the  adrenals  in  1903.  The  significance  of 
this  fact  is  plain  when  we  consider  that  all  the  sound  experimental  evidence 
bearing  upon  the  question  contributed  before  1903  and  since,  has  only  served 
to  strengthen  my  position. 

Now,  it  is  this  action  of  adrenal  preparations  on  oxygenation  and  meta- 
bolism  which   I   have  been   led   to   consider   as    tlu^    foundation,   as    it   were, 


280  THE  ADRENAL  PRINCIPLE  IN  ANIMAL  EXTRACTS. 

of  the  physiological  effects  of  organic  extracts  obtained  from  such  organs  as  the 
pituitaiy,  testes,  and  ovaries  which  are  thought  to  produce  internal  secretions. 
The  evidence  to  this  effect  will  be  reviewed  when  these  various  agents  will  be 
considered  individually. 

Another  factor,  though  hardly  perceptible  clinically  in  the  physiological 
effects  of  several  organic  extracts,  is  the  thyroid  secretion  they  happen  to 
contain.  Though  not  appreciable,  its  action  is  nevertheless  important.  In 
practice,  the  effects  of  thyroid  preparations  we  witness  are  those  of  relatively 
enormous  doses  of  the  thyroid  principle.  The  proportion  of  this  principle 
produced  in  the  body  itself  and  utilized  by  the  tissues  under  normal  condi- 
tions, is  relatively  minute  because  its  purpose  is  not  to  evoke  phenomena 
which  our  experience  would  lead  us  to  expect — loss  of  flesh,  tachycardia,  gen- 
eral vasodilation,  etc. — but  precisely  the  opposite — increased  nutrition,  slow- 
ing and  increased  vigor  of  the  heart  beats,  and  elevation  of  the  blood-pressure. 
These  are  obviously  the  characteristic  effects  of  the  adrenal  secretion  or  prepa- 
rations; indeed,  the  minute  proportion  of  thyroid  secretion  does  but  one 
thing:   it  enhances  the  oxidizing  power  of  the  adrenal  secretion. 

The  wonderful  results  of  thyroid  preparations  in  myxcBdema  and  cretinism 
need  but  be  recalled  to  illustrate  the  potent  influence  these  substances  exert  upon 
the    organism    at    large.     How    are    these    marked    changes    accomplished? 
Eeferring  you  to  evidence  submitted  elsewhere,^  I  will  merely  recall  that  from 
my  viewpoint  thyroid  preparations  bring  them  about  in  the  following  manner : 
In  keeping  with  the  thyro-parathyroid  secretion  itself,  they  increase  the  sen- 
sitiveness or  inflammability  of  the  blood  and  tissue  cells  to  oxidation,  by  acting 
directly,  mainly  through  their  thyro-iodin,  upon  the  phosphorus  which  these 
cells,  and  particularly  their  nuclei,  contain.    This  process  may  be  likened  to 
the  familiar  laboratory  experiment  in  which  iodine  and  phosphorus,  when  in 
contact,  unite,  and  produce  enough  heat  to  cause  ignition  of  the  phosphorus. 
All  nerve  centres  being,  as  such,  rich  in  this  element,  the  adrenal  centre  is  itself 
rendered  more  inflammable  and  functionally  active,  the  result  being  an  increased 
production  of  adrenal  secretion  and  the  appearance  in  the  blood  of  a  correspond- 
ing increase  of  this  substance  as  the  oxidizing  constituent  of  hemoglobin.     Thus 
while,  on  the  one  hand,  the  sensibility  of  all  cells  to  oxidation  is  dependent 
upon  the  proportion  of  thyro-parathyroid  secretion  in  the  blood,  the  latter  also 
governs  the  production  of  adrenal  secretion,  so  that  there  is  always  perfect 
equipoise  between  the  inflammability  of  the  cells  and  the  oxidizing  agent  they 
need  to  insure  the  continuation  of  their  intrinsic  metabolism,  that  is  to  say,  their 
life.     Hence,  under  the  use  of  thyroid  preparations,  the  wonderful  development 
of  the  entire  organism  in  the  cretin ;  all  tissue  cells,  and  particularly  those  of 
the  brain  and  nervous  system  which  are  especially  rich  in  phosphorus,  become 
aglow,  as  it  were,  a  fact  emphasized  by  the  marked  rise  of  temperature.     This  is 
also  exemplified  by  the  excellent  results  afforded  in  sensitiveness  to  cold,  as 
shown  by  Hertoghe. 

The  fact  that  thyroid  preparations  enliance  both  anabolism  and  catabolism 
is  generally  recognized.  Each  tissue,  of  course,  responds  in  its  own  way  to  their 
influence.     Their  beneficial  action  in  myasthenia  and  constipation,  for  example. 


THE  ADRENAL  PRINCirLE  IN  ANIMAL  EXTRACTS.  281 

indicates  their  influence  on  muscular  elements,  just  as  the  improvement 
obtained  in  rickets  and  delayed  imion  in  fractures  attest  to  their  direct  action 
on  osseous  tissues;  the  rapid  development  of  the  intelligence  in  cretins  and  their 
action  in  neurasthenia  shows  their  unmistakable  action  upon  the  nen-ous 
system,  while  their  effects  in  alopecia  and  lupus  testify  to  their  influence  on 
cutaneous  nutrition.  The  increase  of  appetite  which  attends  their  use  points 
clearly,  moreover,  to  the  greater  need  of  food  materials  to  satisfy  the  increased 
demands  of  the  cell  in  every  part  of  the  organism. 

Again,  the  thyroid  gland  has  recently  been  found  to  be  connected  in  some 
way  with  immunity.  In  1903  I  urged  that  the  thyroid  gland,  by  means  of  its 
secretion,  took  an  active  part  in  the  auto-protective  processes  of  the  whole 
organism,  and  in  1907  that  the  thyroid  secretion  corresponded  in  its  properties 
with  Wright's  opsonins.  Both  these  views  have  been  sustained  in  Europe 
recently,  Fassin  having  found  that  bacteriolytic  and  ha^molytic  alexins  were 
increased  when  thyroid  preparations  were  administered,  while,  Marbe  of  the 
Pasteur  Institute,  found  that,  as  did  opsonins,  they  materially  increased  the 
vulnerability  of  various-  bacteria  to  phagocytosis.  This  means  that  they  are 
endowed  with  the  property  of  sensitizing  pathogenic  micro-organisms,  toxic 
wastes  and  other  poisons  that  may  happen  in  the  blood  much  as  they  do  on 
tissue-cells,  as  previously  ex-plained,  thus  rendering  them  vulnerable  to  the 
digestive  or  proteolytic  action  of  the  antibodies,  both  in  the  plasma  and  in  the 
phagocytes.  This  accounts  for  the  beneficial  effects  of  thyroid  preparations  in 
disorders  of  the  gouty  series  such  as  migraine,  asthma,  and  the  cutaneous 
disorders  associated  therewith,  and  in  tetany,  epilepsy,  eclampsia,  and  infantile 
convulsions  due  to  the  accumulations  of  toxic  waste  products  in  the  blood- 
stream. It  explains  also  the  good  results  obtained  in  certain  cases  of  simple 
goiter;  the  remedy  assuming  the  functions  of  the  thyroid  itself,  the  gland  is 
no  longer  overworked  and  recedes.  The  same  line  of  reasoning  is  also  appli- 
cable to  certain  forms  of  exophthalmic  goiter — those  due  to  autointoxication 
from  the  intestinal  canal.  Closely  associated  with  this  process  is  the  action 
of  thyroid  preparations  in  obseity,  in  which  thyroid  enhances  catabolism. 

Here,  again,  therefore,  the  physiological  action  I  attribute  to  the  thyroid 
secretion  explains  the  mode  of  action  of  thyroid  preparations  in  all  the  dis- 
orders in  which  they  have  been  used  more  or  less  successfully.  As  is  the  case 
with  these  preparations,  the  secretion  itself,  being  distributed  throughout  the 
body  at  large,  including  of  course  the  various  organs  thought  to  produce  inter- 
nal secretions,  as  suggested  by  the  presence  of  iodine  in  the  pituitary,  the 
testes,  and  ovaries,  we  would  normally  expect  to  witness  its  influence  as  a 
constituent  of  the  extracts  of  these  organs.  But  as  explained  above,  such  is 
not  the  case,  the  action  of  the  adrenal  principle  being  alone  perceptible  when 
extracts  of  various  other  organs  are  administered,  as  will  now  be  shown. 

(To  he  concluded  in  our  June  issue.) 


282       AUTOINTOXICATION,  INTESTINAL. 


ENDOCARDITIS,  INFECTIOUS. 


Cyclopaedia  of  Current  Isiteraturc 


AUTOINTOXICATION,  INTESTINAL. 

Nature  gives  us  the  cue  in  the  treat- 
ment, by  inducing  vomiting  and  purging, 
which  are  plain  signs  that  the  economy  is 
trying  to  rid  itself  of  noxious  material 
that  interferes  with  normal  metabolism. 
The  stomach  should  be  washed  out  with 
sterilized  hot  water  and  a  dose  of  castor 
oil  given ;  the  writer  has  substituted  this 
for  colonic  irrigation,  which  he  believes 
to  be  a  delusion,  the  tube  simply  coiling 
on  itself  so  that  no  water  ever  reaches  the 
colon.  The  castor  oil  is  followed  by 
copper  arsenite,  guaiacol  carbonate  or 
bismuth  subgallate,  and  a  hypodermic  of 
morphine,  Y^  gr.  and  atropine  %5o  gr. 
A  rigid  abstinence  from  solid  food  for 
a  few  days  is  required.  Many  neuras- 
thenics are  benefited  by  a  long  sea 
voyage  on  a  slow  vessel.  The  Weir 
Mitchell  treatment  is  suitable  in  many 
cases.  Suggestion,  without  the  various 
additions  that  in  composition  constitute 
the  mental  therapeutic  properties,  is  of 
value.  A.  Dixon  (Southern  Medical 
Journal,  November,  1908). 

CORYZA,     RECURRING,     A     MANIFESTA- 
TION OF  AUTOINTOXICATION. 

Numerous  arguments  are  presented  by 
tlie  writer  to  sustain  his  view  that  recur- 
ring coryza,  from  simple  "colds  in  the 
head"  to  pronounced  hay  fever,  is  merely 
one  of  the  manifestations  of  the  arthritic 
diathesis,  that  is,  of  a  family  tendency  to 
sluggish  elimination  of  waste  products 
and  toxins.  He  points  out  that  the 
mucosa  of  the  nose  is  an  excreting  organ, 
and  the  excretion  through  this  mucosa  of 
some  of  the  toxins  generated  in  the 
digestive  tract  may  be  one  factor  in  re- 


curring coryza.  He  has  had  a  number 
of  instances  in  Iiis  experience  in  which 
an  error  in  diet  was  promptly  followed 
by  an  attack  of  coryza.  It  is  like  the 
congestion  observed  in  the  face  during 
difficult  digestion.  Eeflex  irritation  from 
the  digestive  tract  distends  the  vessels, 
heats  and  reddens  the  face,  and  by  stimu- 
lating the  glands  renders  the  skin  greasy 
and  pimply.  This  same  process  in  the 
nasal  mucosa  induces  swelling,  congestion 
and  excessive  secretion;  the  nerve  fibers 
in  the  mucosa  become  irritated  from  the 
recurring  or  continuous  autointoxication 
and  the  consequent  hyperesthesia  renders 
them  peculiarly  sensitive  to  dust  inhaled 
or  changes  in  temperature.  He  has 
found  regulation  of  the  diet,  especially 
avoidance  of  meat  and  alcohol,  the  most 
effectual  means  of  curing  such  patients. 
A  little  white  meat  at  noonday  is  all  lie 
allows.  If  local  measures  are  deemed 
necessary,  he  applies  the  actual  cautery  to 
the  hypersensitive  points.  The  cauter- 
ization must  be  deep  enough  to  destroy 
the  nerve  filaments,  but  this  alone  is 
futile  unless  the  underlying  autointoxi- 
cation is  combated.  The  hypersensitive 
points  in  the  nose  are  mainly  the  protrud- 
ing points  where  lodge  the  inspired  dust 
and  microbes.  P.  Cornet  (Pressc  medi- 
cale,  January  IG,  1909). 

ENDOCARDITIS,  INFECTIOUS. 

Attention  is  called  by  the  writer  to  a 
chronic  type  of  infectious  endocarditis 
in  which,  for  months,  the  only  symptom 
may  be  fever  of  an  intermittent  or  re- 
mittent type.  Malaria  or  tuberculosis  is 
often  suggested.  There  is  almost  always 
an  old  valvular  lesion,  but  the  murmur 


HEMORRHAGE,  SALT  TREATMENT  IN. 


INSOMNIA. 


283 


may  remain  entirely  unaltered  in  spite  of 
fresh  vegetations.  An  important  feature 
in  diagnosis  is  the  appearance  of  eryth- 
ematous spots,  chiefly  on  the  feet  and 
hands.  These  vary  from  the  size  of  a 
pea  to  that  of  a  dime,  and  are  red,  raised 
and  painful;  they  disappear  in  a  day  or 
so.  They  were  seen  in  seven  out  of  the 
author's  ten  cases.  Wm.  Osier  (Quar- 
terly Journal  of  Medicine,  January, 
1909). 

HEMORRHAGE,  INTERNAL,  SALT  IN 
TREATMENT  OF. 
The  writer  has  studied  for  a  j^ear  the 
use  of  salt  by  the  mouth  or  in  infusion  as 
a  means  of  controlling  hemorrhage.  His 
experience  has  confirmed  the  traditions 
in  regard  to  the  influence  of  salt  in  this 
respect.  His  research  on  animals  and 
on  healthy  volunteers,  as  well  as  in  the 
clinic,  has  demonstrated  that  salt  en- 
hances the  coagulating  power  of  the 
blood.  It  is  remarkable,  however,  that  it 
does  not  have  this  action  in  the  test-tube, 
but  it  is  marked  in  the  living  subject. 
He  is  inclined  to  attribute  this  congulat- 
ing  influence  to  the  mobilization  of 
thrombokinase  stored  up  in  the  tissues. 
In  29  cases  of  hemoptysis  the  author 
obtained  excellent  results  from  adminis- 
tration of  5  Gm.  (75  grains)  of  sodium 
chlorid  by  the  mouth,  the  coagulating 
properties  of  the  blood  being  much 
increased  thereby  for  a  period  of  from  an 
hour  to  an  hour  and  a  half.  The  effects 
become  evident  in  a  few  minutes.  If  the 
tendency  to  hemorrhage  returns  later,  the 
dose  of  salt  is  repeated,  or  potassium 
bromid  substituted  in  the  dose  of  3 
Gm.  (45  grains),  the  bromid  having, 
further,  a  sedative  action.  He  does  not 
hesitate  to  keep  up  this  combined  sodium 
chlorid  and  bromid  treatment,  giving  in 
the  most  urgent  cases  from  20  to  30  Gm. 
(3v  to  §j)  of  sodium  chlorid,  and  from 


13  to  15  Gm.  (oiij  to  oiv)  of  the  bromid 
during  the  day.  Any  tendency  to  bromin 
intoxication  is  corrected  by  the  sodium 
chlorid.  In  9  other  cases  he  adminis- 
tered the  salt  or  bromid  by  intravenous 
injection  as  he  did  not  wish  to  irritate  the 
digestive  tract  or  kidneys.  This  series 
includes  seven  patients  with  hemoptysis, 
and  one  each  with  hemorrhage  from 
varices  in  esophagus  or  bladder  or  ty- 
phoid lesions  in  the  bowel. 

The  writer  has  never  witnessed  any 
disagreeable  by-effects  from  this  treat- 
ment. The  beneficial  results  were  ap- 
parent in  hemorrhage  both  in  the  lung 
and  greater  circulation.  Hemophilia  is 
a  chronic  defective  condition  for  which  a 
transient  increase  in  coagulating  power  is 
of  little  avail.  The  hemophilic  tendency 
is  probably  the  result  of  defective  pro- 
duction of  thrombokinase,  according  to 
the  author.  E.  von  den  Velden  (Deut- 
sche medizinische  Wochenschrift,  Feb- 
ruary 4,  1909;  Journal  American  Medi- 
cal Association,  March  13,  1909). 

INSOMNIA. 

Whether  any  of  the  theories  advanced 
as  to  sleep  are  accepted  or  not,  the 
mechanism  of  sleep  remains  as  yet  prob- 
lematic, according  to  the  author.  The 
theories  do  not  explain  with  certainty 
why  cerebral  anemia  or  hyperemia  exists, 
why  the  neurones  become  retracted,  why 
toxins  accumulate  periodically  in  the 
tissues.  Sleep  may  be  normal  or  patho- 
logic. To  the  latter  belong  narcolepsy, 
lethargy,  somnambulism,  night  terrors 
and  sleeping  sickness.  Insomnia  may 
be  total  or  partial. 

The  author  considers  the  conditions  in 
which  insonmia  occurs  under  the  follow- 
ing groupings:  Organic  or  functional 
disorders  of  the  nervous  system;  psy- 
choses; intoxications;  infections;  vis- 
ceral diseases ;  general  state  of  nutrition ; 


284  MENINGITIS,  LEUCOCYTES  IN.  SKIN-GRAFTS,  METHOD  OF  SPLINTING. 


painful,  general  or  local  conditions;   in- 
cidental causes. 

In  the  treatment  of  insomnia,  the 
writer  forbids,  under  all  circumstances, 
the  taking  of  heavy  meals  at  night. 
Sweets  should  be  avoided,  as  should  all 
stimulants,  including  tea  and  coffee; 
tobacco  should  be  reduced  to  a  minimum 
or  abandoned;  at  any  rate,  there  should 
be  no  smoking  in  the  evening.  Constipa- 
tion must  be  remedied ;  a  hot  lukewarm 
bath  of  half  an  hour's  duration  before 
retiring  is  useful  and  may  be  repeated  if 
necessary.  Wrapping  the  patient  in  a 
sheet  wetted  in  tepid  water  for  one 
minute,  or  a  cold  wet  towel  placed  on  the 
neck,  placing  the  feet  in  hot  water  for 
fifteen  minutes,  sometimes  succeeds. 
Cases  due  to  extreme  sorrow  or  persistent 
mental  preoccupation  are  often  rebellious. 
In  these  cases  some  form  of  psycho- 
therapeutics may  be  useful.  Until  these 
various  measures  have  failed,  medication 
should  not  be  resorted  to. 

Among  drugs  10  grains  of  sodimn  or 
strontium  bromid  every  2  hours  may  be 
repeated.  Veronal  5  grains,  with  codein 
Yg  grain  every  hour  for  two  or  three 
doses  is  a  good  hypnotic.  In  insomnia 
from  painful  conditions,  removal  of  the 
cause  is  of  course  the  first  measure. 
Sometimes  a  state  of  exhaustion  follows, 
resulting  in  wakefulness.  A  tepid  bath 
of  from  15  to  30  minutes'  duration  is 
recommended.  A.  Gordon  (Therapeutic 
Gazette,  February  15,  1909). 

MENINGITIS,  LEUCOCYTES  IN. 

The  leucocytosis  which  is  a  constant 
feature  of  epidemic  cerebrospinal  menin- 
gitis has  been  studied  by  the  writer,  and 
he  reaches  the  following  conclusions: 
Cases  of  epidemic  cerebrospinal  menin- 
gitis are  always  accompanied  by  a  leuco- 
cytosis, whether  the  attack  is  acute, 
abortive,  mild,  or  chronic.     The  charac- 


ter of  the  leucocytosis  is  practically  the 
same  in  all  instances,  both  adults  and 
children,  and  is  the  result  mainly  of  an 
increase  in  the  number  of  the  polymor- 
phonuclear cells.  Nevertheless  a  lympho- 
cytosis may  be  very  occasionally  observed 
in  infants  and  young  children.  There  is 
a  relative  decrease  of  the  large  mono- 
nuclear elements  alike  in  fatal  and  non- 
fatal cases,  though  less  marked  in  the 
chronic  t}^e.  In  acute  cases  there  is 
sometimes  an  absolute  decrease  of  the 
large  mononuclear  elements  and  occa- 
sionally total  absence  of  those  cells.  In 
the  clironic  group,  absolute  decrease,  like 
relative  decrease,  is  little  marked. 
Eosinophile  corpuscles  are  always  absent 
in  acute  fatal  cases,  though  present  in 
var3dng  degree  in  all  others.  W.  Dow 
(Lancet,  March  20,  1909). 

SKIN-GRAFTS,  METHOD  OF  SPLINTING. 

A  coarse  meshed  net,  such  as  is  used 
for  curtains,  is  used  by  the  writer  for 
keeping  skin-grafts  in  position.  The 
stiffening  is  washed  out  and  the  net  is 
soaked  in  gutta  percha  30  parts,  cliloro- 
form  150  parts.  It  is  sterilized  by  keep- 
ing in  1  to  1,000  solution  of  bichlorid  of 
mercury.  Of  course,  no  hot  material 
must  come  in  contact  with  it  at  any  time. 
After  placing  the  skin-grafts,  a  piece  of 
this  web  rather  larger  than  the  grafted 
area  is  pressed  snugly  down  on  it.  Its 
advantages  are  that  it  splints  the  grafts 
without  too  much  pressure,  and  is  easy  to 
apply  and  secure  in  place.  It  does  not 
adhere  to  the  grafts  or  to  granulations. 
It  allows  the  free  escape  of  any  secretions 
which  may  form,  and  thus  prevents 
maceration.  Any  sort  of  dressing  may 
be  placed  over  it.  The  progress  of  the 
healing  may  be  observed  at  any  time 
without  danger  of  displacing  the  grafts. 
J.  S.  Davis  (Annals  of  Surgery,  March, 
1909). 


TENOSYNOVITIS  OF  THE  HAND. 


285 


TENOSYNOVITIS  OF  THE  HAND. 

Success  in  the  treatment  of  tendon- 
sheath  infections  of  the  hand  depends 
upon  early  accurate  diagnosis,  upon  in- 
cisions 80  made  as  to  drain  the  proper 
sites  without  involving  uninfected  areas, 
and  upon  careful  after-treatment.    Two 
types  must  be  recognized,  the  fulmina- 
ting and  the  subacute.    The  treatment 
will   vary   with   the    type.      The    most 
marked  symptoms  and  signs  are :    local- 
ized excruciating  pain  over  the  course 
of  the  sheath,  pain  on  extension,  espe- 
cially at  the  proximal  end  of  the  sheath, 
and  characteristic  position  of  the  finger. 
Infection   from   the   tendon-sheath    of 
the  index  finger  will  most  often  extend 
to  the  proximal  interphalangeal  joint, 
thenar  space,  lumbrical  spaces,  and  the 
surface    at   the    proximal   end   of    the 
sheath.    From  the  middle  finger  it  most 
often   extends   to   the  proximal   inter- 
phalangeal joint,  the  lumbrical  spaces, 
the  surface  at  the  proximal  end,  and 
the  middle  palmar  space,  although  it 
may  invade  the  thenar  space.    From  the 
ring  finger  the  extensions  are  the  same, 
except  that  it  always  involves  the  mid- 
dle  palmar   space,   if   extension  takes 
place  into  the  palm. 

From  the  little  finger,  the  most  com- 
mon sites  of  extension  are  to  the  proxi- 
mal interphalangeal  joint  (not  com- 
mon), the  lumbrical  space,  the  middle 
palmar  space,  the  surface  at  the  proxi- 
mal end  of  the  sheath,  and  the  ulnar 
bursa.  From  the  idnar  bursa,  it  may 
extend  to  the  middle  palmar  space, 
radial  bursa,  interosseous  space  below 
the  flexor  profundus,  and  the  wrist- 
joint.  From  the  sheath  of  the  flexor 
longus  pollicis  to  the  thenar  space, 
ulnar  bursa,  wrist-joint,  and  interosse- 
ous space  above  described. 


Incisions  are  best  made  in  the  fingers, 
either  upon  one  or  both  sides  of  the 
tendon-sheath  over  the  length  of  the 
shaft  of  the  middle  and  proximal  pha- 
lanx, avoiding  the  joints,  and  into  the 
proximal  end  of  the  sheaths  or  the  lum- 
brical spaces  to  provide  drainage  there. 
The  ulnar  bursa  is  best  treated  by 
splitting  it  throughout  its  length,  cut- 
ting upon  the  ulnar  side.  The  anterior 
annular  ligament  should  generally  be 
cut.  This  is  commonly  supplemented 
by  incisions  upon  the  radial  and  ulnar 
sides  of  the  forearm  above  the  wrist- 
joint,  and  on  a  level  with  the  flexor  sur- 
face of  the  bones — through  and  through 
drainage  is  then  carried  out  under  the 
flexor  profundus  tendons.  An  ulnar  in- 
cision may  be  sufficient.  If  the  pus  has 
invaded  the  forearm,  an  ulnar  incision 
is  made  at  the  middle  of  the  forearm 
between  the  flexor  carpi  ulnaris  and  the 
flexor  sublimis,  or  between  the  flexor 
carpi  ulnaris  and  the  ulna. 

Incision  of  the  flexor  longus  pollicis 
sheath  is  made  from  a  finger-breadth 
below  the  anterior  annular  ligament  to 
the  end  of  the  sheath.  Opening  may  be 
made  above  the  anterior  annular  liga- 
ment, the  upper  half  of  which  may  be 
cut,  or  drainage  may  be  instituted 
above  the  wrist  by  the  lateral  incision 
mentioned  under  ulnar  bursal  infec- 
tions. 

In  the  after-treatment  the  Bier  con- 
strictor is  used  for  twenty-four  to  forty- 
eight  hours,  hot  moist  dressings  for  two 
to  four  days,  followed  by  dry  dressings, 
hand  being  held  in  overextension  by 
splint,  daily  manipulation  of  joints  and 
muscles  after  immediate  danger  of  sys- 
temic infection  has  ended.  A.  B.  Kana- 
vel  (Surgery,  Gynecology  and  Obstet- 
rics, February,  1909). 


286  NOTICES.  BOOK  REVIEWS. 

American  Medical  Editors'  Association. 

The  coming  meeting  of  this  Association,  to  be  held  at  the  Marlborough-Blenheira  Hotel, 
Atlantic  City,  June  5th  and  7th,  celebrates  its  fortieth  anniversary,  and  an  unusual  program 
has  been  prepared  for  the  occasion. 

It  is  expected  that  delegates  from  the  foreign  medical  press  will  be  present,  and  every 
medical  editor  should  make  an  efl'ort  to  meet  with  this  society. 


Atropine  as  a  Hemostatic. 

Dr.  William  F.  Waugh  is  collecting  material  for  a  paper  upon  atropine  as  a  hemostatic, 
and  would  be  obliged  to  any  of  our  readers  who  would  send  him  notes  of  their  experience 
with  this  remodv.  He  is  particularly  anxious  to  receive  adverse  reports,  as  well  as  those 
favoring  the  reniedy.  Any  such  material  may  be  addressed  to  Dr.  Wangh,  1424  East  Ravens- 
wood  Park,  Chicago,  111. 


5ool<  Reviews 


Text-book  of  Otot.ogy.     For  Rhysicians  and  Students.     In  32  Lectures.     By  Fr.  Bezold,  M.D.. 

Professor  of  Otologv  at  the  University  of  Munich,  and  Fr.  Siebonmann,  M.D.,  Professor 

of  Otolog:^^  at  the   University  of  Basle.     Translated  by  J.  Hollinger,  M.D.,  of  Chicago. 

Chicago:  "E.  H.  Colegrove  Co.,  1908. 

To  call  this  work  a  Text-book  of  Otology  seems  to  be  a  mistake  in  identity.  It  is  merely 
a  series  of  clinical  lectures  on  the  ear,  and  the  subjects  treated  are  not  done  so  in  a  manner 
which  is  characteristic  of  the  usual  text-book.  The  entire  subject  of  otology  is  not  covered, 
but  merely  those  points  which  the  authors  thought  would  be  of  especial  interest  to  physicians 
and  students,  for  w^hom  the  book  is  intended. 

The  first  nine  lectures  contain  a  discussion  of  the  mode  of  examination  and  the  considera- 
tion of  general  topics,  while  those  following  are  devoted  to  special  subjects.  The  anatomy 
of  the  temporal  bone  is  early  considered,  and  the  study  of  the  same  is  augmented  by  the 
presentation  of  wax  models  of  the  main  spaces.  The  importance  of  a  clear  understanding  of 
the  various  parts  of  this  bone  for  the  intelligent  treatment  of  the  various  diseases  is  impressed 
upon  the  reader. 

Statistics  abound  throughout,  thereby  making  the  work  of  some  value  to  the  aurist.  It 
can  hardly  be  recommended,  however,  to  physicians  and  students,  for  their  points  of  interest 
are  usually  diagnosis  and  treatment.  A  disregard  for  grammar  seems  to  be  quite  evident 
throughout  the  book,  and  typographical  errors  are  numerous — R.  B.  S. 

SuBGiCAL  Memoirs  and  Other  Essays.  By  James  G.  Mum  ford,  M.D.,  Instructor  in  Surgery, 
Harvard  Medical  School;  Visiting  Surgeon  to  the  Massachusetts  General  Hospital;  Fel- 
low of  the  American  Surgical  Association,  etc.,  etc.  Illustrated.  New  York:  Moffat, 
Yard  &  Company,  1908. 

This  book  is  composed  of  a  series  of  surgical  essays  prepared  by  the  author  during  the 
past  decade.  The  opening  one  is  a  brief  historical  sketch  of  surgery  as  viewed  through  the 
works  of  diiferent  masters  of  various  ages,  including  Hippocrates,  the  Father  of  Medicine 
and  the  originator  of  the  "Oath"  which  has  given  the  profession  digiiity,  and  which  has 
revealed  its  lofty  aims;  Galen,  our  first  great  physiologist  and  the  discoverer  of  the  true 
function  of  the  arteries;  Versalius,  a  noted  anatomist;  Ambroise  Par6,  a  surgeon  of  the 
sixteenth  century  who  discarded  the  barbarous  methods  of  using  boiling  oil  and  the  like  for 
hemostasis,  and  who  instituted  the  ligature  instead;  Hnller,  a  surgeon  of  prominence  of  the 
eighteenth  century;  and  Hunter  and  Lister,  two  men  of  Scotland,  who  achieved  greatness  in 
surgery.  American  surgery  is  also  considered  under  this  heading,  embodying  a  very  inter- 
esting but  brief  sketch  of  some  of  the  men  who  have  figured  iiitimately  in  the  development 
of  surgery  in  this  country.  This  essay  is  found  as  the  first  chapter  in  Keen's  "Sj'stem  of 
Surgery." 

The  paper  on  the  "Teachings  of  the  Old  Surgeons"  proves  very  interesting,  and  acquaints 
one  with  the  methods  of  treatment  in  vogue  at  various  periods  of  human  existence.  Interest- 
ing biographical  sketches  are  also  given  of  Sir  Astley  Cooper,  Sir  Benjamin  Brodie,  John 
Collins  Warren  and  Jacob  Bigclow. 

"Boston  Medicine  One  Hundred  Years  Ago"  has  for  its  main  character  the  person  of  Dr. 
Samuel  Howe,  who  was  most  energetic  in  his  efforts  to  help  others.  His  energies  were 
especially  devoted  to  the  development  and  education  of  the  blind. 


BOOK  REVIEWS.  .  287 

The  uncertainty  of  early  medicine  and  its  gradual  development  to  the  preaent-day  stand- 
ard is  well  shown  m  tlie  paper  on  the  "Studies  in  Aneurisms."  Passing  down  through  the 
centuries,  it  seems  as  though  each  great  surgeon  had  his  own  peculiar  definition  and  treat- 
ment for  this  malady,  but  it  remained  for  one  of  our  own  surgeons,  of  the  present  generation, 
to  devise  a  simple  treatment  which  is  decidedly  radical  in  its  performance  and  practically  nil 
in  its  fatalities. 

The  remaining  essays  are  on  various  subjects  and  include  addresses  to  nurses  and  a  short 
paper  on  "Ethics  and  Medical  Education."  The  author's  style  of  writing  is  interesting  and 
entertaining,  and  the  various  subjects  selected  are  such  as  to  appeal  to  one  from  an  educa- 
tional, as  well  as  a  historical,  standpoint. — R.  B.  S. 

Psychological  Principles  in  Treatment.  By  W.  Langdon  Brown,  M.D.,  Cantab.  F.R.C.P., 
Physician  to  Metropolitan  Hospital,  etc.,  etc.    London:    BalliOre,  Tindall  &  Cox,  1908. 

Langdon  Brown  has  given  us  in  this  little  book  of  only  350  pages  an  excellent  outline  of 
the  psychologic  principles  applied  to  the  interpretation  of  certain  problems  of  clinical  medi- 
cine, and  although  it  might  with  advantage  be  longer,  it  covers  the  field  of:  (1)  organo- 
therapy; (2)  gastric  disorders;  (3)  work  of  the  pancreas;  (4)  viric  acid;  (5)  oxaluria, 
phosphaturia,  albuminuria;  (6)  glycosuria  and  diabetes;  (7)  acetonuria  and  acid  intoxica- 
tions; (8)  intestinal  intoxications;  (9)  irregular  action  of  the  heart;  (10)  vasomotor  sys- 
tem in  disease;  (11)  cyanosis;  (12)  the  role  of  calcium  in  the  body.  There  are  few  enough 
books  pretending  to  give  the  student  a  symmetrical  conception  of  functionation  in  relation 
to  problems  in  disease.  The  only  other  one  that  we  can  immediately  recall  is  that  of  Ludolf 
Krchl,  of  Straasburg,  which  has  long  enjoyed  a  well-merited  vogue.  This  book  of  Brown's 
covers  a  rather  diflFerent  field,  and  the  two  form  useful  corollaries.  There  is  no  other  subject 
on  which  the  medical  practitioner  needs  to  refresh  himself  so  frequently  (at  least  annually) 
as  on  that  of  clinical  physiology,  and  since  it  is  really  impossible  to  do  this  thoroughly  from 
the  larger  text-books,  such  excellent  interpretations  as  are  aft'prded  in  this  book  of  Langdon 
Brown's  are  to  be  very  strongly  recommended.  It  can  be  read  in  a  couple  of  evenings,  and 
these  evenings  will  be  among  the  best  spent  during  the  year. — J.  M.  T. 

The  Body  at  Work.  A  Treatise  on  the  Principles  of  Physiology.  By  Alexander  Hill,  M.A., 
M.D.,  F.R.C.S. ;  sometime  Master  of  Downing  College,  Cambridge.  With  46  Illustra- 
tions.    London :    Edward  Arnold,  1908. 

Alexander  Hill  has  given  us  the  most  complete  review  of  the  principles  of  physiologs', 
bereft  of  the  customary  technicalities,  that  it  has  been  our  good  fortune  to  read.  The  style 
is  charming,  vigorous,  filled  with  homely  illustrations  and  analogies,  which  assist  in  render- 
ing the  subject  readily  comprehensible.  What  is  known  is  herein  succinctly  sta,ted;  what  is 
inferential  has  been  at  most  only  alluded  to;  what  is  lacking  has  been  pointed  oui>— although 
this  last  is  insufficient.  So  far  as  it  goes,  the  book  is  a  complete  presentation  of  the  outlines 
of  physiology  well  worth  repeated  perusals.  It  does  not  attempt  to  deal  with  the  treatment 
of  disease,  as  does  the  book  by  Langdon  Brown,  but  only  gives  occasional  references  to  morbid 
phenomena.  The  chapter-headings  are  as  follows:  (1)  Prolegomena;  (2)  Basis  of  Life; 
(3)  Unit  of  Structure;  (4)  Fluids  of  the  Body;  (5)  Internal  Secretions;  (6)  Digestion; 
(7)  Respiration;  (8)  Excretion;  (9)  Circulation;  (10)  Muscle;  (11)  Nervous  Svstem; 
(12)  Smell  and  Taste;  (13)  Vision;  (14)  Hearing;  (15)  Skin-Sensations;  (IG)  Voice  and 
Speech.  Tlie  illustrations  are  well  suited  for  teaching,  being  vigorous  outline  drawings, 
entitled  by  the  author  "Blackboard  Sketches,"  which  convey  a  good  notion  of  such  points  as 
require  diagrams  to  make  them  clear.  The  chapter  on  the  "Internal  Secretions"  is  pretty 
good,  notwithstanding  the  fact  that  the  author  betrays  a  complete  ignorance  of  the  researches 
of  Sajous,  who  has  amplified  this  sul)jcct  and  based  upon  it  the  exceedingly  important  infer- 
ences and  clinical   interpretations  which   place  them  at  the   foundation  of  clinical  medicine. 

J.  M.  T. 

Parsimony  in  Nutbition.  By  Sir  James  Crichton-Brown,  M.D.,  LL.D.,  F.R.S.,  Lord  Chan- 
cellor's Visitor  in  Lunacy,  London.     London  and  New  York:    Funk  &  W^agnalls  Co.,  1909. 

In  this  delightful  little  volume,  which  can  be  read  in  an  hour,  is  presented  what  the 
author  is  pleased  to  regard  as  a  complete  refutation  of  the  conclusions  of  Horace  Fletcher 
and  Professor  Chittenden  on  low  proteid  diet  or  minimum  alimentation.  He  presents  a 
strong  plea  for  adequate  food,  consistent  with  varying  requirements;  for  instance,  he  says 
(page  3):  "Physiologists  and  medical  men  of  high  autliority  are  preaching  not  merely  sim- 
plicity of  diet,  but  a  degree  of  abstemiousness  that  would  hitherto  have  been  regarded  as 
dangerous."  He  sympathizes  with  the  trend  toward  reduced  dietaries,  but  fears  that  much 
harm  may  be  received  by  those  who  may  injudiciously  attempt  to  practice  it.  In  this  he  is 
undoubtedly  correct.  Nevertheless,  the  reviewer  is  of  the  opinion  that  neither  of  these  two 
gentlemen,  whom  he  so  cheerfully  attacks,  would  have  the  world  starve  to  death,  and  they 
do  act  as  important  pioneers  in  showing  how  necessary  it  is  for  mankind  to  return  to  simpli- 


288 


BOOK  RE^^LEWS. 


fiod  dietaries  in  order  to  escape  many  troublesome  effects  of  civilization,  induced  by  over- 
eating. After  reading  both  sides  of  the  question  one  becomes  vastly  wiser.  After  all,  the 
clinician  is  the  one  to  say  the  final  word  in  the  specific  instance. — J.  M.  T. 

Hygiene  fob  Nubses.     By  Isabel  Mclsaac,  Author  of  "Primary  Nursing  Technique."     New 

York:    The  Macmillan  Company,  1908.     Cloth,  $1.25. 

This  excellent  little  work  aims  to  secure  for  the  young  nurse  those  features  of  hygiene 
which  are  most  practical  and  within  the  range  of  her  daily  work.  The  subjects  treated  are: 
Food:  Composition,  Varieties,  Preser\'ation,  Adulteration;  Air:  Composition,  Climate,  Ven- 
tilation, Heating,  Lighting;  Soil:  Water;  Sewage:  Garbage;  Causes  and  Dissemination  of 
Disease;  Personal  Hygiene;  Household  Hygiene;  School  Hygiene:  Medical  Inspection  of 
Schools;  Hygiene  of  Occupation:  Employment  of  Women  and  Children;  Disinfection:  Quar- 
antine. Although  it  pretends  to  be  only  a  compilation,  tlie  author  has  contributed  mucli  of 
the  subject-matter,  and  that  in  a  clear,  concise  language,  eminently  calculated  for  the  class 
of  readers  for  which  it  is  intended.  This  book  is  entitled  to  commendation  and  a  large 
patronage. 

Practice  of  Medicine  fob  Nubses.  A  Text-book  for  Nurses  and  Students  of  Domestic 
Science,  and  a  Hand-book  for  all  Those  Who  Care  for  the  Sick.  By  George  Howard 
Hoxie,  M.D.,  Professor  of  Internal  Medicine,  University  of  Kansas.  With  a  chapter  on 
the  "Technic  of  Nursing,"  by  Pearl  L.  Laptad,  Principal  of  the  Training  School  for 
Nurses,  University  of  Kansas.  12mo  of  248  Pages.  Illustrated.  Philadelphia  and  Lon- 
don:   W.  B.  Saunders  Company,  1908.     Cloth,  $1.50  net. 

In  order  to  carry  out  satisfactorily  the  instructions  of  the  attending  physician  and  to 
prove  more  useful  during  emergencies,  nurses  should  be  familiar  with  the  elements  of  practice, 
although,  as  the  author  contends,  they  should  not  enter  into  the  minutife  of  diagnosis  or 
therapeutics.  This  book  aims  to  meet  this  feature  of  the  problem  of  nursing,  and  does  so 
very  satisfactorily,  although  some  of  the  statements  made  that  antitoxin  "is  taken  from  the 
blood  of  horses  which  have  overcome  diphtheria,"  and  that  in  septicaemia  the  germs  them- 
selves "destroy  the  vital  centers,  not  only  by  their  toxins,  but  also  by  their  bodily  presence," 
would  tend  to  convey  erroneous  ideas  into  a  lay  reader's  mind.  On  the  whole,  however,  the 
book  is  well  gotten  up,  and  a  useful  addition  to  the  literature  for  nurses. 

The  Opeeations  of  General  Practice.  By  Edred  M.  Corner,  M.A.,  M.C.,  M.B.  (Cantab.), 
B.Sc.  (London),  F.R.C.S.  (England),  Surgeon-in-Charge  of  Out-Patients  at  St.  Thomas's 
Hospital,  and  to  the  Children's  Hospital.  Great  Ormond  Street;  Consulting  Surgeon  to 
the  Wood  Green  and  Purley  Hospitals;  Formerly  Erasmus  Wilson  Lecturer  to  the  Royal 
College  of  Surgeons;  and  H.  Irving  Pinches,  M.A.,  M.B.,  B.C.  (Cantab.),  M.R.S.C, 
L.R.C.P.  (London),  Clinical  Assistant  to  the  Children's  Hospital,  Great  Ormond  Street; 
Late  House  Surgeon  and  Obstetric  House  Physician  to  St.  Thomas's  Hospital.  London: 
Henry  Frowde,  Oxford  University  Press;  Hodder  &  Stoughton,  Warwick  Square,  E.  C, 
1907. 

The  authors  rightly  hold  that  the  education  of  the  vast  majority  of  medical  men  is  very 
deficient  in  the  practice  and  performance  of  the  many  small  operations  which  lie  so  largely 
on  the  borderland  between  medicine  and  surgery.  This  they  ascribe  to  the  fact  that  but  few 
students  have  the  opportunity  of  doing  practical  post-graduate  work  in  large  clinics  where 
such  experience  is  obtainable.  To  in  a  measure  compensate  for  this  loss,  they  have  published 
the  present  work,  in  which  are  presented  in  imusually  clear,  concise  and  practical  style  all 
of  the  multitude  of  technical  points  that  one  should  be  familiar  with  even  to  jnoet  the  needs 
of  routine  practice.  The  fact  that  the  larger  works  omit  precisely  this  class  of  information 
makes  the  book  an  invaluable  one  to  the  student  and  practitioner. 

Text-book  of  Subqical  Anatomy.  By  William  Francis  Campbell,  M.D..  Professor  of 
Anatomy  at  the  Long  Island  College  Hospital.  Octavo  of  675  Pages,  with  310  Original 
Illustrations.  Philadelphia  and  London:  W.  B.  Saunders  Company,  1908.  Cloth,  $5.00 
net;    Half-morocco,  $6.50  net. 

As  the  author  states,  "Anatomic  facts  are  only  as  they  are  isolated.  Translated  into 
their  clinical  values  they  are  clothed  with  living  interest."  Although  the  word  "anatomy" 
stands  out  prominently,  therefore,  the  anatomic  data  presented  are  those  only  which  have  a 
practical  bearing  upon  surgery  or  which  are  of  special  interest  to  the  surgeon.  A  perusal  of 
the  work  shows  that  this  plan  has  been  carried  out  so  faithfully,  and  its  practical  side  so 
well  borne  in  mind  all  through  its  pages,  that  it  is  entitled  to  a  higher  place  among  the  works 
of  its  kind  than  the  author  modestly  claims  for  it.  Our  own  opinion  of  it  suggests  that  it 
should  bo  regarded  in  the  light  of  a  work  on  scientific  surgery,  and  we  hope  that  in  subsequent 
editions  the  author  will  gradually  incorporate  all  surgical  subjects  in  its  pages,  adding  a 
volume  if  need  be.  The  beauty  of  the  illustrations  contributes  considerably  to  the  value  of 
the  work,  and  the  publishers  are  to  be  congratulated  upon  the  manner  in  which  they  have 
accomplished  their  task.  We  sincerely  hope  the  profession  at  large  will  give  this  work  the 
cordial  reception  to  which  it  is  so  eminently  entitled. 


ONTHLY    Cyclopedia 

AND 

Medical   Bulletin 


Published  the  Last  of  Each  Month 


Medical  Bulletin  Section 


Vol.  II.  PHILADELPHIA,  MAY,  1909.  No.  5. 


Clinical  Lecture 


ACNE  INDURATA. 

By  JOHN  V.  SHOEMAKER,  M.D.,  LL.D., 

Professor  of  Materia  Medica,  Therapeutics,  Clinical  Medicine,  and  Diseases  of  the  Skin, 

in  the  Medico-Cliirurgical  College  and  Hospital  of  Philadelphia. 

Gentlemen  :  I  have  the  pleasure  this  moming  to  show  you  a  very  com- 
mon disease  of  the  skin,  comprising  about  8  per  cent,  of  all  cutaneous  affec- 
tions. 

This  young  woman,  age  22  years,  nativity  America,  gives  a  history  of 
an  eruption  over  her  forehead  and  cheeks  existing  for  over  six  months.  She 
claims  that  small  papules  appear  under  the  skin  which  are  painful  to  the 
touch  and  feel  hard,  but  which  never  have  a  tendency  to  suppurate. 

The  skin  of  her  face  is  red,  feels  oily,  and  many  comedoes  co-exist.  On 
close  examination  you  can  see  small  depressed  scars  which  are  undoubtedly 
the  remains  of  pustular  acne,  which  she  had  prior  to  this  attack.  You  will 
also  notice  that  the  lesions  present  are  deep  seated  and  are  as  large  as  a  pea. 
These  hard  papules  come  in  crops,  following  close  in  succession. 

Her  previous  personal  history  is  negative  as  regards  syphilis,  and  her 
habits  are  good.  She  is  a  domestic  and  works  very  hard,  which  undoubtedly 
consumes  all  her  energy.  Her  tongue  is  coated,  the  conjunctivae  of  her  eyes 
are  jaundiced,  and  she  complains  of  eructations  of  gas  and  flatulence;  appar- 
ently, she  looks  pale  and  anaemic. 

Diagnosis. — This  is  undoubtedly  a  case  of  acne  indurata,  the  diagnosis 
being  based  on  the  characteristic  papules  and  nodules  which  are  painful,  hard, 
and  have  no  tendency  to  suppurate.  Also  the  lesions  are  deep  seated,  involv- 
ing the  subcutaneous  tissue. 

Many  forms  of  acne  are  recognized  and  arc  named  accordingly  to  pre- 
dominating lesions  present.  In  acne  pustulosa  the  pustules  vary  in  size  from 
^  (280) 


290  ACNE  INDURATA, 

a  pin-head  to  a  split  pea,  and  in  all  stages  of  the  development  there  may  be 
associated  papules,  papulo-pustules,  and  frequently  seborrhooa.  The  pustules 
usually  form  rapidly,  contain  a  drop  or  two  of  pus,  and  will  either  terminate 
by  absorption  and  dessication,  or  rupture  and  heal,  leaving  slight  scars.  In  a 
mild  form  of  the  disease  the  eruption  consists  of  pale-red  papules  with  no  ten- 
dency to  suppurate;  comedoes  are  present  over  the  face,  and  especially  over 
the  forehead;  this  condition  is  known  as  acne  papulosa.  Drugs,  such  as  the 
iodides  and  bromides,  iron  and  external  application  of  tar,  often  give  rise  to  a 
form  known  as  acne  artificialis. 

The  diagnosis  of  the  various  forms  of  acne  is  often  confounded  with 
papular,  papulo-pustular  or  tubercular  syphilis,  variola,  eczema,  and  rosacea. 
The  differential  diagnostic  points  are: — 

Acne.  Papxdo- Pustular  Syphilis. 

1.  Specific  history  negative.  1.  Specific  history  positive. 

2.  Eruption   limited   to   face   as   a   rule.  2.  Eruption  general,  and  more  prominent 

over  the  body. 

3.  Course  is  chronic  and  occurs  at  puberty.       3.  Course  acute  and  after  puberty  gener- 

ally. 

4.  Lesions  are  inflammatory.  4.  Lesions  are  new  growths. 

5.  Lesions  red.  5.  Lesions  ham-colored. 

Acne.  Variola. 

1.  Constitutional  sjaiiptoms  absent.  1.  Constitutional  symptoms  present. 

2.  Eruption  papular,  followed  by  pustula-       2.  Eruption  papular,  then  vesicular,  finally 

tion.  pustular  and  umbilicated. 

3.  Chills  and  fever  absent.  3.  Chills  and  fever  precede  eruption. 

Papular  and  papulo-pustular  eczema  differs  from  acne  in  that  the  lesions 
in  eczema  are  not  necessarily  located  in  the  follicles,  and  scales  and  inter- 
papular  infiltration  are  usually  observed,  which  are  not  present  in  the  latter. 

Eosacea,  although  frequently  complicated  with  acne,  differs  from  it  in  the 
local  congestion,  which  primarily  arises  without  particularly  involving  the 
sebaceous  glands. 

PatJwlogy. — The  acne  papule  is  due  to  a  retention  of  sebum  in  the  hair- 
follicle  and  sebaceous  gland,  causing  a  perifolliculitis  and  a  folliculitis.  A 
hypersemia  with  exudation  and  emigration  of  corpuscles  may  take  place  during 
the  first  stage,  and  which  is  sometimes  followed  by  a  destruction  of  the  fol- 
licles and  glands.  Suppuration  resulting  either  in  induration,  hypertrophy 
or  atrophy  of  the  involved  tissues  may  follow  if  the  inflammation  is  active. 
It  is  claimed  by  some  authorities  that  the  inflammation  around  the  follicle 
is  due  to  an  abnormally  developed  epidermis  lining  of  the  follicles  which  thus 
sets  up  the  irritation.  The  blood-vessels  are  always  dilated  and  engorged, 
and  surrounding  the  vessels  is  an  intense  cell-infiltration.  The  process  usually 
terminates  in  suppuration,  with  or  without  destruction  of  the  follicle. 

Etiology. — This  disease  is  most  common  at  puberty  due  to  the  physiolog- 
ical changes  which  take  place  in  the  body,  and  continues  until  the  system 
has  passed  through  this  period  and  has  returned  to  a  state  of  rest.  Acne  is 
found  in  both  sexes,  in  all  climes  and  in  all  nationalities.  It  is  also  attributed 
to  debilitating  conditions,  disorders  of  organs  or  portions  of  the  economy  which 
have  a  reflex  action  on  the  face,  such,  as  gnstro-intestinal  disorders  like  dys- 


PREVENTIVE  MEDICINE.  291 

pepsia  and  constipation,  anaemia,  uterine  diseases,  menstrual  irregularities, 
and  mental  troubles  also  excite  and  aggravate  it. 

Treatment. — In  this  patient  the  treatment  must  largely  be  constitutional. 
Her  blood  is  undoubtedly  in  a  depraved  condition,  as  is  verified  by  the  appear- 
ance of  her  mucous  membranes.  However,  her  gastro-intestinal  canal  is  in  a 
bad  condition,  and  must  first  receive  attention  before  we  will  place  her  on 
alterative  treatment,  hence  we  will  prescribe  for  her  the  following  combina- 
tion : — 

IJ  TincturiE    nuci3    vomicae    f gss. 

Aeidi  hydrochloric!  diluti   f3v j, 

Tincturse  gentianse  compositse q.  s.  ad  f^iij. 

Misce.    Signa.    One  teaspoonful  in  a  little  water  a  half  hour  after  each  meal. 

After  she  has  taken  this  mixture  and  her  digestion  is  improved,  we  will 
give  her  a  capsule  containing: — 

IJ  Massae  f erri  carbonatis   3j. 

Arseni  trioxidi gr.  %. 

Aloini gr.  ijj. 

Extract!  gentianse  3j. 

Misce.    Fiant  capsulse  no.  xxx. 

Signa.    One  capsule  after  each  meal  and  at  bedtime. 

It  is  well  to  incise  the  deep-seated  tubercles  which  are  filled  with  retained 
sebum,  and  press  out  the  contents. 

Locally  a  stimulating  ointment,  containing: — 

IJ  Acidi  salicylic!  gr.  xx. 

Hydrastinae  hydrochlorid!    (colorless) .  .gr.    iij. 

Sulphuris    Sss. 

Unguent!   aquae   rosse    5j. 

Misce.    Fiat  unguentum. 

Signa.  Apply  locally  twice  daily  after  the  face  has  been  thoroughly  washed  with 
hot  water  and  tuicture  of  green  soap. 

This  ointment  is  probably  as  good  a  combination  in  these  particular  cases 
of  acne  as  you  may  wish  to  employ.  Of  course,  as  the  disease  progresses  in 
getting  well,  the  local  applications  should  be  changed  to  less  stimulating 
ointments. 

Prognosis. — In  this  case  the  prognosis  is  favorable,  but  an  early  cure 
cannot  be  promised.  Although  acne  is  one  of  the  most  obstinate  and  relaps- 
ing of  the  skin  affections,  it  can  either  be  limited  or  cured  by  remedies,  or  it 
may  terminate  spontaneously  after  the  individual  has  passed  beyond  the  age 
of  puberty,  and  the  system  is  in  a  state  of  repose. 


Original  Articles 

PREVENTIVE  MEDICINE. 

By  a.  J.  BURKHOLDER,  D.V.Sc,  M.D. 

The  question  may  well  be  asked,  Are  we  progressive?  Do  we  profit  by 
the  large  amount  of  specialized  research  work?  This  question  can  only  be 
answered  in  the  negative — observed  by  few — ignored  by  many. 


292  PREVENTIVE  MEDICINE. 

Some  years  ago  we  were  sufficiently  liberal  to  believe  that  time  would  bring 
about  a  just  appreciation  of  sanitary  science,  and  that  through  the  efforts  of 
sanitarians  the  responsive  cord  would  supply  hearty  co-operation  on  the  part 
of  the  laity;  that  willingly  the  masses  would  accept,  put  into  practice,  and 
generously  aid  in  the  great  fight  that  is  being  made  to  exterminate  dangerous 
diseases.  National,  state  and  municipal  regulations  have  accomplished  much. 
Yet  the  work  done  has  fallen  far  short  for  the  want  of  approval  and  ready 
acceptance  at  the  hands  of  those  who  feel  that  such  restriction  is  simply  per- 
secution. After  disease  makes  its  appearance,  curative  means  become  impera- 
tive. At  present  it  seems  that  more  interest  is  taken  in  this  direction  by  the 
average  person  than  towards  means  of  escape.  Large  sums  of  money  are 
annually  expended  by  the  afllicted  in  search  of  health;  but  very  little  individ- 
ually to  prevent  such  disorders. 

Can  it  be  that  we  are  struggling  through  that  state,  known  in  ancient 
history  as  "The  Dark  Age,"  or  do  the  requirements  of  modem  civilization  so 
overtax  the  mind  that  education  along  these  lines  should  receive  no  attention  ? 
Health  is  wealth.  It  is  an  endowment  from  which  the  possessor  can  draw 
dividends;  it  is  the  only  resource,  the  only  available  asset  upon  which  the 
majority  are  dependent.  Freedom  from  disease  of  the  body  assures  compara- 
tive freedom  from  disease  of  the  mind,  and  instead  of  degenerates,  monstrosi- 
ties and  moulds — living  parasites — an  increasing  burden  to  the  State,  we  should 
see  a  people  strong  in  character,  with  a  purpose  in  life ;  less  crime,  less  need  for 
prisons,  asylums,  sanitariums  and  almshouses. 

An  epidemic  which  would  sweep  away  several  hundred  people  in  a  few 
days  would  create  a  panic;  yet  through  carelessness,  ignorance,  and  criminal 
negligence,  several  thousand  perish  daily  from  causes  within  the  power  of  man 
to  prevent.  As  proof  of  this  a  glance  at  statistics  is  sufficient  to  convince  the 
most  skeptical,  a  review  of  which  space  will  not  admit. 

Many  of  the  most  fatal  diseases  human  flesh  is  heir  to  are  also  known  to 
exist  in  the  lower  animals.  Possibly  we  should  say  "the  wild  and  domestic 
animals,"  for  their  intelligence  is  defined  as  unconscious  reason — instinct — 
yet  their  instinct  in  many  instances  surpasses  the  conscious  reason  of  the  genus 
homo. 

Among  the  most  important  transmissible  diseases  we  will  mention  tuber- 
culosis— very  prevalent  in  cattle,  swine  and  fowls,  differing  somewhat  in  the 
latter;  anthrax,  malignant  pustules  or  wool-sorters'  disease;  glanders,  rabies — 
called  hydrophobia  in  man — diphtheria,  a  disease  most  fatal  among  poultry, 
calves,  sheep,  pigs  and  rabbits — dogs  and  cats  are  also  susceptible.  Many  of 
these  animals— especially  pets— are  capable  of  carrying  the  germ  even  when 
not  actually  affected.  The  mucous  membrane  of  the  nose  and  throat  of  the 
dog  or  cat  furnishes  an  excellent  harbor  for  the  Klebs-Loffler  bacillus.  It  is 
therefore  necessary  to  search  beyond  the  nursery  for  the  origin,  propagation  and 
dissemination  of  these  fatal  maladies. 

The  most  learned  scientists  of  to-day  recognize  comparative  pathology  as 
an  indispensable  branch  of  education ;  essential  to  modem  medical  equipment. 
To  the  medical  philosopher  who  desires  to  see  his  science  stand  on  the  broadest 


ERYSIPELAS:    ITS  ETIOLOGY,  SYIMPTOMS,  ETC.  293 

basis,  is  here  afforded  abundant  opportunity.  By  inoculation  diseases  can  be 
produced,  studied  from  stage  of  inception  to  termination,  or  terminated  at  any 
stage;  thus  aifording  the  most  scientific  pathological  instruction.  It  has 
been  an  occurrence  of  common  observation,  from  the  earliest  times,  that  wide- 
spread pestilence  in  plants  and  in  animals,  have  frequently  either  preceded, 
accompanied  or  followed  closely  on  those  visitations  which  caused  mortality 
and  mourning  in  the  habitation  of  men. 

Biology  and  pathology  are  so  intimately  related  that  comparative  investi- 
gation is  demanded.  When  this  subject  receives  attention  and  is  given  its 
proper  position  in  relation  to  diseases  of  man,  many  problems  will  be  solved 
and  the  definite  and  positive  results  obtained  will  place  human  pathology  upon 
a  broader  and  more  scientific  basis. 

To  physiology,  in  its  most  comprehensive  sense,  and  to  a  knowledge  of  the 
natural  and  normal  development  of  animal  and  vegetable  beings,  we  must  look 
for  future  progress  in  pathology;  while  the  means  and  instruments  which 
advance  physiology  will  simultaneously  advance  our  knowledge  regarding  the 
nature  of  diseases — a  sound  knowledge  of  which  can  alone  enable  us  to  appreciate 
their  causes,  and  arrange  measures  for  the  prevention  of  many  of  them,  based 
on  the  great  truths  of  science. 

It  appears  that  our  most  valuable  discoveries,  the  result  of  the  most 
intricate  and  painstaking  research,  have  to  battle  their  way  through  drastic 
criticism,  and  become  hopelessly  stranded  for  a  time  if  questioned  by  one  whose 
position  only  gives  prestige  to  his  opinion ;  while  the  original  research  worker, 
like  the  beautiful  flower  hidden  away  in  some  quiet  nook,  blooms  unseen.  Why 
is  this  true?  Why  should  years  and  years  elapse,  the  very  summertime  of 
discoveries,  the  golden  opportunity  to  connect  the  missing  links  in  the  chain  of 
etiolog}' — before  any  recognition  is  evidenced?  Jenner  tested  his  discovery 
for  30  years  before  offering  it  to  the  public;  and  yet,  even  to-day,  this  great 
lifesaver  is  being  bitterly  opposed  by  those  who  have  received  the  greatest 
benefit.  Is  the  medical  profession  responsible  for  any  part  pla3^ed  against  con- 
tinuous progress  in  the  field  of  comparative  parasitology?  Would  not  progress 
be  materially  aided  by  the  united  efforts,  or  at  least  not  retarded,  if  allowed 
to  pursue  a  natural  course  free  from  unwarranted  obstacles? 


ERYSIPELAS  ;  ITS  ETIOLOGY,  SYMPTOMS,  COMPLICATIONS,  AND  A 
NEW  AND  SUCCESSFUL  METHOD  OF  EXTERNAL  TREATMENT. 

Bt  LUCIEN  C.  DAVIS,  M.D., 

SOUTH  MELWAUKEE,  WIS. 

In  order  to  make  known  my  new  method  of  treating  this  disease,  I  think 
it  well  to  present  the  subject  in  its  entirety,  so  as  to  establish  a  thorough  under- 
standing of  this  very  troublesome  condition.  Quite  a  number  of  my  own  ideas 
are  radically  different  from  those  of  accepted  authorities,  but  mine,  as  well  as 
theirs,  are  the  result  of  actual  experience,  and  the  facts  here  presented  are 
facts  as  I  have  found  them  in  my  own  extensive  experience. 


294  ERYSIPELAS:    ITS  ETIOLOGY,  SYIMPTOMS,  ETC. 

Definition. — Erysipelas  is  an  acute  contagious  and  infectious  disease, 
manifested  by  a  number  of  different  tj^es  of  inflammation  of  the  skin,  but 
it  is  always  caused  by  the  streptococcus  erysipelatis  seu  pyogenes. 

Etiology. — Erysipelas  is  a  most  widespread  disease,  endemic  in  most  com- 
munities, and  at  times  epidemic.  Here,  most  writers  attribute  epidemics 
to  the  particular  season  of  the  year.  I  think  not,  nor  have  I  found  that  any 
particular  season  has  the  least  to  do  with  its  epidemic  form.  I  have  seen 
epidemics  at  all  seasons  and  have  found  no  particular  cause  in  the  season,  but 
have  decided  that  it  had  simply  become  epidemic  through  its  own  power  of 
contagion.  I  have  seen  one  or  two  instances  in  which  there  were  a  large  nmnber 
of  cases  a  great  distance  apart,  but  unless  they  were  communicated  through  con- 
tagion, I  can  only  attribute  this  state  of  affairs  to  the  ''will  of  the  gods";  I  can 
find  no  other  reason  for  it. 

This  disease  prevails  more  extensively  in  old,  badly  ventilated  dwellings, 
stables,  buildings,  hospitals  and  institutions  in  which  the  sanitary  conditions 
were  defective.  With  the  improved  sanitation  of  recent  years  the  disease  has 
become  less  frequent.  Erysipelas  is  both  contagious  and  inoculable;  but, 
except  under  special  conditions  the  poison  is  not  very  virulent  and  does  not 
seem  to  act  at  any  great  distance.  It  can  be  conveyed  by  a  third  person,  and, 
this  is  the  means  by  which  I  find  an  explanation  for  epidemics,  and,  I  think  is 
a  more  rational  cause  than  any  season  of  the  year  could  possibly  be.  The 
poison  attaches  itself  to  furniture,  bedding  and  the  walls  of  rooms  in  which  the 
patients  have  been  confined. 

The  predisposition  to  the  disease  is  veiy  vsddespread,  but  the  suscepti- 
bility is  more  especially  marked  in  the  case  of  persons  with  wounds  or  abra- 
sions of  the  skin  of  any  character.  Women  of  recent  confinement  or  persons 
who  have  just  undergone  surgical  operations  are  particularly  liable  to  it.  A 
wound  or  abrasion,  however,  is  not  necessary,  and  in  the  so-called  idiopathic 
form,  although  it  may  be  difficult  to  say  that  there  was  not  a  slight  abrasion 
about  the  nose  or  lips,  in  many  cases  there  certainly  is  no  observable  destruc- 
tion of  the  continuity  of  the  skin. 

Any  disease  or  condition  that  tends  to  lower  the  resistive  power  of  the 
individual  will  increase  his  susceptibility  to  this  disease;  chronic  alcoholism 
and  Bright's  disease  are  regarded  by  some  as  special  predisposing  causes.  I  do 
not  agree  with  them  any  more  than  that  these  conditions  lower  the  vitality  of  the 
individual  as  above  referred  to. 

It  is  also  said  that  certain  persons  show  a  special  susceptibility  to  erysipelas, 
and  that  it  may  recur  in  them  repeatedly.  I  do  not  agree  with  this  idea  either, 
any  more  than  that  they  are  persons  of  weak  resistive  power,  and  if  it  recurs,  it 
is  due  to  either  a  new  infection,  this  being  due  to  the  fact  that  they  are  living 
in  the  presence  of  the  infection  in  their  homes,  established  by  their  primary 
attack;  or  if  this  is  not  true,  they  probably  have  some  other  form  of  skin 
disease  closely  resembling  erysipelas,  I  have  had  cases  come  to  me  from  other 
physicians,  who  had  diagnosed  the  disease  as  erysipelas.  But  the  cases  in  view 
had  not  the  slightest  resemblance  to  it.  Family  predisposition  is  also  regarded 
by  some  as  a  potent  factor  in  its  prevalence  in  some  particular  family.     I  also 


ERYSIPELAS:    ITS  ETIOLOGY,  SYMl^TOMS,  ETC.  295 

disagree  with  this  in  fact.  It  may  be  more  prevalent  in  some  families,  but  the 
causes  are  due  to  the  same  things  that  apply  to  individuals,  i.e.,  either  a  diseased 
family,  or  the  result  of  a  primary  establishment  of  the  infection  by  the  first 
case  in  this  family  in  this  particular  dwelling  that  has  never  been  removed ;  and 
habitual  unsanitary  surroundings.  The  specific  cause  is  certainly  due  to  causes 
from  without  and  not  from  within  the  person  or  persons.  It  is  not  at  all  charac- 
teristic of  this  disease  to  harbor  itself  in  a  latent  condition  on  a  fertile  field. 
There  are  certain  symptoms  and  manifestations  that  accompany  its  entrance 
into  the  body;  these  symptoms  in  a  more  or  less  degree  of  severity  accompany 
every  distinct  primary,  secondary  or  subsequent  case.  A  person  cannot  have 
tills  disease  without  these  manifestations  and  vice  versa.  So  that  I  have  con- 
cluded that  every  case  of  erysipelas,  regardless  of  the  number  of  attacks  the 
person  has  had,  is  a  separate  and  distinct  infection — an  entirely  separate  case 
from  any  other  he  may  have  had,  and  has  in  his  own  body  absolutely  no  connec- 
tion whatever  with  any  other  attack  or  case. 

Morbid  Anatomy. — Erysipelas  is  a  simple  inflammation  of  the  skin.  In 
its  uncomplicated  forms  there  is  seen,  post  mortem,  little  else  other  than 
inflammatory  cedema  of  the  skin.  The  cocci  are  found  chiefly  in  the  lymph- 
spaces  and  most  abundantly  in  the  area  of  spreading  inflammation.  In  the 
uninvolved  tissues  beyond  the  inflamed  margin,  they  are  to  be  found  in  the 
lymph-spaces,  and  it  is  here  that  an  active  warfare  goes  on  between  the  leu- 
cocytes and  the  cocci  (phagocytosis).  In  the  extensive  and  virulent  forms  of 
the  disease  there  is  usually  suppuration.  It  is  stated  that  the  inflammation 
may  pass  inward  from  the  scalp  through  the  skull  to  the  meninges. 

The  visceral  complications  of  erysipelas  are  numerous  and  important. 
The  majority  of  them  are  of  a  septic  nature.  Infarcts  occur  in  the  lungs, 
spleen  and  kidneys,  and  there  may  be  the  general  evidence  of  pyremic  infection. 

Some  of  the  worst  cases  of  malignant  endocarditis  are  secondary  to  ery- 
sipelas. Septic  pericarditis  and  pleuritis  also  occur.  Pneumonia  and  acute 
nephritis  are  also  met  with. 

Symptoms. — Erysipelas  of  the  face  and  head  is  the  form  most  commonly 
met  with  in  general  practice.  The  period  of  incubation  varies  in  lengtli  from 
three  to  ten  days. 

The  stage  of  invasion  is  often  marked  by  a  rigor,  and  followed  by  a  rapid 
rise  in  pulse  and  temperature.  When  there  is  a  local  abrasion,  the  spot  is 
slightly  reddened;  but  if  the  disease  is  idiopathic,  there  is  seen  within  a  few 
hours  slight  redness  over  the  bridge  of  the  nose  and  on  the  cheeks.  The  swell- 
ing and  tension  of  the  skin  increases  and  within  twenty-four  hours  the  external 
symptoms  are  well  marked.  Tlie  skin  is  smooth,  tense,  and  oedematous.  It 
looks  red,  feels  hot,  and  the  superficial  layers  of  the  epidermis  may  be  lifted 
as  small  blebs.  The  patient  complains  of  an  unpleasant  feeling  of  tension  in 
the  skin;  the  swelling  rapidly  increases;  and  during  the  second  day  the  eyes 
are  usually  closed.  The  first  affected  parts  gradually  become  pale  and  less 
swollen  as  the  disease  spreads.  When  it  reaches  the  forehead  it  progresses  as  an 
advancing  ridge,  perfectly  well  defined  and  raised;  and  often,  on  palpation, 
hardened  extensions  can  be  felt  beneath  the  skin  which  is  not  yet  reddened. 


296  ERYSIPELAS:    ITS  ETIOLOGY,  SYMPTOMS,  ETC. 

Even  in  a  case  of  moderate  severity,  the  face  is  enormously  swollen,  the  eyes 
are  closed,  the  lips  greatly  cedematous,  the  ears  thickened,  the  scalp  is  swollen, 
and  the  patient's  features  are  quite  unrecognizable.  The  formation  of  blebs  is 
common  on  the  eyelids,  ears  and  forehead;  the  cervical  lymph-glands  are 
swollen,  but  are  usually  masked  in  the  oedema  of  the  neck;  the  temperature 
keeps  high  without  marked  remissions  for  four  or  five  days,  and  defervescence 
takes  place  by  crisis.  The  general  condition  of  the  patient  varies  much  with 
his  previous  health.  In  old  and  debilitated  persons,  or  the  constitutionally 
weak,  depression  from  the  outset  may  be  very  great.  Delirium  is  present,  the 
tongue  becomes  dry,  the  pulse  feeble,  and  there  is  a  marked  tendency  to  death 
from  toxsemia.  In  the  majority  of  cases,  however,  even  with  extensive  lesions, 
the  constitutional  disturbance,  considering  the  height  of  the  fever  range  is  slight. 
The  mucous  membrane  of  the  mouth  and  throat  may  be  swollen  and  reddened. 
The  erysipelatous  inflammation  may  extend  to  the  larynx,  but  the  severe  oedema 
of  this  part  that  is  seen  occasionally  is  commonly  due  to  the  extension  of  the 
inflammation  from  without  inward.  There  are  cases  in  which  the  inflamma- 
tion extends  from  the  face  to  the  neck,  and  over  the  chest,  and  may  gradually 
migrate  or  wander  over  the  greater  part  of  the  body  (Erysipelas  Migrans). 

Small  cutaneous  abscesses  are  common  about  the  cheeks  and  forehead  and 
neck,  and,  beneath  the  scalp  large  collections  of  pus  may  accumulate.  Sup- 
puration seems  to  occur  more  frequently  in  some  epidemics  than  in  others. 

Complications. — Meningitis  is  very  rare.  The  cases  in  which  death  occurs 
with  marked  brain  symptoms  do  not  usually  show  post-morten  meningeal  infec- 
tion.    The  delirium  and  coma  are  due  to  the  fever,  or  to  the  toxaemia. 

Pneumonia  is  an  occasional  complication.  Ulcerative  endocarditis  and 
septicaemia  are  more  common.  Albuminuria  is  almost  constant,  more 
especially  in  the  aged.     True  nephritis  is  occasionally  seen. 

The  diagnosis  rarely  presents  any  difficulty.  The  mode  of  onset,  the 
rapid  rise  of  temperature,  and  the  character  of  the  local  manifestations  are 
distinctive. 

Prognosis. — Healthy  adults  rarely  die.  The  general  mortality  is  small. 
In  the  new-born,  when  the  disease  attacks  the  umbilicus,  it  is  most  always  fatal. 
In  the  aged  and  weak,  erysipelas  is  always  a  serious  affection,  and  death  may 
result  either  from  the  intensity  of  the  fever,  or,  more  commonly,  from  toxaemia. 
The  wandering  or  migratory  erysipelas  which  has  a  more  protracted  course,  may 
cause  death  from  exhaustion. 

Treatment. — For  the  internal  treatment  of  erysipelas,  the  number  of  drugs 
advocated  as  having  a  specific  action  in  this  disease  are  legion;  those  that  do 
have  any  specific  beneficial  action  by  internal  effect  on  the  germ  itself  do  not 
exist ;  at  least  I  have  not  found  it  in  my  experience,  and  I  do  not  believe  that 
anyone  else  can  substantiate  any  such  claims  for  any  internal  medication,  other 
than  the  management  that  I  shall  speak  of.  I  have  found  that  the  internal 
treatment  of  erysipelas  simply  resolves  itself  into  the  simple  plan  of  treating 
any  acute  infection,  accompanied  with  fever,  rigors  and  pain,  viz. :  the  adminis- 
tration of  stimulating  tonic  remedies.  Bowel  asepsis  is  an  important  adjunct 
to  any  plan  of  internal  medication.     Any  one  of  the  suitable  measures  that 


ERYSIPELAS:    ITS  ETIOLOGY,  SYMPTOMS,  ETC.  297 

are  accepted  as  good  for  the  relief  of  pain  and  the  promotion  of  sleep  may  be 
used  as  indicated  in  the  individual  case. 

Complications  must  be  carefully  watclied  for  and  suitable  treatment  insti- 
tuted at  the  earliest  possible  moment.  This  is  doubly  important  in  the  very 
young,  in  the  aged,  and  in  the  more  severe  cases. 

As  the  general  condition  during  a  case  of  erysipelas  is  in  my  opinion 
gauged  by  the  severity  of  the  skin  affection,  its  intensity  and  area,  I  have 
directed  all  my  energies  to  controlling  the  local  focus  of  infection.  By  doing 
this,  and  by  the  method  that  I  present  here,  I  have  a  record  of  nearly  three 
hundred  cases  successfully  treated  from  the  veiy  outset,  and  without  having 
the  pleasure  of  seeing  the  disease  spread  in  the  slightest  from  the  area  it  occu- 
pied when  I  first  saw  the  case.  In  my  opinion  the  severity  of  the  constitutional 
condition  in  this  disease  is  controlled  by  the  intensity,  size  of  area,  and  the 
virulence  of  the  infection,  just  as  much  as  is  in  septicemia.  My  experience 
at  least  has  taught  me  the  truth  of  this  statement.  The  number  of  drugs  and 
measures  for  the  local  treatment  of  erysipelas  are  as  great,  almost,  as  the  number 
of  drugs  that  can  be  spread  on  the  bare  skin.  1  have  tried  them  all,  both  alone 
and  in  combination,  and  until  I  finally  hunted  out  my  own  measure,  I  found  no 
satisfaction  at  all.  True,  some  cases  would  do  nicely,  others  not  quite  so  well, 
and  others  not  at  all.  I  found  that  the  major  portion  of  the  infection  was 
beneath  the  epidermis,  and  that  some  drugs  were  not  absorbed  at  all,  others  only 
slightly,  or  were  too  caustic  or  painful  in  their  action.  While  all  this  experi- 
mentation was  going  on,  trying  to  find  something  that  would  destroy  the 
infection  promptly,  without  any  pain  or  resulting  scars,  the  infection  was  still 
traveling  serenely  on  to  new  fields.  I  have  most  decidedly  overcome  this  by 
the  use  of  the  following  mixture : 

IJ  Acid   carbolic   3  parts. 

Spirits  camphor    6  parts. 

Alcohol    1  part. 

The  amount  of  the  acid  is  large,  it  readily  penetrates  the  entire  skin,  destroys 
the  infection  promptly,  and  leaves  no  scars,  nor  causes  any  pain,  or  very  little 
smarting  for  an  instant.  The  camphor  prevents  the  burning  affect  of  the  acid 
and  counteracts  any  that  may  be  absorbed  into  the  system.  The  alcohol  does 
the  same  thing.  But  a  larger  percentage  of  alcohol  destroys  the  acid  action  too 
greatly.  This  solution  must  be  freely  applied  with  a  cotton  sponge  to  the 
infected  area,  and  fully  an  inch  beyond  the  line  of  demarcation.  In  mild  cases, 
once  a  day  is  often  enough ;  in  the  more  severe  types  two  or  three  times  a  day. 
It  can  be  used  as  often  as  desired  in  any  case  without  the  slightest  fear  of  any 
untoward  result  or  action  of  any  kind.  When  first  applied  it  causes  an  intense 
reddening  of  both  the  healthy  and  diseased  skin;  but  this  is  not  to  be  feared. 
When  the  infection  is  destroyed  and  healing  begins,  and  as  it  advances,  the 
diseased  skin  will  peel  off,  leaving  underneatli  a  perfectly  healthy,  smooth 
normal  skin.  If  the  skin  is  uncomfortably  hot  or  dry,  I  usually,  after  applying 
this  solution,  cover  the  infected  area  with  gauze  wrung  out  of  cold  sterile  salt 
solution.    This  will  be  found  very  soothing  to  a  large  inimbcT  of  these  patients. 


298  PSYCnOLOGY  IN  MODERN  MEDICINE. 

This  method  has  been  perfectly  satisfactory  in  my  practice,  covering 
nearly  three  hundred  cases,  and  not  once  have  I  had  a  single  failure  or  bad 
result,  in  any  case,  at  any  age  from  new-born  babes  to  the  aged. 


THE  CLAIMS  OF  PSYCHOLOGY  AND  ALLIED  BRANCHES  IN  MODERN 

MEDICINE. 

By  CHARLES  B.  HARDIN,  IM.D., 

KANSAS   CITY,  MO. 

Our  aim  in  this  brief  article  shall  be  only  to  embrace  within  its  scope 
generalities  or  general  conceptions  with  reference  to  disease  states  and  by  no 
means  attempting  to  be  statistical  or  specific.  We  hope,  however,  to  be  suffi- 
ciently lucid  and  descriptive  as  to  portray  our  ideas  to  the  reader  along  the 
lines  which  belong  to  the  caption  of  this  production. 

We  shall  contend,  in  the  outset,  that  most  of  the  isms,  false  medical  creeds, 
etc.,  which  have  sprung  into  existence  in  the  past  have  largely  done  so  by 
virtue  of  the  failure  of  the  regular  medical  profession  to  master  the  field  or 
territory  of  its  operations. 

Our  mistakes  have  afforded  opportunity  in  many  instances,  for  the  birth, 
growth  and  development  of  all  forms  of  irrational,  illegitimate  phases  of  prac- 
tice within  the  realm  of  the  healing  art.  Keeping  this  central  idea  and  conten- 
tion in  mind,  will  be  of  advantage  in  grasping  the  idea,  which  in  a  large 
measure  actuated  the  writer  in  preparing  this  article. 

We  are  reminded  that  so  often  (certainly  oftener  than  is  generally  believed) 
error  becomes  the  natural  and  inevitable  product  of  exaggerated  truth.  It 
is  truth  attenuated.  Inductive  and  deductive  philosophy,  as  regards  medical  or 
any  other  study,  carry  you  to  logical  sequences  when  you  remain  in  their 
respective  realms,  yet  an  advance  beyond  their  rightful  confines,  reverses 
conclusions  and  confronts  the  student  with  all  the  possibilities  of  distorted, 
truth. 

In  our  opinion  this  is  greatly  the  result  of  misapplied  and  misunderstood 
medical  thought  of  this  and  preceding  generations. 

This  infliction  of  punishment,  visited  alike  on  patient  and  doctor,  is 
none  the  less  keen  and  poisonous,  nor  is  there  any  comnmtation  of  sentence  by 
virtue  of  intellectual  unpreparedness  upon  the  part  of  the  medical  world,  for 
nature  and  natural  law  become  relentless  task-masters,  and  thus  we  find  in  the 
great  field  of  medical  practice  the  chaff  and  the  tares  amongst  the  golden 
fruitage  of  medical  achievement. 

Inefficiency  in  medicine,  whether  possible  or  not  to  avert,  of  necessity, 
when  recognized  by  the  public,  becomes  the  parent  of  discontent,  dissatisfaction, 
and  at  once  initiates  a  search  in  other  fields  for  relief. 

Pain  and  suffering  are  seeking  for  the  most  speedy  relief,  as  well  as 
anxiety,  fear  and  dread,  and  who  can  censure  this  attempt  by  their  possessors? 
Again,  may  it  be  asked,  who  can  criticise  tbe  profession  of  medicine,  for  we 


PSYCHOLOGY  IN  MODERN  MEDICINE.  299 

believe  its  members,  in  a  large  measure,  have  practiced  as  best  they  could  in 
their  attempt  to  assuage  pain,  avert  and  cure  disease. 

We  are  not  unmindful  that  the  discovery  of  truth  in  medicine  is  a  gradual 
evolution,  it  has  been  a  slow  process,  and  not  yet  can  medicine  and  its  practice 
justly  claim  to  be  scientific.  Yet,  while  this  is  tnae  and  could  not  be  other- 
wise, we  must  expect  the  illegitimate  child  of  quackery,  charlatanism  and  fraud 
to  be  born  and  to  grow  wLilc  we  are  yet  in  the  process  of  development,  and 
aiming  at,  even  if  we  never  achieve,  absolute  proficiency. 

If  the  foregoing  be  time  it  should  serve  as  a  stimulus  to  us  to  gTow  with 
greater  speed.  If  medical  inefficiency  and  error  have  given  birth  to  many  forms 
and  phases  of  quackery  and  illegitimate  claims  to  cure  disease,  medical  efficiency 
and  medical  truth  should  to  that  extent  correct  them. 

We  are  thoroughly  convinced  that  in  our  efforts  to  exterminate  quackeiy 
in  the  legitimate  practice  of  medicine,  that  which  we  have  lost  by  inefficiency 
and  error  in  the  past,  we  can  reclaim  and  redeem  by  knowing  and  practicing 
true  medical  science  when  attained,  in  the  future.  We  further  believe  that 
knowledge,  therefore,  is  to  become  the  most  potent  remedy,  if  not  the  only  one,  in 
the  hands  of  the  medical  profession  with  which  to  defeat  the  false  isms  and 
creeds  with  which  this  age  so  greatly  abounds.  How  long  and  how  often  has  the 
profession  striven  to  eliminate  quackery  and  the  senseless  isms  by  forms  of 
legislation,  and  almost  as  often  failed  in  attempts  to  legislate  virtue  into  these 
pretenders  and  perpetrators  of  false  teaching. 

We  seriously  doubt  the  effectiveness  of  any  means  to  eradicate  and 
eliminate  quackery  adopted  by  the  regular  school  of  medicine  other  than  a 
correction  of  its  o\\ti  errors.  Incorrect  thought  and  practice  within  the  domain 
of  any  system  of  philosophy  renders  it  insecure  and  commensurately  vulnerable 
to  attack  by  spurious  and  opposing  systems. 

Tlie  nebular  hypothesis  of  the  formation  of  our  earth  founded  only  on  a 
theoretical  basis,  naturally  invited  other  hypotheses  and  continued  to  do  so, 
until  the  thought  of  concept  ceased  to  be  a  theory,  and  became  more  or  less 
a  demonstrable  fact. 

False  teaching  of  geology  has  through  the  past  obtained  commensurately 
with  its  lack  of  fixity  of  correct  interpretation. 

When  a  science  or  a  system  of  thought  becomes  a  science,  and  a  demon- 
strable location  is  obtained  in  the  realm  of  thought,  such  is  given  a  fixity,  a 
security  and  ceases,  so  long  as  it  is  thus  recognized,  to  be  molested  by  the 
attack  of  opposing  philosophy. 

Who  is  doing  anything  to-day  to  subvert  our  settled  conception  regarding 
the  law  of  gravitation  so  long  ago  established  by  Newton?  It  is  recognized  as 
a  fixed  principle  in  the  domain  of  scientific  thought,  and  thus  has  ceased  to 
be  a  mere  theory,  and  to-day  securely  rests  undisturbed. 

As  in  the  natural  sciences,  likewise  in  the  great  study  of  medicine,  we  shall 
always  be  disturbed  by  false  teachers  and  teaching,  till  we  achieve  a  fLxity  of 
concept  and  practice  and  a  unity  of  action  as  regards  the  great  principles  of 
truth  underlying  our  profession. 

The  sooner  we  ascertain  and  accept  what  is  true  in  medicine,  the  sooner 


30C  PSYCHOLOGY  IN  MODERN  MEDICINE. 

can  we  hope  for  the  estermination  and  extinction  of  all  forms  of  false  and 
pernicious  medical  teaching,  and  practice  substituting  scientific  for  the  now 
largely  theoretical  aspect  of  medical  thought  affords  us  the  surest  means 
towards  the  accomplishment  of  this  end.  Dowieism,  Eddyism,  the  Emmanuel 
Movement,  etc.,  perhaps  all  possess  a  semblance  of  truth  in  their  claims;  but 
if  so,  it  is  more  than  probable  that  such  was  abstracted  from  the  realm  of 
legitimate  medicine  and  so  attenuated  as  to  have  transformed  sense  into  non- 
sense— truth  into  error. 

There  are  only  two  phases  of  medical  inadequacy  to  which  we  can  briefly 
allude,  viz.,  slo^\Tiess  to  receive  psychological  principles  as  aids  to  the  practice 
of  the  healing  art,  and  a  disinclination  with  many  to  educate  and  enlighten 
the  public. 

Man  is  mind  and  matter;  psychology  and  physiology  inseparably  asso- 
ciated, and  therefore  must  be  inseparably  treated  when  diseased. 

With  many  even  to-day  to  acknowledge  psychic  influence  over  matter, 
smacks  of  effeminacy  and  error.  To  us,  however,  ignorance  in  relation  to  tliis, 
or  reluctance  to  accept  it  has  been  of  telling  influence  towards  inhibiting  prog- 
ress and  afforded  to  a  great  degree  an  opportunity  for  the  advent  of  false 
teaching.  We  have  been  slow  to  take  advantage  of  the  aids  found  in  the 
psychic  precincts. 

Our  tardiness  to  thus  detect  and  utilize  the  hitherto  largely  unused  forces 
of  mind,  manifestly  gave  birth  to  the  so-called  Christian  Science  movement  of 
Mrs.  Eddy.  Tinily  can  it  be  said  in  this  application  that  the  nonsense  of 
Christian  Science  is  a  stolen  truth  attenuated;  error  as  before  said  has  become 
exaggerated  truth. 

The  doctor,  to-day,  who  treats  disease  unaided  by  the  mind  of  his  patient, 
is  largely  bereft  of  medical  fitness  and  should  earn  support  in  some  other 
calling.  Treating  the  sick,  without  (at  least  a  modicum  of)  respect  to  the 
play  and  sway  of  psychology,  is  happily  to-day  largely  history. 

By  whatever  name  you  call  them,  thought,  feeling,  volition  and  the  will 
of  your  patient,  demand  recognition  at  your  hands,  and  none  save  the  failures 
in  medicine,  the  intellectual  myopes,  turn  a  deaf  ear  to  this  appeal.  I  dare 
say  in  many  instances  the  behavior  of  the  doctor  in  the  presence  of  the  sick, 
the  mental  impression  he  makes,  the  confidence  he  inspires,  are  first  in  impor- 
tance in  the  cure.  Truly  the  renaissance  in  medicine  had  its  advent  in  the 
adoption  by  a  large  part  of  the  profession  of  psychological  influence  in  the  treat- 
ment of  disease. 

It  has  been  said  that  error  is  often  exaggerated  truth.  We  ask,  only  for 
sake  of  argument,  what  is  hypnotism  save  an  extension  of  faith,  confidence, 
belief,  trust  reposed  in  the  doctor  by  liis  every  patient?  What  is  the  hope 
and  the  optimism  of  the  so-called  Christian  Science  movement,  save  an  exten- 
sion of  that  which  thrills  the  heart  of  every  patient  on  the  advent  of  his  trusted 
medical  "Adviser"  to  his  presence  ? 

What  is  the  Emmanuel  Movement  save  an  effort,  futile  though  it  proves 
to  be,  to  associate  mind  and  matter  in  the  cure  of  disease?  And  so  with  all 
forms  of  modem  false  morements.    They  have  crept  into  the  precincts  of  our 


PSYCHOLOGY  IN  MODERN  MEDICINE.  301 

honored  territory,  partly  welcomed  and  bidden  by  our  ignorance  and  taken 
from  us  kernels  of  truth,  and  founded  upon  them  a  series  of  false  and  damag- 
ing isms  and  creeds. 

We  think,  not  to  reflect  criticism  however,  that  an  inhibiting  force  to  the 
speedy  recognition  of  this  truth  is  found  in  many  illy-informed  representa- 
tives of  the  surgical  world.  Men  who  practice  the  art  of  surgery,  rather  than 
the  science  and  the  art. 

Ignorant  and  illiterate  members  entering  the  profession  with  merely  a 
wheel  and  crank  idea  of  its  practice,  can  scarcely  hope  to  be  changed.  This 
class,  becoming  teachers  in  medical  colleges,  has  much  to  do  in  framing  the 
mind  of  those  they  purport  to  teach  in  this  mechanical  mould  and  are  surely 
making  of  many  students  "Therapeutic  Nihilists."  In  modem  times  so  often 
do  we  find  in  all  countries  the  prevalence  of  therapeutic  nihilism :  men  in  sur- 
gery who  thus  teach  and  practice  are  ignorant  of  its  grander  half — its  science, 
or  rather  its  approach  to  science. 

Taking  a  tissue  out  of  the  human  body,  the  technic  of  doing  it,  is  surgical 
are ;  the  when  and  the  what  to  thus  extirpate,  become  the  science  of  surgery. 

It  follows  in  logical  sequence  that  a  man  who  says  there  is  little  efficacy 
in  drugs,  would  more  strongly  contend  that  there  is  none  in  the  realm  of 
mental  action  upon  the  part  of  the  afilicted.  So  let  us  move  to  convert  (if 
possible)  these  purely  mechanical  representatives  and  we  shall  go  far  towards 
enthroning  in  medical  practice  mental  influence,  let  it  be  much  or  little. 

We  shall  look  more  hopefully  in  this  direction  in  the  future,  owing  to  a 
more  extended  literary  requisite  or  prerequisite  to  the  study  of  medicine. 

A  thought  or  two  with  reference  to  the  education  of  the  laity.  Many 
excellent  men  in  medical  practice  desire  public  ignorance  and  do  everything 
possible  to  darken  and  mystify  the  path  of  the  layman.  Fearful  as  they  are  of 
an  encroachment  on  sacred  territory,  and  a  mortal  apprehension  of  being  re- 
stricted in  their  practice,  commensurate  with  public  enlightenment.  In  this 
we  are  not  intending  to  instinict  this  class  of  medical  parasites,  for  they  need 
too  much  for  a  short  essay  to  impart,  even  had  we  the  capacity  to  do  so.  In 
one  of  our  local  societies  ten  years  ago  a  gentleman  advocated  educating  the 
public,  particularly  along  the  lines  of  hygiene  and  physiology  and  chemistry, 
and  he  was  severely  ridiculed. 

We  had  not  yet  escaped  from  the  limbo  of  the  purely  mechanical  treatment 
of  diseases;  but  to-day,  thanks  to  scientific  growth,  the  large  majority  of 
medical  men,  certainly  the  educated  part,  gladly  welcome  the  aid  of  mind  in 
its  intimate  and  inseparable  relation  to  matter.  We  shall  not  attempt  to  prove 
by  examples  this  relation,  though  numerous  and  overwhelmingly  convincing. 
By  this  we  mean  the  rightful  use  of  mind — not  the  aspects  as  practiced  by  its 
frenzied  devotees  as  represented  by  Mrs.  Eddy,  Dr.  Wooster,  and  those  who 
practice  the  laying  on  of  hands,  the  intercession  of  prayer,  hypnotism,  etc.  To 
a  limited  degree  these  aids  of  the  mind  have  been  utilized  for  many  years  in 
the  past,  but  education,  scientific  achievement,  development  of  the  profession 
so  conspicuous  in  recent  years,  have  served  to  greatly  add  to  the  legitimate 
forces  of  mind  possessed  by  the  educated  layman.     A  power  of  this  kind  exer- 


302  PSYCHOLOGY  IN  MODERN  MEDICINE. 

cised  by  tlie  modem  physician  linds  such  a  universal  response  and  we  might 
say  demand  upon  the  part  of  the  modem  patient,  as  fully  verifies  to  the  logical 
mind  the  validity  of  the  contention  that  mind  and  mntter  are  inseparably 
associated  in  structure  and  in  function. 

A  moment's  consideration  on  the  side  of  the  patient.  What  effect  would 
enlightenment  in  some  of  the  collateral  branches  of  medicine  have  on  the  gen- 
eral public  ?  The  answer  to  this  query  would  settle  the  matter  of  the  expediency 
or  othenvise  of  using  our  elforts  in  this  direction.  If  a  lajinan  imderstood  the 
possible  dangers  of  diphtheria  attacking  his  child,  with  a  capacity  of  early 
detecting  it,  would  he  invoke  medical  aid  sooner  or  later  by  virtue  of  such 
competency  ? 

If  a  woman  with  a  lump  in  her  breast  suspected  it,  in  its  early  history,  to 
be  cancerous,  and  Icnew  the  dangers  of  surgical  delay,  would  she  sooner  or 
later  invoke  the  aid  of  surgery  ? 

Were  a  young  man  or  woman  competent  to  detect  the  early  evidences  of  a 
pulmonary  tubercular  process,  and  knew  the  dangers  in  its  natural  wake,  would 
he  or  she  the  sooner  or  later  seek  all  security  possible  of  climate,  etc.,  to  arrest 
its  spread? 

As  in  these  few  elementary'  examples,  so  in  the  whole  series  of  diseases 
to  which  we  are  victims.  If  this,  therefore,  be  a  logical  conclusion,  it  would 
make  of  your  patient  an  ally  to  you  in  tlie  attempted  cure  of  his  disability.  In 
our  opinion  the  enlightenment  of  the  pultlic  and  of  your  patient  along  certain 
lines  of  the  allied  sciences  to  the  practice  of  medicine,  as  hygiene,  chemistiy, 
physiology  and  psychology  could  but  redound  to  the  interest  of  the  modern 
physician,  commercially,  morally  and  scientifically. 

We  are  absolutely  convinced  that  the  choosing  of  the  regular  physician  by 
the  public  will  be  more  and  more  fully  secured  as  it  becomes  educated,  thus 
affording  the  masses  an  increasing  capacity  of  differentiation  between  the 
good  and  the  vicious,  of  those  who  purport  to  treat  the  sick.  A  homely 
illustration  comes  to  us,  which  will  well  illustrate  our  position.  Given  a  mixed 
pile  of  oranges,  consisting  of  the  good,  bad  and  indifferent  ones — a  power  or 
capacity  of  differentiation  is  required  in  the  choosing  of  those  that  are  best ;  a 
lack  of  this  would  annul  any  attempt  at  classification.  Just  so  in  the  choosing 
of  a  physician.  The  people  must  possess  this  differentiating  capacity  and  this 
must  be  acquired  and  can  only  be  obtained  as  a  result  of  education.  If  this 
elemental  reasoning  is  not  conclusive  we  cannot  make  it  so.  The  old  and  false 
**dictum"  of  Bamum,  that  people  love  to  be  humbugged  is  in  no  sense  true  and 
has  done  great  harm  in  its  influence.  The  people  do  not  want  to  be  humbugged 
and  it  is  ignorance  on  their  pait  when  they  are,  and  ignorance  on  our  part  in 
that  we  think  so.  Sometimes  the  most  cultured  people  are  the  most  ignorant 
on  medical  lines  and  become  the  most  yielding  victims  to  the  pretenses  of 
quackery. 

Any  sane  man  with  a  pain  wants  to  get  rid  of  it  in  the  most  speedy  and 
effectual  manner. 

In  conclusion,  we  would  urge  on  medical  colleges  to  lay  greater  stress  on 
the  study  of  psychology,  either  by  literary  schools,  imiversities,  etc.,  else  give 


rSYCHOLOGY  IN  JIODERN  ISIEDICINE.  303 

it  rank  in  the  curricula  of  medical  schools  themselves.  Ilitherto  its  study  has 
been  woefully  neglected  and  hence  its  practice  by  physicians  equally  so. 

Your  mind  should  be  bereft  of  the  thought  that  a  recognition  of  mental 
forces  and  an  invoking  of  their  aid  in  medical  practice  is  in  any  way  associated 
with  infinitesimal  dosage  of  drugs,  or  an  admission  of  inadequacy  of  medical 
effort,  or  that  it  is  in  any  Vv-ay  allied  to  religious  prayer,  laying  on  of  hands, 
faith  cures,  hypnotism,  the  social  doctrine,  Eddyism,  the  Emmanuel  Movement, 
or  any  of  the  other  claims  of  fancied  delusions,  but  rather  an  evidence  of 
thought  growth,  development  and  a  proper  conception  of  man  as  he  stands 
related  to  his  doctor. 

Whenever  the  regular  profession  of  medicine  impresses  a  responsive, 
educated  public  that  it  has  the  best  methods  of  alleviating  suffering,  curing 
diseases,  and  that  primarily,  it  is  after  this  result,  rather  than  the  dollar  in 
the  pocket  of  its  patients,  then  the  true  renaissance  of  medical  ambition  will  be 
upon  us  and  it  will  require  no  force,  no  coercion,  no  legal  enactment  (except 
to  restrain  vice),  no  fighting  of  opposing  forces  to  obtain  public  patronage. 

In  our  opinion,  therefore,  there  should  be  a  more  intimate  knowledge  of 
psychology'  and  a  more  thorough  practice  of  it,  along  sensible  lines,  entirely 
bereft  of  insane  interpretations  of  it ;  a  more  thoroughly  educated  public  along 
the  lines  of  the  allied  sciences  to  medicine,  as  chemistry,  physiology  and  hygiene; 
and  the  physician  to  practice  primarily  the  science  of  medicine,  instead  of  the 
science  of  money-making — then  vdll  our  contention  of  being  the  best  be  reason- 
able, and  our  fight  for  it  more  fully  assured  of  victory. 

No,  we  cannot  explain  any  of  the  phenomena  mirrored  by  man  in  the  living 
state,  purely  on  physical  territory,  and  these  physical  processes  dissociated  from 
mentality  would  be  as  mystifying  to  comprehend  as  the  occult  springs  of  mind 
itself.  The  multiplied  millions  of  cells  of  man's  physical  organism  must  be 
viewed  as  a  great  sensitized  plate,  impressionable  and  impressed,  though 
mysteriously  so,  to  and  by  every  wave  and  ripple  of  psychic  power  and  energy. 
This  is  true  in  health — doubly  so  in  disease.  Can  you  tell  us  how  food 
nourishes  and  how  waste  is  separated  and  thrown  off  by  the  emunctory  organs  ? 
You  only  know  a  few  things  about  this  largely  hidden  course  food  pursues  in  the 
economy  subjected  to  processes  of  selection  and  rejection,  and  half  of  pretended 
knowledge  is  uncertain  theoiy.  So  in  eveiy  act  and  movement  of  living  struc- 
ture, most  all  is  mysterious.  So  do  not  disclaim  the  connection  and  relation  of 
mind  and  matter  in  the  treatment  of  disease,  because  such  is  to  you  inexplicable, 
mysterious.  One  is  very  apt  to  negative  things  he  does  not  understand. 
Particularly  should  this  be  borne  in  mind  as  regards  the  influence  of  mind 
over  matter  and  when  practically  nothing  in  man,  no  process  of  construction 
and  of  destruction  of  his  tissues,  can  be  accounted  for  or  explained  solely  on  a 
material  basis. 

You  speak  of  the  state  of  idiocy,  and  in  relating  its  history,  always  speak  of 
this  mental  deficiency  as  having  an  important  bearing  on  the  case  and  the 
destiny  of  the  case.  This  is  a  practical  admissinn  that  the  mental  deficiency 
in  point  in  a  measure  dotcrminos  the  destiny  of  the  disease,  at  least  an  influence 
is  thus  exercised — just  so  in  all  phases  of  human  life,  we  ever  speak  of  and 
treat  man  in  the  associated  sense  of  mind  and  matter. 


304  ACUTE  RETENTION  OF  URINE— BERIBERI. 

In  fact,  mind  in  essence  is  the  man;  the  psychology  of  man  is  the  man 
himself.  He  manifests  himself  in  physiology  and  pathology.  .  Mind  governs, 
guides  as  master,  the  machine  in  which  it  dwells.  The  exhibition  of  the  phrases 
of  mental  thought  and  action  are  pictured  to  us  as  phenomena  by  the  physical 
organism.  Man's  physiology  and  his  pathology  in  a  physical  sense,  become 
the  servants  of  his  mind  and  serve  only  as  mediimis  of  expression.  In  the 
repair,  therefore,  of  the  machine  when  broken,  always  consult  the  hand  that  is 
to  use  it  and  control  it.  Let  us  conceive  that  in  the  ultimate  analysis,  the 
eye  does  not  see,  the  tongue  does  not  taste,  the  finger  does  not  touch,  nor  does 
the  ear  hear.  These  different  organs  serve  only  as  reporters  and  only  convey 
impressions  to  the  mind  or  the  realm  of  consciousness,  whatever  and  wherever 
that  is. 

Were  it  purely  physical,  a  drunken  man  or  an  insane  one  would  be  respon- 
sive to  all  these  sense  stimuli  or  impressions. 

So  let  us  always  recognize  psychology  in  the  treatment  of  disease  as  an  indis- 
pensable aid  in  our  efforts  to  restore  health. 

A  unicist  would  say  that  mind  is  a  product  of  matter.  This  is  yet  the 
theory  of  the  materialist.  We  can't  conceive  the  possibility  of  this  any  more 
than  we  could  argue  that  the  house  in  which  you  dwell  is  you.  It  is  unthink- 
able. It  is  no  more  reasonable  to  contend  that  a  physical  cell  could,  limited  by 
the  properties  of  matter,  cohesion,  adhesion,  extension,  ponderability,  etc., 
give  birth  to  mental  properties  such  as  thought,  feeling,  will,  volition,  etc.,  as 
that  the  house  could,  in  which  you  live.  We  had  as  soon  think  that  an  apple 
tree  could  bear  and  produce  these  psychical  elements  as  to  think  a  cell  in  the 
brain  could  do  so. 

To  us  it  is  much  more  reasonable  to  reverse  this  and  contend  that  the  body 
is  the  product  of  the  mind  (though  we  do  not  claim  this  to  be  so).  We  had 
rather  conclude  (on  the  plane  of  logic,  that  a  stream  can  rise  no  higher  than 
its  source),  that  a  superior  could  produce  an  inferior,  rather  than  that  an 
inferior  could  produce  a  superior. 

We  only  cite  these  to  more  strongly  fortify  our  position — that  the  most 
successful  care  of  the  sick  cannot  be  achieved  by  a  divorcement  of  man's 
psychology  and  his  physiopathology. 


ACUTE  RETENTION  OF  URINE  FROM  IMPACTION  OF  A  PHOSPHATIC 
CALCULUS  IN  THE  PENILE  URETHRA;  AND  A  FATAL 
CASE  OF  BERIBERL* 

By  Captain  FRANK  T.  WOODBURY,  M.C.,  U.  S.  Army. 

ACUTE  RETENTION  OF  URINE  FROM   IMPACTION  OF  A  PHOSPHATIC   CALCULUS  IN 

THE  PENILE  URETHRA. 

While  stationed  at  Panay,  Philippine  Islands,  the  following  notes  were 
made,  one  of  an  unusual  operative  case,  and  the  other  a  medical  case,  which 
seem  worthy  of  publication.     A.  M.,  a  Visayan  of  the  Island  of  Guimaras, 


Publication  approved  by  Surgeon-general's  OflSce,  Washington,  D.  C. 


ACUTE  RETENTION  OF  URINE— BERIBERI.  305 

aged  35,  presented  himself  for  treatment  about  4.00  p.  m.  on  October  27,  1907. 
He  complained  of  having  had  difficulty  of  urination,  intennittent  in  type,  for 
several  months.  During  the  previous  week  it  had  been  almost  impossible  to 
pass  urine,  except  by  straining  and  he  was  suffering  continually  with  an  agony 
of  desire  to  empty  his  bladder. 

At  the  time  of  the  onset  of  this  urgent  symptom  he  noticed  a  small  lump 
in  the  perineum  which  gradually  passed  forward  until  within  two  inches  and 
a  half  of  the  meatus  where  it  could  then  be  readily  felt.  It  was  apparently 
imbedded  tightly  in  the  urethra. 

Through  a  misunderstanding  he  went  to  his  home  to  get  some  clean  cloth- 
ing and  did  not  return  to  the  Hospital  until  the  following  morning  when  he 
appeared  very  weak  with  cold  clammy  skin,  a  rapid  heart  and  a  facial  expres- 
sion of  much  agony. 

He  was  immediately  placed  upon  the  operating  table  and  the  urethra  was 
flooded  with  normal  salt  solution,  then  with  4  per  cent,  cocaine  and  finally  with 
sterilized  olive  oil.  An  attempt  to  dilate  the  urethra  with  sounds  and  to  deliver 
the  calculus  by  external  expression  failed;  as  did  also  attempts  to  withdraw 
or  crush  it  by  means  of  long  armed  nasal  forceps  through  tlie  urethra. 

The  patient  was  given  ether,  and  a  median  external  urethrotomy  was  done 
over  the  foreign  body.  The  stone  was  very  irregular  and  jagged,  and  was 
firmly  imbedded  in  the  urethral  mucosa  in  an  adventitious  pouch,  from  which 
it  was  removed  piece-meal  though  only  by  much  force  and  manipulation. 
Several  smaller  concretions  were  also  found  imbedded  and  were  removed. 

The  wound  was  washed  with  hot  normal  salt  solution,  a  metal  catheter 
was  then  passed  through  the  meatus  into  the  bladder,  which  had  emptied  itself 
through  the  wound.  Using  the  catheter  as  a  sound,  it  was  impossible  to  detect 
other  calculi  in  the  bladder.  The  urethra  was  closed  over  the  catheter  by  two 
fine  silk  sutures  prepared  in  tincture  of  iodine.  The  outside  wound,  which 
passed  partly  through  the  raphe  of  the  scrotimi,  was  packed  with  gauze  soaked 
in  alcohol,  and  a  large  gauze-cotton  pad  applied. 

The  patient  made  a  steady  recovery;  the  metal  catheter  was  replaced  by 
a  rubber  one  November  10th  and  the  patient  discharged  November  23d. 

Hexamenthylenamine  (Urotropin)  650  milligrams  was  administered  four 
times  a  day  for  a  week,  a  light  diet  maintained,  and  magnesium  sulphate  given 
to  keep  the  bowels  open.  The  temperature  was  very  irregular,  between  normal 
and  101°  F.  for  three  days  when  it  became  finally  normal.  The  urine  escaped 
in  part  through  the  wound  until  the  eighth  day  and  the  presence  of  the 
catheter  caused  at  first  frequent  emptying  of  the  bladder.  The  fragments  of 
the  stone  were  very  sharp,  irregular  and  phosphatic  in  character;  its  full  size 
when  in  the  urethra  was  about  that  of  a  rery  small  hazelnut. 

REPORT  OF  A  CASE  OP  ACUTE  PERNICIOUS  BERIBERI  IN  A  WHITE  MAN. 

W.  B.,  a  sergeant  of  Infantry.    Age  41  %  2  years  was  admitted  to  the  Camp 

Hospital,  October  8,  1907.    His  family  history  was  negative.    He  had  had  the 

usual  diseases  of  childhood  and  was  addicted  to  the  steady  use  of  alcoholic 

stimulants,  though  rarely  intoxicated.     He  had  suffered  from  an  annoying  alco- 

6 


306  ACUTE  RETENTION  0¥  URINE  -BERIBERI. 

holic  gastritis  for  a  number  of  years  with  poor  and  precarious  appetite  and  more 
or  less  discomfort  in  the  stomach  after  eating. 

His  present  attack  apparently  began  about  Oct.  1st  with  entire  loss  of 
appetite  and  acute  severe  pains  in  the  epigastrium,  the  bowels  being  very 
irregular. 

The  patient  when  admitted  to  the  hospital  complained  of  general  muscular 
weakness  and  bodily  depression  with  no  appetite,  pains  in  the  epigastrium 
extending  downward  as  far  as  the  navel,  some  vomiting  of  a  bilious,  very  sour 
smelling  liquid  in  small  quantities,  and  irregular  bowel  movements. 

Physical  Signs. — There  was  general  muscular  weakness  particularly  in  the 
legs,  locomotion  was  uncertain  and  swaying;  gait  somewhat  spastic,  the  legs 
soon  became  tired  after  a  walk  up  the  ward.  The  grip  in  both  hands  and  the 
biceps  resistance  were  good. 

The  station  was  swajdng,  knee-jerks  lessened  vath  no  incoordination  of  leg 
movement  when  the  patient  lay  down.  >To  loss  of  sensation,  and  no  area  of 
hyperesthesia  of  the  surface  of  the  body  could  be  demonstrated.  The  patient 
seemed  apathetic  and  in  a  dream  state;  but  there  was  no  other  mental  dis- 
turbance. The  mind  was  clear  and  questions  were  answered  promptly  and 
intelligently.    There  was  no  paralysis  of  the  organs  of  speech  or  special  senses. 

The  temperature  and  respiration  were  normal;  pulse  110,  irregular  and 
weak;  but  no  organic  lesion  of  the  heart  was  apparent. 

The  patient  was  put  to  bed  and  given  a  course  of  calomel  and  soda  bicar- 
bonate. The  bowels  seemed  obstinately  constipated  and  enemata  of  soap-suds 
were  needed  to  effect  a  movement.  Triple  elixir  of  iron,  quinine  and  strj^ch- 
nine  was  administered  as  a  tonic. 

Examination  of  the  blood  showed  poljrDeuclear-leucocytes,  66.87  per  cent. ; 
lymphocytes,  26.25  per  cent.;  myelocytes,  3.18  per  cent.;  eosinophiles,  3.8  per 
cent. ;  total  leucocytosis,  6,000. 

No  malarial  parasites  were  found.  The  urine  and  feces  were  apparently 
nonnal.  The  patient  was  tried  on  various  diets  none  of  which  proved  especially 
suitable.  Bicarbonate  of  soda,  650  mg.,  was  given  every  four  hours.  The 
pain  in  the  stomach  abated  in  severity  and  on  the  19th  the  stomach  was  washed 
out.  The  contents  were  without  interest.  The  patient  continued  to  grow 
weaker  and  more  apathetic.  The  knee-jerks  disappeared  about  the  25th  and 
internal  ophthalmoplegia,  myosis  and  lack  of  response  to  light  and  accommoda- 
tion appeared.  The  patient  could  not  read  ordinary  or  large  sized  newspaper 
print  without  a  mag-nifying  glass.  Iodide  of  mercury,  16  mg.,  was  given  t.  i.  d. 
Oct.  27th  and  replaced  by  Lugols'  solution  650  mg.  Oct.  28th.  The  patient  could 
not  stand  alone  on  27th  and  seemed  very  apathetic,  depressed  and  weak.  There 
was  some  emaciation  though  not  marked.  The  grip  in  both  hands  was  good 
but  both  legs  were  completely  paralyzed.  The  mind  remained  clear,  there  were 
no  anassthesias  or  h5T)era3sthesias  of  the  skin.  The  special  senses  were  unim- 
paired except  for  loss  of  accommodation  in  both  eyes.  The  heart  remained  rapid 
and  irregular  110-120.  There  was  much  tenderness  on  pressure  in  the  epigas- 
trium. All  the  other  organs  were  apparently  normal.  Heart  stimulants  were 
administered. 


VIVISECTION  AND  ITS  RESULTS.  307 

The  patient  died  at  1.10  p.  m.  Oct.  29,  1907  of  acute  heart  failure;  diag- 
nosis— acute  pernicious  beriberi. 

Findings  at  Autopsy. — Left  lobe  of  the  liver,  rudimentary;  stomach, 
enlarged,  mucosa  somewhat  inflamed ;  transverse  colon,  undeveloped  with  lumen 
admitting  two  fingers  only. 

Brain,  thoracic  and  abdominal  organs,  save  as  above  noted,  apparently 
normal. 

In  the  absence  of  an  epidemic  this  case  was  extremely  puzzling  and  it  was 
not  until  the  autopsy  that  the  diagnosis  seemed  at  all  clear. 

The  source  of  this  case  can  be  traced  to  the  native  village,  of  which  this 
soldier  was  a  m.ore  or  less  constant  visitor,  which  was  in  the  vicinity  of  the  post 
and  where  chronic  tropical  diseases  are  at  all  times  endemic  and  latent  in  the 
majority  of  the  native  inhabitants. 


Editorial 


VIVISECTION  AND  ITS  RESULTS. 

At  the  present  time  medicine  is  not  merely  an  art:  it  is  no  longer  prac- 
ticed by  simple  rules  and  suppositions.  It  has  become  an  exact  science  in 
many  of  its  branches,  and  definite  knowledge  has  supplanted  empirical  facts 
and  fancies.  The  means  by  which  this  change  has  been  accomplished  has 
been  mainly  through  vivisection;  it  is  by  experiment  alone  that  we  are  able 
to  distinguish  betv/een  fact  and  fancy,  between  ideas  and  suggestions  that 
arise  in  the  minds  of  the  investigators  and  the  realities  in  the  apparent  physio- 
logic functions.  It  is  therefore  essential  that  vivisection  is  necessary  in  the 
teaching  of  the  medical  sciences.  "We  could  not  understand  the  circulation  of 
the  blood  if  our  only  resource  was  the  study  of  dead  bodies.  We  could  never 
determine  the  functions  or  office  of  organs  if  we  resorted  to  the  use  of  dead 
bodies  alone. 

The  principal  object  of  science  is  to  be  useful  to  mankind,  and  when 
we  know  the  laws  of  nature  we  can  then  alleviate  the  miseries  of  our  existence. 
The  innumerable  and  mysterious  facts  of  the  medium  in  which  we  live  are 
subject  to  fixed  laws  that  are  only  imperfectly  known,  and  our  efforts  should 
be  to  elucidate  these  laws  by  investigating  the  grand  laws  of  nature.  Prior 
to  vivisection  supposition  had  been  the  basis  of  medicine.  These  suppositions 
had  constantly  misled  men  as  to  the  cause,  nature,  and  treatment  of  disease, 
and  so  long  as  they  were  no  longer  subjected  to  the  test  of  experiment,  one 
supposition  succeeded  another  only  to  be  itself  replaced  by  another  no  less 
delusive  and  fanciful  than  the  first.  To  tliis  is  attributed  the  tardiness  in  the 
progress  of  medicine.  The  modem  advance  of  our  medical  knowledge  has 
been  mainly  due  to  vivisection,  and  thus  is  reaching  a  point  of  exactitude 
which,  as  time  goes  on,  will  make  the  grandest  and  most  beneficial  of  all 
sciences. 


308  VIVISECTION  AND  ITS  RESULTS. 

The  principal  object  in  treating  disease  is  not  sjonptomatic  treatment, 
but  the  treatment  of  the  cause.    Our  chief  aim  is  to  localize  the  cause  and 
seat  of  the  disease;   also  the  action  of  the  remedies  to  be  employed,  and  in 
this  manner  we  are  able  to  treat  the  disease  with  certainty  and  not  on  sup- 
position as  was  prior  to  vivisection.    If  it  were  in  our  power  to  localize  the 
cause  and  seat  of  the  diseases  with  certainty,  and  know  definitely  the  action 
of  our  remedies,  we  would  possess  a  power  to  arrest  and  prevent  disease  which 
would  render  death  by  old  age  the  usual,  instead  of,  as  at  present,  the  exceptional 
premature  termination  of  the  many  human  lives.     Our  exact  knowledge  is 
obtained  by  experiment— that  is,  by  experiment  upon  animals.    The  anatom- 
ical examination  of  organs  teaches  us  very  little  concerning  their  function. 
How  could  we  understand  the  circulation  of  the  blood  if  our  only  resource  was 
the  study  of  the  heart,  arteries,  and  veins?    What  idea  would  be  conveyed 
to  our  minds  concerning  the  functions  of  the  brain  from  a  mere  description 
of  the  brain  ?    We  could  never  determine  the  function  or  office  of  the  various 
lobes  and  convolutions  just  by  noting  the  complexity  of  their  structure.    It 
is  by  these  experiments  upon  the  living  animals  that  we  are  studying  and 
working  out  the  nature  of  the  morbid  processes  which  occur  in  the  various  dis- 
eases and  the  conditions  which  give  rise  to  them.    For  example,  we  study  a 
disease  by  inoculating  the  microorganism  from  the  afflicted  and  unfortunate 
individual  to  a  few  animals,  and  in  this  manner  we  are  enabled  to  preserve 
the  lives  of  thousands  of  human  beings  and  thus  avert  the  anguish  which  their 
untimely  death  would  cause  to  their  relatives.    In  order  to  prevent  the  suf- 
fering, unmerciful  ravages  of  disease,  and  death  of  human  beings,  it  is  abso- 
lutely necessary  to  sacrifice  a  few  animals  and  not  allow  ourselves  for  the 
momentary  gratification  of  our  human  feelings  which  would  lead  us  to  avoid 
the  sacrifice  of  the  various  experimental  animals,  and  thus  neglect  the  acquire- 
ment of  knowledge  which  would  be  productive  of  lasting  widespread  benefit  to 
mankind.      Without   experiments   and   vivisection   we   can   have   no   means 
whereby  we  may  prevent  and  cure  disease.    It  is  only  by  an  accurate  knowl- 
edge of  the  cause  of  the  disease  that  we  can  hope  to  prevent  its  occurrence, 
and  it  is  only  by  an  accurate  knowledge  of  its  nature  and  seat  and  of  the  action 
of  the  drugs  that  we  can  hope  to  use  it  when  it  is  present.    The  science  of 
medicine  can  only  be  advanced  by  the  performance  of  experiments— that  is, 
by  vivisection,  and  the  only  question  to  be  decided  is,  Are  these  experiments 
to  be  performed  upon  animals  or  upon  himian  beings  ?    The  idea  of  inflicting 
pain  upon  innocent  animals  is  naturally  repugnant  to  every  well  regulated 
mind;  but,  however,  the  thought  that  they  are  working  out  and  revealing  the 
mysteries  that  cause  disease  ought  to  be  one  of  the  greatest  pleasures  that 
tender-hearted  and  sensitive  persons  can  experience.    However,  if  we  exercise 
pity  and  compassion  for  these  few  animals,  we  would  pay  dearly  for  it  by 
allowing  a  much  greater  amount  of  suffering  to  be  wrought  upon  thousands  of 
individuals  due  to  our  lack  of  knowledge. 

An  anti-vivisectionist  exhibition  took  place  in  this  city  a  few  days  ago, 
where  they  portrayed  vivid  pictures  and  sliowed  the  laity  the  hard  and  cruel- 
hearted  (  ?)  investigators  inflicting  untold  suffering  upon  experimental  animals 


ALLOPLASTIC  SUBSTITUTION  OF  THE  DURA.  309 

in  a  physiological  laborator}''.  The  laity  is  thus  misled  by  these  graphic  descrip- 
tions and  by  the  literature  distributed  by  those  in  attendance.  Many  have 
joined  in  the  agitation  and  consequent  legislation  against  vivisection.  They  are 
not  aware  that  the  pain  inflicted  in  a  vivisection  experiment,  except  in  very  rare 
instances,  is  done  under  painless  conditions,  and  that  the  pain  is  far  exceeded 
both  in  intensity  and  duration  by  the  suffering  of  many  human  beings  in  the 
course  of  a  mortal  disease.  They  seem  to  be  ignorant  of  the  fact  that  this  is 
done  for  the  development  of  the  medical  science  and  their  own  personal  welfare. 

We  physicians  are  inspired  by  humane  sentiments,  by  love  not  only  for 
the  present  generation,  but  also  for  the  future  as  well.  The  laity  take  little 
account  and  consideration  of  the  martyrs  to  our  science.  They  do  not  con- 
sider the  tedious  weeks  and  months  spent  in  the  nauseating  dissecting  rooms, 
in  hospitals  surrounded  by  moaning  and  shrieking  individuals.  "We  love  the 
science  and  the  grand  results  that  it  is  destined  to  give,  and  we  hope  that  the 
time  will  come  when  our  brethren  will  be  relieved  of  a  great  deal  of  suffeiing 
which  we  are  unable  to  relieve  at  the  present  time.  If  we  look  back  at  some 
of  the  achievements  of  vivisection  we  find  that  to  vivisection  is  due  the  dis- 
covery of  the  circulation  of  the  blood  upon  which  all  surgery  and  medicine 
rest.  In  almost  all  the  recent  improvements  in  the  various  surgical  operations 
nearly  every  step  has  been  dependent  upon  the  experience  gained  in  experi- 
ments upon  animals.  Why  then  should  so  much  account  be  taken  of  a  few 
animals  in  the  face  of  the  thousands  of  lives  that  we  have  saved  from  suffer- 
ing and  death?  To  interdict  this  practice  of  vivisection  would  be  to  slay  the 
science  of  physiology  and  thus  retard  the  progress  of  the  medical  science. 

Every  winter  hundreds  of  animals  die  of  cold,  hunger,  and  as  a  result 
of  disease.  Many  housewives,  in  order  to  rid  their  houses  of  the  rats  and  mice, 
poison  them  with  phosphorus  or  arsenic,  and  in  this  manner  bring  untold 
misery  and  more  suffering  than  these  animals  would  suffer  at  the  hands  of  a 
vivisectionist.  Then  why  should  our  earnest  investigators  be  unjustly  abused 
in  their  endeavors  to  gain  knowledge  for  the  purpose  of  alleviating  pain  and 
curing  disease?  We  can  readily  see  that  experiments  are  the  necessary  in- 
struments of  research  in  order  that  we  may  bring  our  ideas  and  suppositions 
in  accordance  with  facts  and  do  away  with  hypotheses. 


Jlateria  Jlcdicci  and  Therapeutics 


ALLOPlASTic  SUBSTITUTION  OF  THE  mended  by  Morris,  and  the  author  per- 

^^^^-  formed    experiments    in    this    direction 

Dr.  Hanel  reports  the  results  of  the  upon  dogs;   making  use  of  the  so-called 

employment  of  animal  membranes  as  a  fiph-bladder  condoms,  which  are  prepared 

substitute   for  the   dura.     The  employ-  from  sheep's  intestine  and  treated  accord- 

ment  of  animal  membranes  was  rccom-  ing  to  Hofmeister's  method  of  catgut- 


310 


AURAL  DIAGNOSIS. 


sterilization.  The  experiments  served  to 
show  that  the  membranes  underwent 
softening  as  soon  as  three  days  later.  At 
the  end  of  seven  days,  a  cellular  tissue, 
rich  in  blood-vessels  could  be  seen  to 
enter  the  softened  membrane  by  way  of 
the  adjacent  dura  and  neighboring 
muscle-tissue.  No  substitution  was  noted 
proceeding  from  the  pia,  when  this  had 
not  been  injured  during  the  operation. 
In  the  further  course,  the  entire  mem- 
brane became  replaced  by  granulation 
tissue,  rapidly  followed  by  transforma- 
tion into  permanent  connective  tissue. 
The  membrane  again  becomes  consider- 
ably diminished  in  thickness.  It  results 
that  the  condom-membrane  heals  in,  and, 
while  it  undergoes  absorption  itself, 
yields  the  basis  for  the  formation  of  a 
dura-like  membrane.  At  any  rate,  one 
or  two  months  later  there  existed  a  mem- 
brane solidly  adherent  to  the  dura,  and 
presenting  no  adhesions  of  any  kind  with 
the  brain.  (Centralblatt  f.  Chirurgie, 
No.  5,  1909.) 


AITSAI  DIAGNOSIS. 
G.  E.  Shambaugh,  Chicago,  describes 
the  anatomy  and  physiology  of  the 
auricular  apparatus  and  the  methods  of 
examining  it  for  diagnostic  purposes. 
He  la3's  down  the  following  propositions 
as  established :  "First,  if  the  semicircular 
canals  are  normal  and  the  ear  is  syringed 
with  cold  water,  vertigo  will  result  and 
there  will  be  set  up  a  nystagmus  increased 
by  directing  the  eyes  toward  the  opposite 
side.  If  the  ear  is  syringed  with  warm 
water  the  same  symptoms  will  occur,  but 
the  nystagmus  will  be  toward  the  same 
side.  Second,  should  tliere  exist  an 
irritation  of  the  endings  of  the  vestibular 
nerve  in  the  lab3Tinth,  such  as  may  be 
occasioned  by  a  circumscribed  suppura- 
tion in  the  labyrinth,  there  will  be 
spontaneous  nystagmus  directed  toward 


the  same  side.     Syringing  the  ear  with 
cold  water  will  produce  a  positive  re- 
action.    Third,  if  there  occurs  a  sudden 
destruction  of  endings  of  the  vestibular 
nerve,  such  as  would  be  occasioned  by  a 
diffuse    suppuration    in    the    labyrinth, 
there    will    be    set    up    a    spontaneous 
nystagmus  directed  tov/ard  the  opposite 
side,  but  lasting  only  from  a  few  days  to 
several  weeks.     Tliis  nystagmus  has  its 
origin  in  the   opposite  normal  ear. 
Syringing  the  affected  ear  with  hot  and 
cold  water  produces  no  response.    Fourth, 
in  case  of  long-standing  destruction  of 
the  nerve  endings  in  the  vestibular  nerve, 
such  as  occurs  in  chronic  diffuse  laby- 
rinth suppuration,  there  will  be  no  spon- 
taneous nystagmus  and  no  reaction  can 
be  obtained  by  syringing  the  ear  with  hot 
or  cold  water.     Fifth,  in  case  of  cere- 
bellar disease,  such  as  cerebellar  tumor, 
cerebellar  abscess  or  a  meningitis  in  this 
locality,  there  will  occur  a  spontaneous 
nystagmus  directed  toward  the  aifected 
side."     Hence  with  pronounced  rotating 
nystagmus   and  normal  tympanum   the 
presence  of  a  cerebellar  tumor  may  be 
suspected.     On  the  other  hand,  the  rotat- 
ing nystagmus  in  a  case  of  suppurative 
otitis  media  without  fever  but  with  severe 
deafness    and    nystagmus    toward    the 
affected  side,  while  the  syringing  with 
cold  water  producing  no  response  sug- 
gests a  cerebellar  abscess.     The  complete 
destruction  of  the  hearing  in  the  affected 
ear  would  indicate  a  probable  diffuse  sup- 
puration of  the  labyrinth.     The  failure 
to    get    caloric    response    on    syringing 
points  to  destruction  of  end  organs  in 
the  semicircular  canals.     The  only  spon- 
taneous nystagmus  caused  by  this  would 
be   directed    toward   the    opposite   side. 
The  lack  of  rise  of  temperature  in  most 
cases  would  exclude  a  meningitis,  while 
a    cerebellar    abscess    pressing    on    the 
vestiliular  nerve  could  produce  a  spon- 


INTOXICATION:    CHLOROFORM  TREATMENT. 


lODIPIN. 


311 


taneous  rotating  nystagmus  which  would 
be  increased  by  directing  the  eyes  to  the 
opposite  side.  (Journal  of  the  American 
Medical  Association,  April  3.) 


INTOXICATION  WITH  CHLOROFOIIM, 
TREATMENT  OF. 

Dr.  K.  Wirth  reports  two  cases  of 
intoxication  with  chloroform.  His  first 
patient  was  a  young  man  who  drank  150 
Gm.  (5  ounces)  of  pure  chloroform  with 
suicidal  intent.  The  patient  died  in 
twenty-two  hours  without  recovering  con- 
sciousness notwithstanding  rinsing  of  the 
stomach  with  water  and  milk,  saline  in- 
fusion, etc.  The  fact  that  chloroform 
does  not  dissolve  readily  in  water  and 
sinks  to  the  bottom,  suggested  that  better 
results  might  be  obtained  by  rinsing  the 
stomach  with  oil,  and  he  soon  had 
occasion  to  verify  this  assumption.  A 
man  of  43  drank  from  80  to  90  Gm.  of 
chloroform  as  a  cure  for  sleeplessness, 
and  Wirth  rinsed  out  the  stomach  with 
warm  sesame  oil,  as  this  was  first  at  hand, 
and  then  rinsed  with  olive  oil  until  there 
was  no  odor  of  chloroform  in  the  stomach 
content.  He  thus  used  up  7,000  c.c.  of 
oil,  the  lavage  continued  for  one  and  a 
half  hours.  On  account  of  asphyxia, 
artificial  respiration  had  to  be  done  for  a 
time,  interrupting  the  lavage.  Venesec- 
tion, withdrawing  300  c.c.  of  blood  was 
followed  by  saline  infusion,  and  in  24 
hours  the  patient  was  himself  again  ex- 
cept for  a  slight  headache.  He  did  not 
seem  to  suffer  from  the  usual  chloroform 
irritation  of  the  digestive  tract.  The 
favorable  termination  in  this  case  is  un- 
doubtedly to  be  ascribed,  Wirth  declares, 
to  the  thorough  washing  o\it  of  the 
stomach  with  the  warm  oil  until  the  last 
trace  of  chloroform  had  been  removed. 
(Wiener  klinische,  Wochenschrift,  Jan- 
uary 7,  1909.) 


lODIN  IN  SURGICAL  TUBERCULOSIS. 

Dr.  W.  A.  Tatchell  says  that  tuber- 
culosis of  the  joints,  bones,  glands  and 
skin,  is  the  most  common  disease  in 
China  and  highly  recommends  the  appli- 
cation of  iodin  liniment  after  operative 
treatment.  After  operating  or  scraping, 
the  cavity  is  thoroughly  swabbed  with 
iodin  ointment.  A  piece  of  absorbent 
cotton  twisted  around  the  end  of  a  probe 
forms  a  good  swab,  and  can  be  graduated 
according  to  the  size  of  the  sinus.  The 
liniment  is  applied  every  day.  The  appli- 
cation does  not  cause  pain,  except  a 
momentary  sensation  when  applied  to 
some  surfaces ;  neither  does  it  destroy  tis- 
sues, as  does  pure  carbolic  acid.  Granu- 
lations do  not  become  excessive.  At  the 
first  application  he  inserts  a  thin  piece  of 
gauze  or  packs  lightly,  but  never  at  sub- 
sequent dressings.  Gauze  plugs  and 
strips  for  drainage  have  undoubtedly  been 
responsible  for  many  chronic  sinuses. 
From  the  first  he  gives  a  mixture  inter- 
nally, containing  syrup  of  iodid  of 
iron,  1  dram,  and  potassium  iodid,  5 
grains,  three  times  a  day.  (British 
Medical  Journal,  February  13,  1909.) 


lODIPIN  IN  EYE  AFFECTION  OF  LUETIC 
ORIGIN. 

Dr.  W.  Zimmerman  reports  a  case  in 
a  patient  who  had  been  complaining 
for  from  twelve  to  thirteen  years  of 
pains  in  the  limbs,  and  for  three  years 
of  stiffness  in  the  limbs,  weakness  in 
the  back,  vesical  weakness  and  impo- 
tence. Within  the  last  year,  vision  was 
considerably  impaired,  with  severe  head- 
aches and  increasing  ataxia.  When  the 
patient  was  first  seen  he  gave  the  im- 
pression of  being  drunk.  The  left  pupil 
was  larger  than  the  right,  but  both 
reacted  to  light.  With  the  ophthalmo- 
scope, both  discs  appeared  indistinct. 
The  facial  muscles  were  not  affected. 


312 


MASTITIS. 


OPERATIVE  TREATMENT  OF  ASCITES. 


sensation  was  impaired  in  the  lower 
extremities,  the  knee  jerks  were  much 
exaggerated,  and  Babinsky's  reflex  was 
absent,  owing  to  anaesthesia  of  the  soles. 
Though  no  history  of  his  could  be  ob- 
tained, the  author  believes  the  lesion  of 
the  optic  discs  was  due  to  a  gummous 
process  at  the  base,  and  the  spinal 
symptoms  to  meningo-myelitis  luetica. 
Treatment  was  soon  instituted,  and  two 
injections  of  ten  cubic  centimeters  of  a 
25-per-cent.  solution  of  iodipin  were 
given,  and  almost  immediately  the 
vision  and  ataxia  improved,  and  after 
four  injections  the  patient  could  be  sent 
home;  after  the  seventh  injection  the 
pupils  were  again  equal  in  size.  The 
remarkable  prompt  action  of  the  iodipin 
proved  the  luetic  origin  of  the  affection, 
despite  the  negative  history.  (Ophthal- 
molog.  klinik,  1908,  Nos.  18,  19.) 


ing  the  more  extensively  implicated. 
The  treatment  consisted  in  performing 
Bardenheuer's  operation,  which  consists 
in  making  an  incision  along  the  lower 
border  of  the  gland,  separating  the 
gland  from  the  pectoral  fascia  and  rais- 
ing it  up.  Then  all  the  inflammatory 
tissue  is  removed.  After  the  wound  is 
drained  and  cleaned,  healing  takes 
place  in  five  to  eight  weeks.  No  scar 
is  left  on  the  surface,  and  it  is  difficult 
to  distinguish  the  healed  from  the  af- 
fected gland.  The  author,  in  treating 
gangrenous  mastitis,  removes  the  af- 
fected part  of  the  breast  and  the  other 
half  is  drained.  His  results  have  been 
favorable.  In  the  case  of  puerperal 
tubercular  mastitis  the  entire  gland  was 
removed.  (Deutsche  Zeitschrift  fiir 
Chirurgie,  Bd.  94,  Heft  3.) 


MASTITIS,  TREATMENT  OF. 
Dr.  Feinen,  of  Bardenheuer's  clinic, 
recognizes  four  forms  of  mastitis, 
namely,  simple  acute  mastitis,  mammary 
abscess,  interstitial  or  parenchymatous, 
and  gangrenous  mastitis,  to  which  may 
be  added  a  fifth,  or  tuberculous  form. 

The  inflammation  subsided  in  a  few 
days  in  the  acute  form  of  mastitis  after 
the  patient  was  put  at  rest  and  a  laxa- 
tive given.  The  breasts  were  held  up 
with  moist  bandages  and  the  child  was 
kept  away.  A  puncture  was  made  in 
case  of  abscess,  and  then  a  wick  drain 
was  put  in  after  the  part  was  made  hy- 
persemic  with  Bier's  apparatus.  The 
cosmetic  result  was  good.  The  scar  was 
small,  in  a  few  weeks  became  invisible, 
and  there  was  no  retraction  about  the 
scar. 

In  the  interstitial  or  parenchymatous 
form  of  mastitis  both  the  connective 
and  glandular  tissue  are  involved,  at 
times  the  one  and  at  times  the  other  be- 


OPEEATIVE  TREATMENT  OF  ASCITES 
DUE  TO  HEPATIC  CIRRHOSIS. 

Dr.  Bogojawlcnsky  after  an  expression 
of  opinion  that  omentopexy  in  cases  of 
ascites  due  to  cirrhosis  of  the  liver  has 
not  completely  fulfilled  early  expecta- 
tions, holds  that  such  good  results  as 
have  resulted  from  this  operation  are 
due  mainly  to  the  simple  laparotomy  and 
not  to  the  endeavor  to  establish  a  col- 
lateral circulation  by  suturing  the  omen- 
tum to  the  abdominal  wall.  The  good 
obtained  by  mere  exposure  of  the  abdom- 
inal cavity  is  attributed  to  an  increased 
capacity  of  th'e  peritoneum  for  absorption 
being  set  up  by  the  hyperamia  resulting 
from  this  operation.  The  author  agrees 
with  Klopstock  that  in  many  cases  of 
hepatic  cirrhosis,  the  ascites  is  due  rather 
to  an  inflammatory  condition  of  the 
peritoneum  than  to  a  mechanical  ob- 
struction in  the  portal  circulation.  This 
chronic  inflammation,  it  is  suggested,  is 
set  up  by  irritation  of  the  membrane  by 
toxic  matter  which,  in  consequence  of 


OSMIC  ACID  IN  NEURALGIA. 


POSTOPERATIVE  TREATMENT. 


313 


the  impaired  function  of  the  liver,  is  car- 
ried by  the  blood  to  the  whole  organism, 
and  particularly  to  the  contents  of  the 
abdominal  cavity.  In  10  cases  treated 
by  the  author,  after  the  whole  of  the 
ascitic  fluid  had  been  withdrawn,  the 
parietal  peritoneum  was  moistened  by 
normal  solution,  and  afterwards  dried  by 
gauze.  This  method  of  treating  ascites 
by  laparotomy  and  artificial  irritation  of 
the  peritoneum  should  be  regarded,  the 
author  points  out,  as  strictly  contra- 
indicated  in  cases  in  which  the  renal 
functions  are  compromised.  (Zentralbl. 
fur  Chir.,  N"o.  9,  1909.) 


OSMIC  ACID  IN  TRIFACIAL  NEURALGIA. 
Dr.  H.  H.  Germain,  Boston,  briefly 
reports  eleven  cases  and  concludes:  (1) 
Osmic  acid  injections  will  relieve  tri- 
facial neuralgia  for  a  longer  or  a  shorter 
period  of  time.  (2)  Eelief  from  pain  is 
not  immediate  but  follows  in  a  few  days 
after  injection,  (3)  It  may  be  followed 
by  a  certain  amount  of  necrosis  of  tissue 
at  the  point  of  injection.  (4)  It  is  little, 
if  any,  better  than  other  peripheral  opera- 
tions. (5)  It  is  best  used  in  a  2-per- 
cent, solution  injected  directly  into  the 
nerve,  using  a  glass  syringe  and  a  plati- 
num needle.  (6)  It  is  to  be  used  only  in 
purely  sensory  nerves,  as  its  employment 
in  mixed  nerves  is  followed  by  motor 
paralysis.  In  regard  to  the  latter  he 
pleads  for  greater  conservatism  and  the 
treatment  by  hygienic  measures  and 
astringents.  He  gives  the  indications  for 
the  complete  removal  of  adenoid  vegeta- 
tions as  follows:  (1)  Nasal  obstruction, 
causing  mouth  breathing  and  its  sequela3 ; 
(2)  recurring  attacks  of  earache;  (3) 
stupidity  and  inability  of  the  children  to 
concentrate  attention  ;  (4)  stunted 
growth,  and  in  all  cases  of  purulent 
otitis  media  in  children;  (5)  in  infanta 
whose  inability  to  nurse  is  due  to  ade- 


noids, otherwise  he  never  operates  on  in- 
fants under  1  year  of  age,  and  believes  it 
a  crime  to  do  so.  He  describes  the 
operation.  (Boston  Medical  and  Sur- 
gical Journal,  February  4,  1909.) 


PLACENTA  PRa;VIA,  TREATMENT  OF. 

Dr.  W.  Hannes  relates  the  experience 
with  placenta  prjevia  at  Kiistner's  clinic 
at  Breslau,  a  total  of  246  cases.  The 
maternal  mortality  was  6.6  per  cent,  and 
this  mortality  would  have  been  much 
more  reduced  if  the  inflatable  bag,  which 
is  the  main  reliance  in  the  treatment  of 
placenta  prsevia,  had  been  applied  earlier. 
The  eight  deaths  among  the  143  women 
treated  with  the  hystereurjmter  were  not 
connected  with  the  use  of  the  bag  in  any 
way.  If  it  had  been  used  in  more  cases 
and  earlier,  there  would  have  been  fewer 
deaths  from  anaemia,  he  is  convinced. 
Of  the  147  viable  children,  70  per  cent, 
left  the  hospital  in  good  condition  and  75 
per  cent,  in  the  132  cases  in  which  the 
hystereur3Titer  had  been  used.  He  urges 
that  the  old  method  of  version,  with  its 
foetal  mortality  of  75  or  80  per  cent., 
should  be  discarded  for  the  hyster- 
eurjTiter  with  75  to  80  per  cent,  living 
children.  Every  woman  with  placenta 
pra3via  should  be  placed  in  the  hands  of 
an  expert  at  the  earliest  possible  moment 
but  every  practitioner  should  be  an  ex- 
pert in  the  use  of  the  h3^stereur}Titer. 
(Zentralblatt  fiir  Gynakologie,  Leipsic, 
Januaiy  16,  1909.) 


POSTOPERATIVE  TREATMENT. 

Dr.  0.  D.  Hamlin,  Oakland,  Cal.,  says 
that  it  is  the  duty  of  the  surgeon  to  con- 
tinue and  watch  his  patient  until  con- 
valescence has  set  in,  in  order  to  pre- 
vent any  complications  wliich  might 
arise.  He  should  institute  after  treat- 
ment in  order  that  he  may  be  able  to 
treat   the    complications,    if    any   arise, 


314 


PKOPHYLAXIS  IN  MENINGITIS. 


PYEENOL  IN  ASTHMA. 


intelligently,  so  as  to  secure  not  only- 
recovery,  but  the  best  functional  results. 
The  author  urges  the  right  side  posture 
when  the  patient  is  taken  from  the 
operating  room  or  begins  to  recover  from 
the  ana3sthetic  and  also  discusses  special 
postures  for  special  cases.  For  ana3S- 
thetic  vomiting  he  recommends  large 
draughts  of  water  containing  some  alkali, 
such  as  sodium  bicarbonate.  After  lav- 
age of  the  stomach,  cocain  hydrochlorid, 
gr.  ^2  (0.005  Gm.)  bismuth  subuitrate, 
gr.  5  (0.033  Gm.)  and  cerium  oxalate, 
gr.  ^  (0.003  Gm.)  may  be  given  dry  on 
the  tongue.  Sometimes  it  is  useful  to 
spray  the  nostril  with  4  per  cent,  cocain 
solution.  Finall}^,  he  discusses  at  length 
post-operative  shock  under  four  different 
classes,  namely  that  due  to  vasomotor 
depression,  haemorrhage,  the  toxic  effect 
of  the  anaesthetic,  and  mental  disturb- 
ance, psychic  shock.  This  last  is  par- 
ticularly likely  to  occur  in  neurotic  and 
alcohol  patients,  children  and  others  of 
timid  nature.  (California  State  Jour- 
nal of  Medicine,  December,  1909.) 


PROPHYLAXIS  IN  EPIDEMIC  CEREBRO- 
SPINAL MENIIIGITIS. 

Dr.  Seibert  sums  up  what  we  now 
Icnow:  (1)  Epidemic  cerebrospinal 
meningitis  is  communicable  only  by 
direct  contact  with  fresh  mucus  from 
the  nasopharynx  of  patients.  (2)  A  per- 
son who  has  taken  the  germ  from  a  pa- 
tient may  acquire  meningitis.  (3)  Such 
a  person  may  only  acquire  meningococcus 
pharyngitis  and,  thus  acting  as  inter- 
mediary host,  may  carry  this  infection  to 
others  near  and  far. 

The  author  recommends  the  applica- 
tion of  a  solution  of  equal  parts  of 
resorcin  and  alcohol  to  disinfect  the  naso- 
pharynx. The  alcohol  must  be  heated 
before  the  resorcin  is  added.     Two  appli- 


cations, one  past  each  side  of  the  uvula, 
are  sufficient.  The  stomach  must  be 
empty.  The  solution  is  said  to  destroy 
every  organism  it  comes  in  contact  with. 
The  applications  are  best  repeated  every 
forty-eight  hours.  Six  treatments  will 
usually  suffice.  The  author  concludes 
that  resorcin  and  alcohol  should  be  used : 
(1)  In  the  nasophaiynx  of  the  patient  to 
prevent  further  absorption,  as  well  as 
expectoration,  of  meningococci.  (3)  In 
all  persons  coming  in  contact  with  a 
patient,  especially  when  postnasal  catarrh 
is  present.  (Journal  American  Medical 
Association.)       

PYRENOL  IN  THE  TREATMENT  OF 
ASTHMA  AND  EMPHYSEMA. 

Dr.  Boellke  has  found  this  drug  of 
great  service  in  the  treatment  of  emphy- 
sema and  asthma.  It  is  given  in  doses  of 
3  to  4  grams  per  day.  It  is  a  product  of 
Siam  benzoic  acid  and  thymol  with  syn- 
thetic benzoic  acid  and  oxybenzoic  acid, 
and  is  therefore  an  expectorant,  and 
possesses  by  reason  of  the  thymol  an  an- 
aesthetic property.  Dr.  Boellke  has 
observed  its  action  in  39  cases,  of  which 
notes  are  given  of  five.  The  dyspnoea  is 
relieved  in  three  to  four  days,  and  ex- 
pectoration becomes  looser  generally  on 
the  second  day.  The  cough  soon  loses  its 
hard  and  paroxysmal  character.  A  num- 
ber of  patients  experienced  a  sense  of 
well-being  to  which  they  had  long  been 
strangers.  The  bronchitic  sounds  dis- 
appeared from  the  chest,  in  many  cases 
almost  entirely.  Eelapses  were  observed 
in  one  case  only.  No  harmful  influence 
of  the  drug  was  observed,  even  with  long- 
continued  use.  No  lessening  of  the  effect 
with  time  or  cumulative  action  was 
found.  Complications  on  the  part  of  the 
heart,  kidneys,  or  liver  are  not  contra- 
indications. Those  who  had  formerly 
been  treated  with  atropine  or  potassium 


RUPTUHED  KIDNEY. 


SALT  IN  INTERNAL  HiEMOIlRHAGE. 


815 


iodid  declared  that  pyrenol  gave  the  best 
results.  (Med.  Klin.,  February  21, 
1909.)  

RUPTURED  KIDITEY,  TREATI4ENT  OF. 

Dr.  Morestin  discusses  the  indications 
for  direct  surgical  intervention  in  ex- 
tensive laceration  of  the  kidney.  The 
author  states  that  when  there  is  free  and 
persistent  bleeding  with  large  perirenal 
hasmatoma ;  and  the  condition  of  the  pa- 
tient is  such  as  to  excite  much  anxiety, 
the  surgeon  should  not  hesitate  by  the 
simple  and  harmless  procedure  of  a  lum- 
bar incision  to  expose  the  injured  kid- 
ney with  the  views  of  dissipating  doubt, 
of  arresting  the  flow  of  blood,  and  of  pro- 
tecting the  patient  against  remote  com- 
plications. Eemoval  of  the  kidney 
should  only  be  practised  for  the  extreme 
forms  of  traumatism  in  which  the  kidney 
has  been  either  completely  crushed  or 
torn  away  from  its  hilum.  In  most 
cases.  Dr.  Morestin  asserts,  the  condition 
of  the  ruptured  kidney  will  permit  a  con- 
servative operation.  Suture  of  the  lac- 
erated kidney  is  possible,  and,  indeed,  a 
relatively  simple  measure.  It  may  enable 
the  surgeon  to  re-establish  the  shape  of 
the  organ,  and  will  suffice  to  arrest 
bleeding. 

The  sutures  are  indicated  in  those 
cases  where  the  laceration  is  not  extensive 
because  the  sutures  favor  the  formation 
between  the  apposed  surfaces  of  torn 
renal  tissue,  cicatricial  septa  which  will 
tend  to  keep  the  fragments  anatomically 
distinct.  Moreover,  the  tension  of  the 
sutures  may  modify  the  functional  value 
of  the  preserved  organ.  If  the  kidney  be 
much  torn,  but  still  in  a  condition  favor- 
ing conservatism,  it  might  be  well,  it  is 
suggested,  to  arrest  the  bleeding  and  to 
treat  the  injury  by  simple  packing.  It 
remains  uncertain  whether  the  conserva- 
tive treatment  of  ruptured  kidney  which 


is  so  satisfactory  and  free  from  danger  in 
its  immediate  residts,  is  likely  or  not  to 
lead  in  course  of  time  to  any  serious  dis- 
turbance of  the  function  of  the  retained 
organ.  (Bull.  et.  Mem.  de  la  So.  de. 
Chir.  de  Paris,  No.  36,  1908.) 


SALT  IN  THE  TREATMENT  OF  INTERNAL 
HiEMOSRHAGE. 
Dr.  von  den  Velden  has  studied  for  a 
year  the  use  of  salt  by  mouth  or  in  infu- 
sion as  a  means  of  controlling  hgemor- 
rhage.  His  experience  has  confirmed  the 
traditions  in  regard  to  the  influence  of 
salt  in  this  respect.  In  the  living  sub- 
jects the  salt  enhanced  the  coagulating 
power  of  the  blood  and  attributes  this 
coagulating  influence  to  the  mobilization 
of  thrombokinase  stored  up  in  the  tissues. 
The  author  obtained  excellent  results  in 
29  cases  of  hsemoptj^sis  from  administra- 
tion of  5  Gm.  (75  grains),  of  sodium 
chlorid  by  the  mouth,  the  coagulating 
properties  of  the  blood  being  much  in- 
creased thereby  for  a  period  of  from  an 
hour  to  an  hour  and  a  half.  The  effects 
became  evident  in  a  few  minutes.  If 
the  tendency  to  hscmorrhage  returns  later, 
he  repeats  the  dose  of  salt  or  substitutes 
sodium  or  potassium  bromid  in  the  dose 
of  3  Gm.  (45  grains),  the  bromid  having 
further,  a  sedative  action.  He  does  not 
hesitate  to  keep  up  this  combined  sodium 
chlorid  and  bromid  treatment,  giving  in 
tlie  most  urgent  cases  from  20  to  30  Gm. 
(3v  to  §j)  of  sodium  chlorid  and  from 
12  to  15  Gm.  (oiij  to  5iv),  of  the 
bromid  during  the  day.  Any  tendency 
to  bromin  intoxication  is  corrected  by 
the  sodium  chlorid.  In  nine  other  cases 
he  administered  the  salt  or  bromid  by 
intravenous  injection  as  he  did  not  wish 
to  irrigate  the  digestive  tract  or  kidneys. 
This  series  includes  seven  patients  with 
haemoptysis,  and  each  with  haemorrhage 
from  varices  in  esophagus  or  bladder  or 


316 


SCARLET  FEVER. 


SUPERFICIAL  PNEUMOCOCCAL  AFFECTIONS. 


typhoid  lesions  in  the  boweh  He  never 
witnessed  any  disagreeable  effects  from 
this  treatment.  The  beneficial  results 
were  apparent  in  haemorrhage  both  in  the 
lung  and  greater  circulation.  Hemophilia 
is  a  chronic  defective  condition  for  which 
a  transient  increase  in  coagulating  power 
is  of  little  avail.  The  hemophilic  tend- 
ency is  probably  the  result  of  defective 
production  of  thrombokinase.  (Deut- 
sche medizinische  Wochenschrift,  Feb- 
ruary 4,  1909.) 


SCARLET  FEVER,  TREATMENT  OF. 

Dr.  Gordon  discusses  the  treatment  of 
uncomplicated  cases  of  average  severity, 
toxic  cases  (serotherapy),  septic  cases 
(local  treatment),  complications  and  con- 
valescence. In  order  to  prevent  the 
swallowing  of  the  septic  faucial  secretion, 
lozenges  should  not  be  given.  The  neck 
should  be  packed  externally  with  ice  bags 
in  order  to  relieve  the  pain.  The  author 
uses  a  douche  of  warm  water  which  has 
been  rendered  faintly  alkaline  with 
sodium  bicarbonate  in  order  to  diminish 
absorption  of  the  toxines  from  the  fauces. 
The  object  of  this  procedure  is  flushing 
and  not  disinfection.  The  patient  should 
lie  on  his  stomach  with  the  head  project- 
ing over  the  edge  of  the  bed,  the  forehead 
supported  by  one  hand  of  the  nurse.  At 
least  two  pints  should  be  used  for  each 
irrigation.  Gentle  swabbing  with  a  solu- 
tion of  borax  is  sometimes  useful  in 
adults,  but  the  application  of  germicidal 
solutions  should  not  be  used,  and  neither 
the  spray  nor  the  paint  brush  has  any 
legitimate  place  in  the  treatment  of  the 
throat.  A  separate  nozzle  should  be  used 
for  each  patient.  In  toxic  cases  he  dis- 
cusses the  use  of  serum,  which  should  be 
polyvalent,  sterile,  and  not  more  than  six 
months  old.  From  50  to  100  c.c,  should 
be  given,  and  he  has  never  seen  any  harm- 


ful result  therefrom.  In  septic  cases, 
germicides  should  be  used  in  as  concen- 
trated a  form  as  possible,  in  small  quan- 
tity and  should  be  applied  with  a  swab. 
The  douche  also  should  be  constantly  used 
as  before  recommended.  It  is  not  advis- 
able to  incise  enlarged  and  tender  cervical 
glands  unless  definite  evidence  of  f  ructu- 
ation  is  obtained,  so  long  as  the  skin  over 
them  is  not  affected.  In  septic,  as  dis- 
tinguished from  toxic  cases,  streptococcus 
serum  should  be  avoided.  Alcohol  in  Dr. 
Gordon's  experience  is  usually  both  un- 
necessary and  harmful  in  septic  cases. 
(Practitioner,  London,  January,  1909.) 


SUPERFICIAL  PNEUMOCOCCAL  AFFEC- 
TIONS OF  THE  GLOBE,  TREATMENT 
OF,  BY  MEANS  OF  RABBIT'S  BILE. 

Dr.  V.  Morax  reports  a  number  of 
cases  of  pneumococcal  corneal  ulcers  in 
which  he  brought  about  a  cure  in  from  a 
week  to  a  fortnight,  with  complete  trans- 
parency or  very  slight  cloudiness  of  the 
cornea.  He  used  a  sheep's  bile  which 
was  gathered  aseptically  at  the  abattoir 
immediately  after  the  slaughtering  of  the 
animal  by  means  of  sterilized  pipettes. 
In  one  case  iodoform,  atropin  and  hot 
compresses  were  combined  with  the  use  of 
the  bile. 

Dr.  Neufeld  has  pointed  out  that  if 
two  or  three  drops  of  rabbit's  bile  be 
added  to  a  pneumococcus  culture  in 
bouillon  which  has  been  kept  for  twenty- 
four  hours  at  a  temperature  of  thirty- 
seven  degi'ees  centigrade,  the  culture 
clears  rapidly  and  after  a  short  time  the 
bouillon  can  be  shown  to  be  free  from 
any  activity,  whether  the  examination  be 
made  with  the  microscope,  by  culture  or 
by  inoculation.  The  bile  from  dogs,  rats, 
goats  and  human  beings  also  possesses 
bacteriolytic  power.  This  property  of 
the  bile  has  been  shown  to  be  due  to  the 


SYPHILIS  OF  THE  NERVOUS  SYSTEM. 


THYROID  IN  ICHTHYOSIS.      317 


presence  of  biliary  salts  and  these  salts 
have  been  arranged  in  their  order  of 
eflficacy.  (Annales  d'oculistique,  Novem- 
ber, 1907.) 


SYPHIIIS  OF  THE  NERVOUS  SYSTEM, 
TREATMENT  OF. 

Dr.  G.  Koster  states  that  great  care 
should  be  exercised  in  the  treatment  of 
sj'philis  with  mercury  even  when  there 
are  already  signs  of  atrophy  of  the  optic 
nerve,  as  it  has  been  known  to  aggravate 
the  condition.  Since  suspension  of  this 
treatment  does  not  arrest  the  aggravation, 
he  advises  potassium  iodid  first,  and  if 
mercurial  treatment  becomes  necessary 
on  account  of  other  syphilitic  manifesta- 
tions, the  eye  should  be  examined  every 
third  day  by  the  ophthalmologist.  If 
mercurial  treatment  is  undertaken,  it 
should  be  with  constant  oversight  of  the 
conditions  in  the  fundus.  The  author 
greatly  emphasizes  the  fact  that  atoxyl — 
a  widely  advertised  drug,  alleged  to  be 
free  from  toxic  action  and  to  be  a  sort  of 
a  panacea  for  diverse  diseases,  in  treat- 
ment of  syphilis,  is  proving  a  two-edged 
sword  which  should  be  used  only  with 
extreme  caution.  This  atoxyl  is  not  only 
liable  to  have  an  injurious  influence  on 
vision,  but  may  induce  disturbances  in 
the  voiding  of  bladder  and  bowel  con- 
tents, leading  to  total  incontinence.  A 
course  of  mineral  waters,  as  at  Aachen, 
Wiesbaden  or  Tolz,  is  a  powerful  adju- 
vant in  treatment  of  S}^hilis  of  the 
nervous  system  on  account  of  the  stimula- 
tion of  the  general  metabolism.  Even  if 
no  benefit  is  derived  from  the  first  course 
of  the  kind,  experience  has  shown  that 
hitherto  apparently  irreparable  symptoms 
may  subside  during  a  second  or  third 
repetition.  (Portschritte  der  Medizin, 
Leipsic,  January  20, 1909.) 


THE  KNEE-JOINT,  SURGICAL  CONDITIONS 
OF. 

Dr.  Tenney  (Annals  of  Surgery,  Nov., 
1908),  thus  concludes  an  article  on  this 
subject  containing  many  illuminating 
case  histories: 

1.  Asepsis  and  drainage  are  more 
essential  in  knee-joint  work  than  in 
laparotomies  because  of  the  difference  in 
the  skin  of  the  operative  field  and  in  the 
natural  drainage  of  the  cavaties. 

2.  Sepsis  and  immobility  mean  anky- 
losis. Drainage  and  mobility  may  leave 
some  motion. 

3.  There  is  an  increasing  tendency 
toward  operative  repair  of  patellar  frac- 
tures and  an  increasing  use  of  absorbable 
material.  This  should  be  the  rule,  to 
which  exceptions  may  sometimes  occur. 

4.  By  far  the  most  common  mechanical 
cause  of  trouble  within  the  joiut  is  the  tab 
from  the  infrapatellar  pad.  This  may  be 
a  part  of  a  general  obesity,  in  which  case 
the  usual  antifat  treatments  are  appro- 
priate. If  it  be  foimd  in  a  vigorous  and 
otherwise  normal  person,  it  should  be 
removed.  Some  temporary  relief  may  be 
obtained  by  properly  applied  adhesive 
straps,  but  a  cure  only  be  removal. 

5.  Prepatellar  bursitis  can  be  cured  by 
incision  and  drainage.  Other  bursae 
should  be  dissected  and  removed. 

6.  Ligamentous  injuries  must  be  care- 
fully treated  and  some  must  have  opera- 
tive repair  to  prevent  recurring  or  con- 
stant disability.  No  apparatus  is  so 
good  as  a  normal  knee.  (The  Thera- 
peutic Gazette,  February  15,  1909.) 


THYROID  TREATMENT  OF  ICHTHYOSIS. 

Drs.  Weill  and  Mouriquand  report  in 
detail  two  cases  of  congenital  ichthyosis 
in  which  the  connection  between  the 
afTection  and  the  defective  functioning  of 
the  thyroid  was   plainly  apparent.     In 


318 


TREATIklENT  OF  ANEURYSM. 


TREATMENT  OF  RHEUMATISM. 


the  first  patient,  the  thyroid  treatment 
was  commenced  at  the  age  of  five 
months;  in  two  month's  the  congenital 
ichthyosis  subsided  and  in  two  months 
later  it  had  entirely  disappeared.  After 
suspending  the  thyroid  treatment,  a 
preparation  of  arsenic  was  given.  The 
ichthyosis  returned  but  yielded  again  to 
the  resumption  of  the  thyroid  treatment 
which  the  child  seemed  to  tolerate  per- 
fectly and  at  the  present  time  the  child 
is  lively  and  well,  all  evidences  of  myxce- 
dema  have  likewise  vanished.  In  an- 
other child  in  which  there  were  also  signs 
of  myxoedema  and  the  presence  of  a 
mongolian  aspect,  very  favorable  results 
were  obtained  from  the  thyroid  treat- 
ment. After  reviewing  the  literature  on 
this  subject.  Dr.  Weill  is  convinced  that 
certain  cases  of  ichthyosis  ascribed  to 
inherited  syphilis,  were  really  of  thjn^oid 
origin,  the  thyroid  lesion  being  possibly 
secondary  to  sypliilis.  He  believes  that 
sufficient  data  are  at  hand  to  demonstrate 
the  influence  of  the  thyroid  on  the  nutri- 
tion of  the  subcutaneous  cellular  tissue 
(myxoedema)  and  of  the  derma  (sclero- 
derma in  exophthalmic  goiter  and  in 
myxoedema.)  It  is  logical,  therefore,  to 
ascribe  a  similar  influence  to  it  in  the 
development  of  the  superficial  layer  of 
the  skin,  so  that  disturbance  in  thyroid 
functioning  may  possibly  entail  ichthy- 
osis. (Presse  Medicale,  Paris,  February 
17,  1909.)  

TREATMENT  OF  ANEURYSM  OF  THE 
NECK. 

Dr.  Guinard  discusses  the  various 
methods  of  treating  aneurysms  of  the 
base  of  the  neck  and  commands  simulta- 
neous ligation  of  the  carotid  and  sub- 
clavian on  the  right  side,  commencing 
always  with  the  carotid.  His  technic  is 
simple  and  harmless  as  shown  from  his 
experience   of   fifteen   cases.     He  states 


that  the  aneurysm  can  be  pushed  to  one 

side,  if  it  hides  the  vessels  to  be  iigated. 
Silk  or  catgut  can  be  used,  and  drainage 
is  not  necessary  unless  the  operation  has 
been  long  and  difficult.  It  makes  no 
difference  whether  the  aneurysm  is  on  the 
ascending  portion  of  the  aorta  to  the 
right  or  on  the  subclavian  or  common 
carotid.  His  method  of  treatment  is 
applicable  for  all  aneurysms  at  the  base 
of  the  neck  and  the  results  are  better,  the 
greater  the  distance  between  the  aneu- 
rysm and  the  heart.  The  symptoms  in 
respect  to  the  pulse,  sphygmography  and 
compression  of  neighboring  organs  are 
deceptive,  but  radioscopy  may  render 
good  service.  One  hundred  per  cent,  of 
cures  are  reported  in  the  recent  statistics 
in  regard  to  aneurysm  of  the  innominate. 
The  author  reports  a  case  of  aneur}^sm  of 
the  left  end  of  the  arch  of  the  aorta  in 
which  he  Iigated  the  aorta  below  the 
aneurysm.  As  the  ligation  was  drawn 
tight,  the  femoral  pulse  stopped  at  once 
and  the  lower  part  of  the  body  grew  pale 
and  cold,  but  in  less  than  15  minutes 
circulation  became  re-established  and  the 
parts  grew  warm.  The  upper  part  of 
the  tinink  and  head  began  to  sweat  pro- 
fusely, suggesting  that  the  kidneys  were 
not  working  properly  and  that  urosmia 
was  pending.  Ligation  of  the  aorta 
above  the  renal  arteries  proves  inevitably 
fatal  owing  to  the  arrest  of  the  physio- 
logic functions  of  the  kidneys  which 
require  a  considerable  degree  of  blood- 
pressure  in  the  renal  arteries.  (Revue 
de  Chirurgie,  Paris,  February  29,  No.  2.) 


TREATMENT  OF  CHILDREN  STIFFERING 
FROM  RHEUMATISM  OR  CHOREA. 
Dr.  D.  B.  Lees  states  that  every  case 
of  chorea  in  childhood  should  be  con- 
sidered as  presumably  rheumatic,  and 
ought  to  have  the  benefit  of  this  prob- 
ability.    Every  such  patient  should  be 


TUBERCULIN  TREATMENT. 


TUBAL  DISEASE,  TREATMENT  OF. 


319 


at  once  sent  to  bed,  and  treated  vigor- 
ously for  rheumatism.  He  claims  that 
almost  the  whole  of  the  heart  diseases 
which  exist  in  patients  imder  tliirty  years 
of  age,  as  well  as  a  very  considerable 
proportion  of  the  heart  disease  of  later 
life,  is  the  result  of  rheumatic  infection 
of  childhood  that  was  either  unrecognized 
or  ineffectively  treated.  The  author  em- 
phasizes the  point  that  every  child  who 
complains  of  sore  throat  or  of  pains  in 
the  joints,  muscles  or  tendinous  struc- 
tures, every  child  who  suffers  from  ma- 
laise and  unexplained  pyrexia,  every  child 
whose  skin  shows  spots  of  erythema  or 
who  has  subcutaneous  nodules  on  his 
tendons  or  round  his  joints,  or  subperios- 
teal nodules  on  his  bones,  every  child 
who  has  pain  in  his  chest,  or  shortness 
of  breath,  or  marked  pallor,  and  every 
child  exhibiting  even  slight  choreic  move- 
ments or  merely  weakness  and  inco- 
ordination of  muscular  action  or  emo- 
tional instability  should  at  once  be  put 
to  bed  and  his  heart  should  be  promptly 
and  carefully  examined.  The  author 
cites  Poynton  and  Paine's  demonstration 
of  a  diplococcus  in  rheumatism  and 
chorea  which  is  capable  of  producing  in 
rabbits,  not  merely  endocarditis,  but  car- 
diac dilatation,  myocarditis,  pericarditis, 
arthritis,  pleurisy  and  pneumonia,  also 
subcutaneous  nodules  and  tenosynovitis; 
in  short,  all  the  severe  lesions  found  in 
a  rheumatic  child.  (British  Journal  of 
Children's  Diseases,  London,  March, 
1909.)  

TUBERCULIN  TREATMENT  FOR  INFANTS 
AND  CHILDREN. 

Dr.  A.  Schlossman  reports  very  good 
results  from  the  use  of  tuberculin  in  the 
treatment  of  infants  and  children.  The 
tuberculous  child  does  not  react  with 
formation  of  antibodies  until  rather  large 
doses    are    given.      Treatment    should. 


therefore,  commence  with  a  stage  of  small 
doses,  to  render  the  child's  organism 
tolerant  to  the  tuberculin.  The  child 
reacts  to  tuberculin  with  a  vigorous  pro- 
duction of  antibodies  when  it  has  reached 
a  tolerance  for  the  dose  of  0.1  Gm.  (1.5 
grains)  of  tuberculin.  After  the  child 
has  been  given  small  doses,  it  should  be 
followed  by  a  period  of  prolonged  treat- 
ment with  large  doses  at  suitable  inter- 
vals, and  production  of  antibodies  fol- 
lows. In  any  case  he  has  never  observed 
untoward  effects  from  large  doses.  He 
is  convinced  that  the  children  were 
doomed  from  the  start  in  the  cases  in 
which  the  cautious  use  of  tuberculin 
failed  to  arrest  the  tuberculous  process. 
These  occasional  failures  should  not  deter 
from  the  use  of  tuberculin,  which  he  re- 
gards as  the  best  means  of  diagnosis  and 
therapeutics  at  our  disposal  in  the  fight 
against  tuberculosis  in  children.  Among 
the  experimental  experiences  related  were 
some  with  guinea-pigs  artificially  fed 
after  birth;  deprived  of  their  natural 
food  they  displayed  much  less  resistive 
vitality.  (Deutsche  medizinische  Woch- 
enschrift,  Berlin,  February  18,  1909.) 


TUBAL  DISEASE,  TREATMENT  OF. 

Dr.  Palmer  Findley  advocates  the 
following  conservative  measures  applic- 
able in  the  treatment  of  chronic  sal- 
pingitis : — 

Vaginal  douches  of  water  at  110°  F,, 
twenty  minutes  in  duration  and  re- 
peated twice  daily,  are  given  in  the  re- 
cumbent position.  Glycerin  (93  parts) 
and  ichthyol  (7  parts)  tampons  are  ap- 
plied daily.  Combination  of  the 
douches  and  tampons  affords  the  most 
effective  means  of  depleting  the  con- 
gested pelvic  tissues.  Under  the  treat- 
ment tenderness  and  pain  are  relieved, 
inflammatory  swellings  are  reduced, 
and   the   functions    of   the   tubes   and 


320 


TUBERCULOSIS,  TUBERCULIN-ARSENIC  IN.         TYPHOID  FEVER. 


neighboring  organs  are  in  part  or 
wholly  restored.  Under  this  treatment, 
extending  over  a  period  of  one  year,  he 
has  seen  a  case  of  bilateral  pyosalpinx 
arrive  at  a  functional  cure,  and  to  the 
degree  which  provided  for  pregnancy 
and  a  successful  delivery.  Pelvic  mas- 
sage, properly  directed  and  persisted  in 
for  the  requisite  time,  will  bring  favor- 
able results  in  selected  cases,  but  in 
America  this  method  of  treatment  has 
found  little  favor.  He  has  personally 
found  little  satisfaction  in  it.  (Interst. 
Med.  Journal,  December,  1908.) 

TUBERCULOSIS,  TUBERCULIN-ARSENIC 
TREATMENT  OF. 
Dr.  Mendel  calls  attention  to  the  com- 
bination of  tuberculin  and  arsenic  for 
the  purpose  of  favoring  nutrition,  pro- 
mote the  rital  energy  and  thus  increase 
and  protect  the  resisting  power  of  the 
cells.     This  combination  of  drugs  utilizes 
the  influence  of  the  tuberculin  in  induc- 
ing   an    inflammatory    reaction   in    the 
vicinity  of  the  tubercidous  focus.     This 
local  inflammatory  reaction  attracts  the 
injected  drug  to  the  spot,  so  that  the 
arsenic  accumulates  in  and  around  the 
tuberculous  focus,  stimulating  the  tissues 
at  this  point  to  extreme  defensive  and 
resisting    action,    and   thus    raising    an 
effectual    wall    around    the    tuberculous 
focus,    preventing    its    furtlier    spread. 
The  union  of  these  two  drugs  thus  fulfil 
all  the  conditions  which  Ehrlich  demands 
for  an  ideal  chemotherapy :  the  supply  of 
the  "distributive  substance"  (tuberculin), 
and  of  a  "pharmacophor  group"  with  a 
specific  action  (arsenic  plus  tuberculia). 
The  author  has  long  been  an  advocate  of 
this  method  of  treatment  and  his  ex- 
periences have  confirmed  the  surprising 
way  in  which  minimal  doses  of  tuberculin 
injected  into  a  vein  stimulate  the  pro- 
duction of  the  protecting  substances  in 


the  organism  infected  with  tuberculosis. 
( Miincher    medizinische    Wochenschrift, 

January  5th.)      

TYPHOID  FEVER,  TREATMENT  OF. 

Treatment  of  typhoid  fever  perforatim 
is  thus  summed  up  by  Dr.  J.  D.  S.  Davis 
of  Birmingham,  Ala. : 

1.  Typhoid  fever  is  a  surgical  disease. 

2.  About  five  per  cent,  of  typhoid 
fever  cases  perforate. 

3.  JSTearly  all  perforating  cases  die  if 
left  to  nature's  resources. 

4.  A  large  per  cent,  may  be  saved  by 
prompt  operative  interference. 

5.  Incision  should  be  large  enough  for 
expeditious  work,  preferably  through 
right  rectus  fascia. 

6.  Lavage  with  hot  saline  is  essential 
in  a  large  number  of  cases,  especially 
when  fecal  extravasation  has  taken  place. 

7.  If  a  perfect  peritoneal  toilet  can  be 
secured,  abdominal  closure  may  be  made 
without  drainage. 

8.  Treatment  by  posture  (Fowler's 
position)  to  confine  bacteria  and  septic 
material  to  lower  abdomen  is  important. 

9.  Treatment  should  be  directed  to 
destroy  or  impede  growth  of  bacteria 
already  in  the  tissues  and  blood — anti- 
streptococcus  serum  and  unguentum 
Cred6. 

10.  Elimination  should  be  secured  by 
physiological  salt  solution  hypodermic- 
ally  when  indicated  for  failing  heart,  and 
proctoclysis  continually  until  sepsis  is 
overcome. 

11.  Supportive  treatment  should  con- 
sist in  transfusion  of  salt  solution  or 
blood ;  strychnine  and  digitalis  for  heart 
stimulant;  sparteine,  in  large  doses,  for 
general  stimulant  and  prophylactic 
against  suppression  of  urine;  moi-phine 
should  be  given  to  control  peristalsis  and 
produce  rest,  control  shock ;  and  nourish- 
ment should  be  given  as  early  as  possible. 
(Medical  Times,  March,  1909.) 


Monthly    Cyclopaedia 

AND 

EDicAL   Bulletin 


Published  the  Last  of  Each  Month 


Monthly  Cyclopaedia  Section 


Vol.  II.  PHILADELPHIA,  JUNE,  1909.  No.  6. 


Original  Articles 


Department  in  charge  of  J.  MADISON  TAYLOR,  A.M.,  M.D. 


DIET  AS  A  PROPHYLACTIC  AND  THERAPEUTIC* 

Bt  H.  W.  WILEY,  M.D., 
Chief  of  the  Bureau  of  Chemistry,  U.  S.  Department  of  Agriculture,  Washington,  D.  C. 

TnEKE  is  an  increasing  "belief  in  the  medical  profession,  and  this  belief 
is  founded  on  substantial  evidence,  that  diet  is  an  important  factor  in  the 
production  and  cure  of  disease.  Both  the  words  "production"  and  "cure" 
are  used  here  in  their  ordinary  sense,  meaning  as  aids  to,  or  favorable  to,  and 
not  as  possessing  specific  properties  of  production  or  effacement.  By  reason 
of  the  provisions  of  the  Food  and  Drugs  Act  the  term  "cure"  is  now  some- 
what restricted  in  its  applications.  The  common  practice  of  advertisers  of 
patent  or  proprietary  medicines  in  the  past  was  to  advertise  them  as  a  "cure" 
or  "sure  cure"  or  "infallible  cure"  for  various  diseases,  and  also  to  place 
similar  statements  on  the  labels.  When  the  law  was  enacted  forbidding  the 
use  of  a  statement  which  was  false  or  misleading  in  any  particular,  and 
especially  since  the  courts  have  judged  that  the  word  "cure,"  in  the  strict 
sense  of  that  term,  may  not  be  applied  to  a  remedy  or  medicine,  less  use  is 
made  of  the  word.  For  this  reason  I  have  used  the  term  above  in  the 
restricted  sense  of  establishing  favorable  conditions  whereby  the  natural 
removal  of  the  disease  might  take  place,  rather  than  as  exerting  a  specific 
influence  in  the  removal  of  the  disease  and  the  restoration  of  the  diseased 
organ  to  a  state  of  health.  I  propose  to  eliminate  from  the  present  discus- 
sion the  well-known  effects  of  adulterated  or  debased  foods  in  the  promotion 
of  disease,  and  shall  confine  myself  in  the  main  to  the  influence  of  nutritious, 
palatable,  wholesome,  and  clean  foods,  both  as  a  preventive  and  as  a  remedy. 

•  Read  before  the  American  Therapeutic  Society,  New  Haven,  Conn.,  May  6-8.  1909. 
3  _  (321) 


322  ^^i^'^  AS  A  PROrilYLACTiC  ANi)  TilERAPEUTIC. 

If  we  accept  the  modern  theory  of  specific  iufectiou  in  the  etiology  of 
disease,  we  shoukl  also  accept  its  attendant  theories,  which  may  be  briefly 
stated  as  follows:  A  perfectly  health}^  well-nourished  organ  becomes  infected 
with  any  disease  germ  with  great  difficulty;  in  other  words,  it  is  self -protec- 
tive. I  shall  not  enter  here  into  any  details  concerning  this  theory,  but  only 
state  it  briefly.  Granting  this,  therefore,  it  is  self-evident  that  the  food  or 
diet  must  play  a  most  important  part  in  the  prevention  of  disease.  The 
normal  condition  of  the  body,  or  any  organ  of  the  body,  and  hence  its  maxi- 
mum power  to  protect  itself  against  infection,  is  directly  dependent  upon  the 
character  and  the  amount  of  the  diet.  It  follows,  then,  as  a  necessary  con- 
clusion that  the  debasement  of  the  diet,  the  addition  of  injurious  substances 
tlicreto,  or  the  abstraction  of  valuable  ingredients  therefrom,  diminishes  the 
power  of  that  diet  to  maintain  the  body  in  a  state  of  hygienic  equilibrium. 
Hence,  the  normal  condition  follov.'s  when  foods  are  furnished  of  a  proper 
quality,  assuming  as  a  basis  of  the  discussion  that  such  foods  shall  not  be  so 
manipulated  as  to  incorporate  with  them  an  ingredient  injurious  to  health; 
to  take  from  them  any  quantity  of  their  nourishing  properties  which  would 
unbalance  their  nutritive  value;  or  to  treat  them  in  any  manner  so  as  to 
impair  their  power  to  sustain  life. 

The  second  condition  regarding  diet  as  a  prophylactic  is  its  quantity.  It 
will  be  easily  understood  from  the  above  assumption  of  the  basis  of  discussion 
that  the  proper  quantity  of  food  to  maintain  the  equilibrium  is  a  condition 
of  efficiency.  If  less  food  than  is  necessary  is  ingested,  the  body  must  lose 
a  portion  of  its  sustenance  and  a  part  of  its  ability  to  withstand  infection. 
On  the  contrary,  if  a  larger  quantity  of  food  is  ingested  than  is  necessary,  an 
additional  burden  is  placed  upon  the  organs  of  digestion  in  ridding  the  body 
of  the  excess,  or  of  storing  the  excess  of  nutriment  in  some  form,  usually  that 
of  fat,  in  the  tissues  of  the  body.  Either  condition  must  be  regarded  as 
unfavorable  to  complete  prophylaxis,  and  hence  either  a  deficiency  or  an 
excess  of  food  would  to  that  extent  predispose  to  diseases  of  the  kind  men- 
tioned. It  is,  of  course,  understood  that  these  variations  within  ordinary 
limits  are  not  of  any  appreciable  effect.  If  on  one  day  a  person  should  eat 
a  little  less  food  than  necessary  for  normal  nutrition,  and  on  the  next  eat  a 
little  more,  varying  in  this  Avay  from  time  to  time,  no  appreciable  effect  would 
be  noticed.  On  the  other  hand,  the  person  who  continuously  uses  less  food 
than  is  necessary,  or  one  who  continuously  uses  more  than  is  necessary,  must 
to  that  extent  become  more  obnoxious  to  disease.  In  the  second  place,  assum- 
ing that  the  total  quantity  of  the  food  remains  the  same,  any  marked  and 
continuous  change  in  the  relations  of  its  natural  constituents  must  be  looked 
upon  with  suspicion. 

The  normal  food  of  man,  and  of  other  animals  as  far  as  that  is  concerned, 
may  be  divided  into  five  great  classes,  namely:  protein,  fat,  sugar  (starch, 
etc.),  mineral,  and  waste  or  indigestible  portions.  Each  of  these  constituents 
has  a  useful  function  and  the  sum  of  nutrition  is  the  normal  ingestion  of  all  of 
these  ingredients  in  their  usual  proportions.     Here  again  it  must  be  acknowl- 


DIET  AS  A  PROPHYLACTIC  AND  THERAPEUTIC.  323 

edged  that  slight  variations  in  distribution  of  ingredients  may  take  place  with- 
out any  notable  injury,  just  as  is  the  case  with  the  variation  of  total  amount  of 
nutrients.  But  if  one  essential  ingredient  to  which  the  human  body  is  accus- 
tomed, and  on  which  it  has  been  develoj^ed  to  its  present  state  of  normal 
equilibrium,  should  be  persistently  removed  from  the  food,  in  my  opinion 
mankind's  ultimate  power  of  resistance  to  disease  would  be  diminished.  It  is 
well  known  for  instance,  that  a  diet  of  protein  alone  will  speedily  lead  not 
only  to  the  danger  of  infection,  but  also  to  positive  weakness  and  starvation. 
In  like  manner  a  diet  of  carbohydrates  alone  would  result  in  the  same  con- 
dition, and  this  is  true  of  a  diet  of  fat,  or  a  diet  of  the  mineral  constituents, 
or  a  diet  of  the  waste  constituents.  I  take  it  as  a  proposition  very  difficult  to 
disprove,  and  sustained  by  every  principle  of  analogy  and  reasoning,  that  the 
ordinary  normal  diet  of  man,  selected  by  the  necessities  of  nutrition  and  by 
taste,  is  considered  all  in  all  the  best.  To  illustrate  more  particularly,  I  heard 
the  Surgeon-general  of  the  Japanese  Navy,  in  a  lecture  in  Washington,  about 
two  years  ago,  ascribe  the  disease  known  as  beriberi  to  a  carbohydrate  diet. 
Eice  being  one  of  the  principal  foods  of  the  Japanese,  and  almost  the  only 
food  of  the  poor,  the  Surgeon-general  ascribed  the  prevalence  of  beriberi 
among  the  Japanese,  especially  the  Japanese  sailors,  solely  to  the  use  of  that 
diet.  On  the  other  hand,  it  has  been  thought  that  scurvy  is  a  disease  due 
largely  to  the  elimination  from  the  dietary  of  the  vegetables  that  are  eaten  in 
the  normal  condition  of  nutrition.  These  two  illustrations,  which  are  more  or 
less  founded  upon  observation  and  scientific  investigation,  I  think  may  be 
accepted  as  at  least  indicative  of  what  might  be  expected  should  any  usual 
elements  of  the  diet  be  either  increased  or  decreased  proportionately  to  the 
other  elements. 

Among  other  statements  which  have  been  made  in  this  line  by  most 
eminent  men,  and  those  whose  scientific  learning  and  judgment  we  all  respect, 
is  the  one  that  the  normal  diet  of  man,  especially  in  the  United  States,  con- 
tains too  large  a  percentage  of  protein.  Data  have  been  collected  in  an  experi- 
mental way  which  tend  to  show  that  diminution  in  the  amount  of  protein  in 
the  food  leads  to  very  beneficial  results,  increasing  the  strength  and  endurance 
of  the  subjects  experimented  upon.  It  is  true  that  this  conclusion  has  also  been 
questioned  by  high  scientific  authority,  and  so  we  may  regard  it  at  the  present 
time  as  neither  established  nor  disproved  by  scientific  data.  Applying  the 
principle  of  analogy  to  this  condition  of  affairs,  we  may  properly  ask  if  a  diet 
so  low  in  protein  should  be  continued  for  a  long  period  of  time,  whether  some 
notable  injury  vrould  not  be  done  to  the  human  body  which  would  render  it 
more  obnoxious  to  disease.  In  fact,  might  we  not  expect  an  approach  to  that 
condition  of  affairs  already  alluded  to  in  the  case  of  the  beriberi  of  the  Japanese 
sailors?  Might  not  there  be  other  effects  also  not  immediately  noticeable 
which  would  render  the  general  introduction  of  a  diet  into  the  United  States 
containing,  for  instance,  only  half  as  much  protein  as  that  already  consumed, 
dangerous  to  the  general  health  of  the  community?  I  ask  this  witliout  in  the 
least  calling  into  question  the  fact  that  the  actual  amount  of  protein  which  we 
coni?ume  may  be  greater  than  is  desirable.       In  that  case  we  would  expect 


324  r)IET  AS  A  rROrilYLACTIC  AND  THERAPEUTIC. 

that  the  human  body  would  be  subject  to  other  diseases,  especially  of  those 
organs  which  are  called  upon  particularly  to  excrete  the  protein,  or  its  decom- 
position products,  from  the  body.  In  other  words  if,  for  the  sake  of  illustra- 
tion, and  the  figures  are  somewhat  exaggerated,  we  should  assimie  that  the 
noi-mal,  healthy  man  of  the  United  States  at  the  present  day  consumes  20 
grams  of  nitrogen  per  day  in  the  form  of  protein  and  the  man  under  the  pro- 
posed regim6  only  ten  grams,  would  the  new  order  of  affairs  produce  a  race 
of  men  less  subject  to  disease  than  the  present  one?  We  might  all  admit  that 
the  reduction  of  the  quantity  of  nitrogen  from  20  to  18  grams  might  be 
desirable,  but  would  not  be  inclined  to  go  to  the  extreme  of  supposing  that  it 
should  be  diminished  by  one-half  or  two-thirds,  or  even  more. 

I  need  hardly  refer  here  to  another  question  in  respect  of  wholesome  foods 
in  their  relations  to  health,  namely,  that  of  mastication.  I  believe  that  all 
admit  the  desirability  of  mastication,  both  as  a  mechanical  necessity  pre- 
liminary to  deglutition  and  also  preliminary  to  the  proper  mechanical  state 
for  the  first  steps  of  hydrolysis  in  the  process  of  digestion.  This  having  been 
properly  accomplished,  the  question  may  arise  whether  or  not  the  carrying  of 
mastication  to  excess  might  result,  first,  in  diminishing  the  actual  quantity  of 
food  necessary,  and,  second,  in  actually  interfering  with  the  proper  process  of 
digestion.  Since  the  beginning  of  the  human  race,  and  before,  the  sense  of 
hunger  has  been  the  normal  gauge  of  the  quantity  of  food  ingested,  and  I  think 
it  must  be  admitted,  if  we  believe  in  the  principles  of  evolution,  that  this 
sense  of  hunger  has  fixed  properly  the  quantity  of  food  necessary.  We  need 
not  discuss  those  abnormal  cases  where  the  natural  sense  of  hunger  leads  to 
over-eating,  or  where  its  absence  leads  to  under-eating,  but  I  speak  only  of 
the  average  normal  condition.  I  believe  it  may  be  accepted  that  excessive 
mastication,  therefore,  would  tend  to  satisfy  the  sense  of  hunger  with  a  less 
quantity  of  food  than  is  needed  in  normal  conditions.  Let  me  put  the  case  a 
little  differently :  Normal  man  must  masticate  his  food  in  a  manner  whereby  it 
can  be  easily  swallowed,  and  this  fits  it  for  the  ordinary  process  of  digestion. 
If  a  man  should  excessively  chew  his  food  it  seems  to  me  that  it  is  almost  cer- 
tain that  a  less  quantity  of  it  would  satisfy  his  craving.  In  other  words,  a 
man  who  gives  his  whole  attention  to  mastication  must  necessarily  in  a  short 
time  lose  the  sense  of  hunger — in  a  much  shorter  time,  in  so  far  as  the  quantity 
of  food  is  concerned,  than  he  would  otherwise.  Hence,  while  it  is  perfectly 
easy  of  demonstration  that  a  somewhat  more  extensive  degree  of  comminution 
of  the  food  may  be  desirable,  it  does  not  hold  that  it  should  be  carried  to 
extremes;  or  putting  it  another  way,  speedy  digestion  is  not  to  be  regarded  as 
synonymous  with  nutritive  digestion.  I  think  it  may  be  easily  understood 
that  just  the  contrary  would  be  the  case.  Suppose,  for  the  sake  of  argument, 
tliat  mastication  could  be  continued  until  the  food  was  reduced  to  its  molecular 
condition.  Such  food,  we  might  assume,  would  be  digested  almost  instan- 
taneously, but  if  the  absorbent  system  remains  in  its  present  condition  it 
would  be  quite  impossible  for  that  food  to  enter  the  circulation  in  an  instanta- 
neous manner.  Much  of  it  would  necessarily,  in  the  natural  motion  of  the 
intestinal  organs,  soon  pass  beyond  the  region  of  absorption  and  escape  enter- 


DIET  AS  A  PROPHYLACTIC  AND  THERAPEUTIC.  325 

ing  into  the  nutritive  processes  entirely.  Thus  I  venture  to  ask  the  question 
whether  it  may  not  he  possible  that  excessive  mastication,  that  is,  converting 
the  meal  hour  into  a  mere  mechanical  exercise,  may  not  in  the  end  threaten  the 
human  family  with  grave  dangers  of  insufficient  nutrition  ?  I  ask  this  ques- 
tion without  in  the  least  denying  the  principle  that  mastication  is  a  desirable 
and  necessary  process. 

I  come  now  to  the  second  part  of  the  discussion,  that  is,  a  condition 
where  disease  has  already  become  established.  What  now  is  the  function  of 
food  respecting  its  therapeutic  value  ?  Every  physician  recognizes  the  neces- 
sity of  sustaining  to  the  utmost  the  vegetative  functions  of  the  body  in 
disease.  Disease,  as  it  is  usually  found,  may  be  defined  as  that  condition  of 
metabolism  in  which  cataholism  is  more  active  than  anabolism.  In  another 
sense  the  contrary  is  true,  and  the  excessive  production  of  tissue,  especially 
of  adipose  tissue,  is  in  some  respects  just  as  much  a  disease  as  the  loss  of 
weight,  which  we  usually  associate  with  most  diseases.  In  my  opinion  the 
disease  which  results  in  hypertrophy  may,  as  a  rule,  he  entirely  controlled  by 
diminishing  the  amount  of  food,  unless  it  has  gone  so  far  as  to  be  prac- 
tically irremediable.  The  excess  of  activity  of  anabolism  is  associated  very 
frequently  with  advancing  years.  The  habit  of  eating  becomes  fixed  in  child- 
hood, youth  and  manhood,  that  is  during  the  period  of  growth  and  maximum 
activity  of  life.  \Yhen  senectitude  approaches,  if  the  habit  of  eating  remains 
unchanged,  larger  quantities  of  food  are  ingested  than  are  required  for  the 
new  conditions  that  attend  incipient  old  age.  There  is  thus  an  accumulation 
of  tissues  which  may  become  of  a  character  conditioned  upon  an  actual 
derangement  of  nutrition.  On  the  other  hand,  the  condition  usually  found 
in  disease  is  the  activity  of  cataholism.  The  moment  the  temperature  of  the 
body  rises  above  the  normal,  cataholism  gains  the  ascendency.  This  is  based 
upon  the  plain  laws  of  thermodynamics.  The  waste  of  tissue  that  is  the 
attendant  of  disease  often  becomes  so  great  as  to  threaten,  and  even  actually 
cause,  the  death  of  the  patient.  To  combat  this  condition  and  stimulate 
anabolism,  food  of  a  proper  kind  is  one  of  the  most  valuable  of  the  arma- 
ments of  the  physician.  But,  in  this  condition,  we  have  an  entire  change  of 
relations.  The  natural  desire  for  food  usually  has  passed  away.  The  char- 
acter and  activity  of  the  digestive  ferments  are  changed.  There  is  often 
disease  of  the  digestive  organs  themselves,  and  when  not  actually  dis- 
eased their  activity  is  so  impaired  by  the  disease  of  other  organs  that  they 
cannot  be  treated  as  in  the  case  of  health.  Hence,  the  use  of  food  in  disease 
is  regulated  by  entirely  different  conditions  from  use  of  it  in  health.  I  may 
say  that  the  introduction  of  drugs  of  any  description  into  foods  which  are 
intended  for  invalids  is  not  only  undesirable,  but,  in  my  opinion,  criminal. 
Let  me  illustrate  this  by  a  simple  statement:  Among  all  the  foods  which  are 
proposed  for  conditions  of  disease,  there  is  none  which  is  so  valued  as  milk. 
The  value  of  sweet  milk  as  a  food,  even  in  a  state  of  health,  depends  largely 
upon  its  purity  and  freshness,  and  in  a  state  of  disease  these  two  qualities  are 


326  I'lET  AS  A  rilOPKYI.ACTIC  AND  THERAPEUTIC. 

absolutely  imperative.  The  healthy  man  may  use  considerable  quantities  of 
milk  that  contains  millions  of  organisms  per  cubic  centimeter,  or  milk  dosed 
with  formaldehyde,  boric  acid,  beuzoate  of  soda  or  other  preservative,  and 
receive  no  apparent  injury;  but  the  case  is  entirely  different  with  the  invalid. 
The  injestion  of  even  minute  quantities  of  these  bodies,  or  of  old  milk  not 
yet  sour,  may,  and  probably  does,  induce  positive  injury.  Even  pasteurized 
milk  may  be  undesirable,  especially  in  the  case  of  infants,  as  has  been  illus- 
txated  by  the  reports  of  many  physicians.  The  healthy  adult,  in  my  opinion, 
can  drink  pasteurized  milk  with  impunity,  provided  the  milk  was  good  when 
pasteurized,  and  did  not  need  pasteurizing,  but  the  same  good  milk,  pasteur- 
ized and  used  in  a  state  of  disease,  might  be  open  to  serious  objections. 
Another  illustration :  Physicians  often  prescribe  fresh  fruit  juices  for  invalids 
and  convalescents.  The  fresh  juices  of  the  apple  and  of  the  grape  are  those 
usually  employed.  About  a  year  ago  Judge  Morrow,  of  the  Federal  Court  of 
San  Francisco,  came  to  my  office  on  his  way  home  from  Germany.  While 
there  his  physician  had  advised  him  to  drink  fresh  pasteurized  apple  juice, 
and  he  had  done  so  with  great  benefit.  He  came  to  see  me  to  ask  where  he 
could  get  fresh,  pasteurized,  unchemicalized  apple  juice  in  this  country.  I 
reluctantly  told  him  that  I  did  not  know;  that  my  experience  in  buying  fresh 
apple  juices  on  the  market  had  led  me  to  believe  that  they  were  almost  uni- 
versally dosed  with  some  antiseptic,  either  salicylic  acid,  benzoate  of  soda,  or 
sulphurous  acid.  He  said  his  physician  had  told  him  to  avoid  all  such  mix- 
tures. At  the  present  date,  however,  I  can  say  that  matters  have  improved 
very  much.  Large  quantities  of  fresh  apple  juice  and  fresh  grape  juice  are 
now  placed  upon  the  markets  without  the  addition  of  any  chemical  whatever, 
and  they  are  preserved  in  a  much  more  palatable  and  much  more  salable  state 
than  ever  before.  This  is  illustrated  by  a  letter  I  have  recently  received  from 
a  manufacturer  of  fresh  grape  juice  at  Sandusky,  Ohio,  which  is  as  follows: — 

"Sandusky,  Ohio,  IMareli  25,  1009. 
"We  wish  to  state  that  the  three  barrels  of  Grape  Juice  which  you  and 
our  Mr.  Appel  had  sealed  last  October  kept  in  first-class  condition,  as  did 
also  our  entire  output,  and  we  are  pleased  to  advise  you  that,  with  the  excep- 
tion of  a  small  stock  of  Sulphur  Grape  Juice  still  on  hand,  which  we  are 
placing  in  a  limited  section  of  territory,  we  have  withdrawn  the  sale  of 
Sulphur  Juice  altogether  from  the  market,  and  are  now  ofTering  nothing  but 
the  Absolutely  Pure  Article." 

The  first  requisite  which  we  should  make  for  foods  for  invalids  is  that 
they  should  be  pure.  The  next  most  important  thing  is  to  find  a  pure  food 
that  the  invalid  can  digest.  You  cannot  nourish  an  invalid  vi  et  armis. 
You  must  find  out  what  he  can  eat  and  give  him  that,  whatever  it  may  be, 
and  if  the  digestive  organs  themselves  are  diseased,  a  greater  care  must  be 
exercised.  Very  often  sick  people  have  an  irreconcilable  antipathy  to  arti- 
cles of  which,  when  they  are  well,  they  arc  frequently  very  fond,  and  this 


DIET  AS  A  PROrHYLACTIC  AND  TIIP^RAPKUTIC.  327 

idios}Ticrasy  of  the  invalid  must  bo  respected  by  the  physician.  Tt  has  fre- 
quently been  observed  in  cases  of  low  nutrition  that  sour  milk,  or  koumiss, 
may  be  taken  with  relish  and  with  benefit  when  other  forms  of  food  seem  to 
be  rejected.  I  am  not  a  protagonist  of  the  belief  of  Metchnikoff  tliat  sour 
milk  is  the  elixir  of  life.  A  theory  of  this  kind  would  have  to  be  demon- 
strated, and  it  would  take  a  hundred  years  to  demonstrate  it.  But  even  from 
theoretical  considerations  the  theory  does  not  appeal  to  me,  and  I  am  not 
going  to  discuss  it  here.  In  my  limited  experience  at  the  bedside  of  the  sick, 
as  physician  or  friend,  I  have  seen  some  excellent  results  from  the  use  of 
koumiss.  In  my  opinion  the  physicians  of  this  country  should  undertake  to 
promote  tlie  production  of  a  pure  koumiss,  and  I  do  not  mean  by  that  that  it 
shall  be  made  of  mare's  milk,  as  it  originally  was;  nor  do  I  use  the  word  in 
tbe  strict  sense  of  the  Food  and  Drugs  Act — I  mean  good  milk  fermented  in 
a  bottle,  or,  in  other  words,  "lacteal  champagne."  This  is  only  mentioned, 
however,  as  one  of  the  things  that  might  be  more  properly  prescribed  in 
conditions  where  inanition  is  often  a  greater  danger  than  the  disease  itself. 
And  here  I  am  led,  in  the  kindest  of  spirits,  to  remark  that  the  science  of 
nutrition  is  unfortunately  not  very  extensively  included  in  the  curricula  of 
our  medical  schools. 

I  must  also  be  allowed  to  say  that  the  most  preposterous  dicta  that  I 
have  ever  heard  concerning  diet  have  come  not  from  teachers  of  dietetics  and 
cooking,  but  from  physicians  themselves.  In  the  progress  of  medical  educa- 
tion the  near  future,  in  my  opinion,  will  see  the  professorship  of  dietetics  in 
a  m.edical  school  advanced  to  the  same  rank  as  that  of  medicine,  and  I  am 
even  going  further  than  this,  and  say  that  the  practice  of  medicine  in  the 
future  will  be  largely  a  practice  of  dietetics. 

When  I  sat  down  to  write  this  article  I  had  expected  to  apply,  to  some 
particular  disease,  the  principles  which  I  have  tried  to  lay  down,  and  especially 
did  I  have  in  mind  tuberculosis,  but  the  time  allotted  to  me  has  been  used  up, 
and  not  one  of  the  ten  leading  authorities  on  dietetics  which  I  had  marked  and 
placed  upon  my  desk  has  been  opened.  I  shall  leave  this  for  another  time.  I 
simply  want  to  say  that  I  believe  it  is  now  acknowledged  by  physicians  that  the 
successful  treatment  of  tuberculosis  depends  largely  upon  the  diet.  Here  is 
one  of  the  cases  where  apparently, 

"While  the  l^iuidi  holds  out  to  burn, 
The  lo'.vest  lunger  may  return." 

I  have  the  greatest  faith  in  the  future  of  prophylactic  medicine,  aud 
perhaps  the  day  will  come  when  the  physician  will  be  paid  in  proportion  to 
the  efFcctiveness  of  prophylaxis.  While  it  is  true  that  diet  is  only  one  of  the 
factors  in  prophylaxis,  as  well  as  in  therapeutics,  it  is,  in  my  opinion,  one  of 
the  most  potent  factors;  aiul  undoubtedly  a  symposium,  such  as  that  of  to- 
.lay,  in  which  all  the  various  points  of  view  relating  to  diet  are  prominently 
brought  out,  cannot  fail  in  doing  efCective  work  for  good. 


328  THE  THERAPEUTICS  OF  SOLUTION  OF  CALCIUM  CREOSOTE. 


THE  THERAPEUTICS  OF  SOLUTION  OF  CALCIUM  CREOSOTE. 

Bt  LOUIS  KOLIPINSKI,  M.D., 

WASHINGTON,   D.   C. 

Creosote  administration  has  been  hampered  by  the  acrid  taste  of  the 
substance,  and  by  the  nausea  and  vomiting  too  readily  induced  in  many  with 
any  other  than  small  doses.  Those  who  had  successfully  absorbed  large 
amounts  were  looked  upon  by  medical  men  as  exceptional  curiosities,  and  sooner 
or  later  these  cases  diminished  in  interest  because  of  their  refusal  to  continue 
the  use  of  it  or  through  positive  revolt  from  attaining  still  larger  quantities. 
The  various  formula3  for  combining  it  with  aromatics  and  vinous  liquids,  are 
very  ineflficient  to  obtund  its  local  effects  as  are  digestants  or  the  use  of  pills 
or  capsules. 

Thereupon  this  subject  was  seized  upon  by  the  makers  of  secret  remedies 
and  various  wonderful  substitutes  and  derived  compounds  of  creosote  discovered 
and  proclaimed  with  all  the  ardor  of  words  that  the  thirst  for  gold  can  stimulate. 

A  preparation  possessing  in  a  perfect  degree  all  of  its  medicinal  virtues 
and  not  any  of  its  objectional  actions  is  calcium  creosote.  This  has  been 
employed  in  therapy  by  the  writer  long  and  extensively.  In  the  preparation 
and  uses  of  it  he  has  been  aided  by  his  friend  and  colleague,  Dr.  Arthur  J. 
Hall.  All  of  the  following  therapeutic  actions  have  been  confirmed  by  him 
and  several  original  effects  on  disease  observed. 

Creosote  has  marked  chemical  affinity  for  calcium  and  this  property  early 
recognized  was  the  basis  of  a  method  of  its  extraction  from  wood  tar.  When 
molecular  weights  of  creosote  and  calcium  hydrate  are  triturated  together, 
there  results  a  purple-red  granular  mass  with  a  slight  odor  of  creosote  and  a 
sharp  taste,  which  is  soluble  in  water  and  stable  in  preservation.  The  solution 
of  this  body  prepared  according  to  the  following  method  was  the  form  used. 

Take  an  excess  of  calcium  hydrate,  freshly  prepared,  four  or  five  pounds 
and  having  introduced  it  into  a  suitable  percolator,  add  with  stirring  a  pound 
of  creosote.  In  a  little  while  when  the  mass  begins  to  cool  pour  upon  it 
enough  water  to  convert  the  whole  into  a  magma  or  thick  fluid.  Collect  the 
solution  by  slow  percolation.  The  specific  gravity  should  be  1.010-1012.  If 
the  first  liquid  collected  is  less  than  this,  return  it  into  the  percolator. 
When  most  of  the  calcium  creosote  is  dissolved  as  is  evident  by  the  sudden 
sinking  of  the  specific  gravity,  add  another  pound  of  creosote  to  the  residue 
and  resume  the  process.  A  poimd  of  creosote  yields  twenty  pints  of  calcium 
creosote  solution.  It  is  a  light  refracting  reddish-yellow  liquid  becoming 
brown  on  keeping  and  depositing,  on  exposure  to  air,  a  precipitate  of  calcium 
carbonate.  It  has  the  odor  of  creosote  and  a  smart  peppery  taste  but  no  irri- 
tating or  caustic  effect  on  tegumentary  membranes.  It  has  a  strong,  alkaline 
reaction.  Its  antiseptic  properties  are  like  those  of  creosote.  It  is  a  good 
preservative  for  meat,  for  animal  specimens  and  for  urines. 

The  proper  doses  of  calcium  creosote  are :   for  an  infant  of  one  year,  from 


THE  THERAPEUTICS  OF  SOLUTION  OF  CALCIUM  CREOSOTE.  329 

three  to  five  drops  in  water  every  2  or  3  hours.  For  a  child  of  six  to  eight 
years  one  teaspoonful  as  often  as  the  former;  for  an  adult,  two  to  four  tea- 
spoonfuls  in  a  tumbler-glass  or  less  of  water.  These  quantities  can  often  be 
given  day  and  night.  The  patient  is  thus  able  to  take  four  fluidounces  more 
or  less  per  diem  a  quantity  equivalent  to  ninety-six  drops  of  creosote.  A 
fluid  dram  of  the  solution  contains  1+  grain  of  the  compoimd. 

Six  fluid  ounces  a  day  have  at  times  been  -given  without  protest  or  any 
unpleasant  reaction.  An  efficient  dose  for  an  adult  in  all  cases  of  acute  disease 
is  two  teaspoonfuls  and  this  amoimt  need  not  be  increased. 

There  are  several  disturbances  that  may,  in  rare  instances  mar  the  harmony 
of  its  action.  In  frail  children  the  dose  of  a  teaspoonful  may  result  in  speedy 
vomiting  or  regurgitation.  This  requires  a  reduction  to  one-half  or  one-quarter 
of  the  first  quantity  for  further  tolerance. 

In  very  infrequent  examples  it  produces  a  skin  eruption;  affecting  in 
succeeding  order  the  extremities,  trunk  and  face.  This  is  a  roseola,  with  an 
efflorescence  in  size  like  that  in  secondary  syphilis  and  of  a  bright  red  or  pur- 
plish color.  It  may  be  mistaken  for  that  of  the  venereal  disease  or  morbilli, 
hardly  for  that  of  copaiba  balsam.  There  is  moderate  itching  felt,  but  insuffi- 
cient to  disturb  sleep. 

The  appearance  of  this  rash  need  not  demand  a  suspension  of  the  use  of 
the  solution.  It  was  seen  to  disappear  in  eight  days  in  a  woman  with  typhoid 
fever  whilst  the  treatment  continued  as  before. 

Solution  of  calcium  creosote  has  been  with  the  writer  a  favorite  and  con-, 
stant  remedy  in  the  following  diseases : 

In  croupous  pneumonia  and  pleuropneumonia,  it  should  be  given  at  two 
hour  intervals  without  interruption.  The  high  fever  of  the  first  day  sinks  or 
becomes  a  normal  temperature,  on  the  second  where  it  so  remains  with  cure 
by  abortion  or  else  rising  again  to  a  moderate  degree  continues  so  for  a  week 
or  less.  Where  the  administration  of  the  remedy  can  be  started  soon  after 
the  chill  of  the  onset  the  disease  is  often  cut  short  and  the  cure  of  a  grave 
malady  accomplished  in  a  day  or  two,  is  apparent  to  the  patient  by  the  languor 
and  weakness  of  his  convalescence  which  persists  for  one  or  two  weeks.  Whilst 
absolute  confidence  is  felt  in  the  treatment  of  pneumonia  with  this  remedy  yet 
from  habit  or  other  cause  the  writer  as  a  custom  associates  with  it  the  use  of 
hot  water  bags  applied  to  the  posterior  thorax  and  refilled  every  five  hours, 
and,  incredibile  diclu,  in  infants  and  small  children,  with  the  faith  of  old 
women,  the  flaxseed  meal  poultice. 

In  pneumonia,  calcium  creosote  cuts  short  the  disease,  lowers  the  fever, 
slows  the  respiration  and  pulse,  facilitates  and  increases  the  cough  and  very 
probably  acts  as  a  pulmonic  antiseptic.  As  dispatch  and  constant  ministration 
are  necessary  for  a  rational  result  and  cure,  sedatives  and  hypnotics  as  harmful 
to  labored  breathing  should  never  be  given. 

Typhoid  fever  is  very  successfully  treated  with  calcium  creosote.  The 
average  duration  for  all  ages  is  15  days.  l^Iany  eases  yield  in  7  to  9  days. 
The  patient  is  kept  in  bod,  a  nurse  attends  constantly.  Extraneous  impulses 
and  excitement  are  disbarred.     He  receives  a  milk  diet  and  drinking  water 


330     THE  THERAPEUTICS  OF  SOLUTION  OF  CALCIUM  CREOSOTE. 

liberally.  The  use  of  the  bed  pan  is  never  omitted.  He  is  given  the  creosote 
ever}-  two  hours  day  and  night  until  the  fever  declines.  When  the  night  begins 
to  offer  long  and  refreshing  sleep,  his  rest  is  not  disturbed  by  awakening  him. 
During  the  immediate  apyretic  end  stage,  four  doses  are  required  each  day. 

In  typhoid  fever  calcium  creosote  acts  as  an  efficient  non-poisonous  anti- 
septic to  the  mouth  cavity,  stomach  and  intestine.  It  deodorizes  and  disinfects 
the  stools.  It  slows  and  strengthens  the  pulse,  deepens  the  respiration,  refreshes 
and  revives  the  patient.  Prevents  toxemia  and  delirium,  reduces  the  fever  ia 
three  days,  makes  the  hyperpyrexia  innocuous  and  stops  the  disease  in  one- 
half  the  time  of  its  natural  course.  It  reduces  the  mortality  to  the  lowest 
number.  As  the  deaths  are  lessened,  so  are  the  many  complications,  and 
above  all  do  intestinal  haemorrhage  and  intestinal  perforation  diminish,  they 
may  even  be  said  to  cease  to  occur. 

Any  treatment  that  cures  needs  the  aid  of  none  other  and  therefore  with 
calcium  creosote  in  typhoid  fever  other  drugs  are  not  exhibited  or  other  means 
of  fever  reduction. 

Its  great  efficiency  is  shovm  in  the  total  abrogation  of  the  cold  vvater 
bath,  packs  and  sponging.  The  first  especially  is  abhorrent  to  aU  patients, 
past  or  present  and  a  work  of  arduous  toil  for  nurses.^ 

Cholelithiasis  has  received  both  medical  and  surgical  treatment.  The 
latter  of  late  years  with  great  benefit  and  brilliancy.  An  operation  is 
indicated  where  medicinal  remedies  fail  or  where  constantly  recurring  attacks 
of  hepatic  pain,  fever,  jaundice,  indicate  active  progression.  Operation  is 
needed  where  any  of  the  sudden  or  pronounced  complications  appear  or  are 
frankly  suspected,  as  cholesystitis,  gall-bladder  adhesions  ^vith  pain  and 
stenosis  chronic  obstruction  of  the  cystic  or  common  duct,  perforation, 
peritonitis,  purulent  cholangeitis  and  liver  abscess.  The  indications  for 
operating  are  numerous,  frequent,  and  almost  always  sufficiently  clear. 
Surgical  relief  of  gall-stones  is,  however,  very  often  refused  either  from  great 
fear  or  prejudice. 

It  was  amongst  this  class  of  patients  that  calcium  creosote  was  first 
tentatively  tried  and  soon  by  repeated  examples  it  became  evident  that  in 
gall-stone  subjects  of  the  severely  active  t}7-)es  with  frequent  attacks  of  colic, 
jaundice,  fever  with  or  without  chills;  much  emaciation,  the  peculiar  blanched 
facies  of  those  not  jaundiced,  with  gall-stones  obviously  producing  a  slow 
chronic  infection,  with  enlargement  of  tlie  liver,  tenderness  of  gall-bladder 
and  epigastrium,  in  all  such  cases  refusing  surgery  the  calcium  creosote  has 
been  found  to  be  of  great  value.  It  seems  to  make  all  active  symptoms 
quiescent.  The  patient  resumes  his  journey  of  life  no  longer  harrassed  by 
his  burden. 

The  solution  is  given  four  times  a  day  and  may  be  continued  for  months. 
A  liberal  milk  diet  is  a  valuable  aid  as  the  anomalous  dyspeptic  symptoms  of 
gall-stones  soon  abate  with  its  use.     Calcium  creosote  seems  to  act  as  an  anti- 


1  A  fuller  description  of  this  treatment  can  be  found  in  the  Monthly  Cyclopaedia 
and  Medieal  Bulletin,  vol.  ii,  1900,  page  05. 


THE  THERAPEUTICS  OF  SOLUTION  OF  CALCIUM  CREOSOTE.  331 

septic  to  the  stomach,  upper  intestine  and  bile  tracts  and  thereby  prevents  the 
continuance  or  recurrence  of  the  septic  fevers  of  the  disease.  In  what  other 
way  to  explain  the  remarkable  clinical  efficiency  of  its  action  is  obscure.  It 
is  not  a  solvent  of  hepatic  calculus  in  vitro. 

The  following  cases  are  instances  from  practice : 

Case  I. — A  woman  of  55,  whose  menstruation  ceased  at  50,  had  a  first 
attack  of  hepatic  colic  with  jaundice  four  years  before.  For  two  years  thereafter 
her  health  was  good.  Then  the  hepatic  colic  reappeared  of  great  severity  and 
frequency,  the  subsequent  jaundice  was  prolonged,  so  that  fresh  attacks  of  acute 
pain  would  set  in  before  the  color  of  the  skin  had  returned  to  normal.  The 
later  attacks  were  followed  by  chills  of  regular  or  irregular  type,  and  lengthened 
fevers,  of  high  or  low  variety.  The  febrile  infection  persisted  for  the  greater 
part  of  three  months.  Before  and  during  this  time  the  history  of  the  case 
was  reviewed  and  careful  physical  examination  made  by  several  surgeons  who 
suggested  speedy  operation.  The  patient  declined  to  submit,  fearing  the  risk 
to  life.  She  was  then  in  a  bed-ridden  state,  much  debilitated.  Her  original 
weight  of  212  pounds  was  reduced  to  140.  In  this  condition  the  use  of 
calcium  creosote  was  begun  and  continued  for  nearly  six  months,  during  which 
time  her  health  was  good  and  her  recovery  astonishingly  rapid. 

Case  II. — An  old  woman  had  at  long  intervals  mild  paroxysms  of  hepatic 
colic  with  faint  jaundice  at  times,  simulating  attacks  of  acute  indigestion.  Fur- 
ther on  the  painful  seizures  reappeared  every  week  or  two  lasting  from  an  hour  to 
a  day,  producing  nausea  and  vomiting  and  accompanied  with  a  heavy  chill  and 
a  high  fever  (105°  F.),  with  diHrium  and  unconsciousness.  The  Liver  and 
gall-bladder  fundus  were  tender.  She  becomes  debilitated  and  helpless.  The 
thought  of  surgical  aid  was  beyond  the  fortitude  of  the  family  to  endure  on 
account  of  the  patient's  feebleness  and  great  age,  she  being  beyond  90  years. 
The  calcium  creosote  was  given;  in  the  succeeding  five  months  there  was  one 
mild  attack  and  no  further  disturbance  which  could  be  ascribed  to  the  active 
irritation  of  gaU-stones. 

In  scrofula,  calcium  creosote  is  an  efficient  remedy.  In  tuberculous  dis- 
eases of  the  bones  and  joints  in  children  and  young  people  it  is  also  of  great 
value.  In  Pott's  disease  of  the  spine,  hip-joint  disease,  in  white  swelling  of 
the  knee-joint,  great  improvement  has  been  repeatedly  observed. 

In  scrofulous  nasal  catarrh,  its  action  is  good.  In  tuberculous  lymphatic 
glands  particularly  of  the  neck  all  reliance  is  placed  on  it  to  the  total  exclusion 
of  surgical  extirpation.  Calcium  creosote  has  also  been  successfully  used  in 
cases  after  operation  where  persistent  sinuses  remained  from  infiltrated  con- 
nective tissue  or  what  is  common  enough,  a  new  progeny  of  glandular  swellings 
along  the  lines  of  incision. 

In  scrofulous  keratitis  its  action  in  healing  is  beautifully  rapid  and  sure. 
To  the  skeptic  in  drugs,  to  the  mystic  or  superstitious  the  curing  of  such 
obvious  lesions  is  a  silencing  argimient  of  the  virtue  of  therapy.  In  these 
painful  corneal  ulcerations  no  local  treatment  is  needed.  Where  the  diet  can 
be  enriched  that  should  alwavs  be  done. 


332  THE  THERAPEUTICS  OF  SOLUTION  OF  CALCIUM  CREOSOTE. 

In  tuberculosis  of  the  viscera,  the  mucous  and  serous  membranes  above  all 
others  in  pulmonary  tuberculosis  the  writer  has  not  observed  any  beneficial 
eirect  on  the  unfavorable  progress  of  the  disease  or  in  the  abatement  of  any  of  the 
severer  s}Tnptoms.  Not  so,  however,  in  the  pretubercular  state.  This  is  very 
common  amongst  young  people,  many  later  on  becoming  victims  of  the  parent 
cause,  others  carrying  their  debility  to  old  age.  The  classic  description  of  the 
tuberculous  habit  need  not  be  too  closely  followed  in  the  recognition  of  this 
state.  Proof  sufficient  is  had  where  parents,  or  grandparents,  died  of  phtliisis. 
The  body  weight  twenty  pounds  under  normal  of  age  and  sex.  The  mucous 
membrane  pale  and  dry,  the  skin  white,  the  small  veins  visible.  Whilst 
not  sick  these  subjects  are  never  well  in  feeling  and  constantly  present  minor 
symptoms  of  ill  health.  Chronic  nasopharyngeal  catarrh  is  excessively  com- 
mon. They  are  very  prone  to  catch  cold,  to  catarrhal  inflammation,  dyspepsia, 
constipation  and  often  a  latent  chronic  enteritis;  migraine  attacks  of  a  severe 
form.  To  premature  graying  of  the  hair — to  chronic  lesions  of  the  skin. 
They  are  prone  to  pneumonia  in  youth. 

The  solution  of  calcium  creosote  corrects  the  dyspeptic  disturbances,  aids 
digestion  and  nutrition.  Its  immediate  effect  is  that  of  a  non-intoxicating 
exhilarant.  Patients  declare  they  feel  better  as  long  as  they  continue  to  take 
it.  It  increases  the  appetite,  the  vigor  and  weight  of  the  body.  The  various 
chronic  affections  of  the  pretubercular  state,  diminish  or  cease  to  be.  In 
frail  children  it  will  be  found  to  be  taken  with  avidity. 

In  the  summer  diarrhoea  of  infants  it  is  usually  a  very  efficient  remedy. 
It  must  be  given  early  and  in  oft  repeated  doses  and  in  all  cases  with  the 
prompt  correction  of  the  offending  food  or  diet. 

Dr.  Hall  has  more  particularly  observed  the  action  of  calcium  creosote 
in  appendicitis  not  demanding  section.  In  a  number  of  cases  there  was 
prompt  abatement  of  pain,  tenderness,  gastric  disturbance  and  fever.  Fre- 
quent doses  are  necessary. 

Also  in  haemorrhoids  it  is  a  good  palliative.  It  corrects  the  itching  and 
stops  the  bleeding.  When  inflamed,  the  pain  and  local  discomfort  are 
relieved.  The  pile  tumor  itself  has  been  seen  to  shrink  or  disappear  altogether. 
These  various  diseases  represent  what  has  been  learnt  by  a  long  use  of  solution 
of  calcium  creosote  in  their  treatment. 

This  form  of  creosote  possesses  perhaps  other  virtues  than  those  here 
described  and  may  be  found  to  be  very  useful  in  other  systemic  affections  and 
local  pathologic  changes,  not  alone  by  its  internal  administration  but  by  topic 
application. 

Dermatology  seems  to  be  a  field  inviting  a  fair  and  varied  trial.  What 
has  so  far  hero  been  said,  is  offered,  confident  of  success  in  its  use  to  practi- 
tioners of  medicine  and  clinicians. 


THE  TREATMENT  OF  THE  STOKES-ADAMS  SYNDROINHi].  333 


THE  TREATMENT  OF  THE  STOKES-ADAMS  SYNDROME.* 

By  REYNOLD  WEBB  WILCOX,  M.D.,  LL.D., 

Professor  of  Medicine  at  the  New  York  Post-Graduate  Medical  School  and  Hospital; 

Physician  to  St.  Mark's  Hospital. 

NEW  yOBK  CITY. 

The  title  of  this  paper  may  be  misleading  in  that  there  is,  strictly 
speaking,  no  treatment  of  a  syndrome,  but  rather,  of  tlie  imderlying  lesions  of 
which  the  syndrome  is  the  expression,  and  of  the  patient  presenting  these 
symptoms. 

Dcfitiition. — The  syndrome  consists  of  (1)  bradycardia,  (2)  cerebral 
attacks  and  (3)  pulsation  of  cervical  veins  in  excess  of  pulse  rate  (Stokes, 
1846;  Adams,  1827). 

Pathology. — In  a  few  cases  so-called  uraemia  may  be  present.  The  spnp- 
toms  suggest  vascular  disease  of  the  cerebrum  analogous  to  intermittent 
claudication  (Huchard,  also  Gibson  and  Jacquet,  1904)  or  disease  of  the 
medulla  (Charcot).  It  may  be  the  result  of  various  infections,  intoxications 
or,  possibly,  of  prolonged  use  of  digitalis. 

Pathological  anatomy. — Stokes'  original  opinion  was  that  there  vras 
always  (1)  organic  disease  of  the  heart  muscle.  Some  instances  were  inex- 
plicable after  careful  post-mortem  examinations,  and  so  remained  until  the 
suggestion  of  Gaskell's  bridge  (1883)  and  the  discovery  of  the  column 
(bundle)  of  His  (1893)  and  the  work  of  Erlanger  (1905,  also  Humblet  and 
Hering)  who  demonstrated  the  results  of  interference  with  it.  To  (1)  should 
be  added  (2)  localized  disease  of  the  column  of  His  which  may  be  sclerotic 
change  in  the  endocardium,  gumma,  cartilaginous  tumors,  fatty  infiltrations, 
with  atroph}^  or  endarteritis  in  its  artery,  and  (3)  dromotropic  inhibition  of 
pneumogastric  resulting  from  various  lesions. 

Symptoms. — To  those  cited  in  the  definition  of  the  syndrome,  others  must 
be  added: 

1.  Cardiac;  precordial  oppression,  pallor,  anginal  pain^  sweating,  syncope. 

2.  Cerebral;  consciousness  suddenly  and  completely  lost,  vertigo,  epilepti- 
form convulsions  often  preceded  by  an  aura  (olfactory  gustatory,  auditory  or 
tactile),  apoplectiform  attacks  not  followed  by  paralysis  during  or  after  them. 

3.  Eespiratory;  stertorous  breathing,  rarely  apncea,  sometimes  Cheyne- 
Stokes  breathing.     Lassitude  after  the  attack  is  pronounced. 

Signs. — Palpation  of  the  cervical  veins  will  show  a  difference  between 
their  pulse-rate  and  that  of  the  radial  artery.  The  stethoscope  will  determine 
auricular  systoles  in  greater  frequency  than  the  ventricular,  and,  finally,  the 
fluoroscope  will  give  visible  confinnatory  evidence. 

Diagnosis. — Strictly  speaking,  the  Stokes-Adams  syndrome  should  not 
include  those  instances  of  bradycardia  due  to  infections  or  intoxications.     If 


•Read  before  the  American  Thcrap-^utic  Society,  at  its  Tenth  Annual  Meeting,  at 
New  Haven,  Connecticut,  on  May  8,  1909. 


334  1T^^  THEAlTkfENT  OF  THE  STOKES- ADAMS  SYNDROME. 

these  can  be  excluded   and  arteriosclerosis,   especially   of  the   coronaries,   is 
believed  to  exist,  the  diagnosis  should  be  clear. 

Prognosis. — This  is  uncertain,  many  die  in  the  attack.  Others  recover 
and  may  live  for  years.  If  a  syphilitic  history  is  obtainable,  the  outlook  is 
much  more  favorable. 

Treatment. — (1)  Prophylactic;  avoidance  of  fatiguing  exercise,  emo- 
tional excitement,  ingestion  of  copious  and  indigestible  food,  all  of  which  have 
been  assigned  as  valid  causes.  (2)  Mechanical;  if  cerebral  symptoms  are 
associated,  the  body  should  be  inverted,  since,  in  some  instances,  bulbar  anajraia 
may  cause  heart  block.  (3)  Medicinal;  this  must  be  based  upon  Erlanger's 
observations  which  demonstrate  that,  in  complete  heart  block,  stimulation 
of  the  vagus  has  no  effect,  but  when  the  accelerator  is  stimulated,  the  rate  of 
both  auricular  and  ventricular  systole  is  increased.  This  rate  is  not  affected 
by  variations  of  general  blood  pressure,  by  asphyxia  or  interference  with  the 
coronary  circulation.  This  would  seem  to  exclude  the  use  of  the  glyceryl 
nitrate  group,  which  is  not  successful,  and  the  digitalis  group,  which  would 
likely  do  harm.  Of  the  remedies  which  increase  the  rate  of  cardiac  beat,  those 
mostly  studied  as  to  their  effect  on  the  ventricle,  are  atropine,  (hyoscyamine 
daturine,  duboisine),  cocaine  and  saponin.  The  following  which  also  increase 
its  force,  ammonium  salts,  alcohol,  (ether,  chloroform),  cactus,  arsenical  salts, 
quinine  and  strychnine,  should  be  cited.  Drugs  which  are  known  to  act  upon 
the  accelerator  centre  are  ammonia,  caffeine,  picrotoxin,  cactus  and  staphisagria. 
Obviously,  many  of  these  drugs  present  disadvantages,  or  are  not  of  pronounced 
action,  so  that  they  may  be  excluded  from  consideration. 

Usually  a  combination  of  atropine  for  diminishing  the  tone  of  the  vagus 
terminations,  in  conjunction  with  strj^chnine  for  increasing  the  force  and 
frequency  of  the  ventricular  systoles,  has  been  advocated.  Of  course,  atropine 
is  useless  in  affections  of  the  myocardium  of  which  the  syndrome  is  the  ex- 
pression. Alcohol  has  at  times,  apparently  shortened  the  duration  of  the 
attacks.  Theoretically  cactus,  which  is  found  to  both  increase  the  force  and 
rate  of  ventricular  systole,  as  well  as  to  act  on  the  accelerating  centre,  is 
indicated.  Practically,  in  those  instances  in  which  I  have  employed  it, 
recovery  from  the  attack .  and  subsequent  attacks,  has  taken  place.  In  the 
urgency  of  the  symptoms,  and  they  so  appear,  it  should  be  preceded  by  ammonia 
and  the  gravity  of  the  syndrome  warrants  its  use  by  hypodermatic  injection. 
The  fluid  extract  is  the  only  preparation  of  cactus  which  is  recommended  and 
active  specimens  are  readily  obtained  at  the  pharaiacies.  The  dose  is  thirty 
minims  every  hour  or  two,  so  long  as  may  be  required.  After  the  acute  attack 
is  under  control,  it  is  well  to  administer  arsenic  iodide,  in  doses  of  one  one- 
hundredth  to  one  one-fiftieth  of  a  grain,  thrice  daily,  for  a  considerable  period 
of  time. 

Since  gimimata  have  been  frequently  found  on  post-mortem  examination, 
involving  the  column  of  His,  inunctions  of  oleate  of  mercury,  or  better,  for 
immediate  results,  h}'podermatic  injections  of  red  mercuric  iodide,  in  one 
per  cent,  solution  in  sterilized  oil,  in  one-fourth  grain  doses  daily  should  be 
administered.     The  insoluble  mercury  salts  have  not  yielded  so  favorable  an 


THE  STANDARDIZATION  OF  aiATERIA  MEDICA  PRODUCTS.  335 

outcome  in  my  hands.  In  these  instances  mercury  is  useful  no  matter  how 
much  time  has  elapsed  since  the  primary  lesion.  In  addition  to,  and  contem- 
poraneous with,  the  mercury,  strontium  iodide  should  be  administered,  increas- 
ing up  to  massive  doses. 

In  addition,  a  careful  study  of  the  patient  should  be  made,  and  all  other 
pathological  conditions  carefully  studied  and,  so  far  as  is  jjossible,  rectified. 


THE  STANDARDIZATION  OF  MATERIA  MEDICA  PRODUCTS. 

By  F.  E.  STEWART,  Pu.G.,  M.D. 

As  usually  employed,  the  term  standardization  applied  to  materia  medica 
products,  means  their  adjustment  to  chemical  and  physiological  standards. 

The  meaning  of  the  word  "standard"  as  defined  in  the  dictionaries  permits 
a  much  wider  application  to  the  term. 

According  to  the  Standard  Dictionary,  I  am  justified  in  using  the  term  to 
include  the  comparison  of  materia  medica  products  with  any  "type,"  model, 
example,  thing  or  circmnstance  forming  a  basis  for  adjustment;  a  criterion  of 
excellence." 

Before  the  Pure  Food  and  Drugs  Act  of  June  30,  1906,  went  into  effect, 

conformity  with  the  standards  of  the  Pharmacopoeia  was  purely  voluntary. 

This  gave  an  excuse  for  certain  manufacturers  to  set  up  standards  of  their  own. 

In  addition  to  these  variations  due  to  neglect  to  conform  with  Pharma- 

copoeial  standards,  cases  of  wilful  adulteration  were  common. 

This  unfair  competition  made  it  very  difiScult  for  honestly  disposed  manu- 
facturers to  get  living  prices  for  their  goods,  and  some  manufacturers  justified 
themselves  in  adopting  questionable  methods  to  hold  their  trade. 

Pure  Food  and  Drug  legislation  has  done  much  to  change  all  this.  The 
enforcement  of  these  laws  is  gradually  driving  out  unfair  competition. 
Honestly  disposed  manufacturers  are  everywhere  rejoicing.  Now  it  is  possible 
to  get  better  prices,  which  permit  the  employment  of  experts  for  standardiza- 
tion. The  quality  of  materia  medica  products  on  the  market  is  steadily  im- 
proving in  consequence.  We  have  a  right  to  be  proud  of  the  work  of  our  fellow 
member.  Dr.  Harvey  W.  Wiley,  for  his  services  in  this  connection. 

The  subject  of  materia  medica  standardization  embraces  a  much  wider 
scope  than  is  usually  realized  either  by  the  medical  profession,  pharmacists, 
manufacturers  or  the  public.  Many  problems  are  involved  scientifically,  pro- 
fessionally and  commerically.  Conflicting  interests  are  opposed  to  the  stand- 
ardization of  the  materia  medica,  and  are  exerting  enormous  pressure  to 
prevent  it  except  in  so  far  as  it  promotes  individual  commercial  interests. 
The  altruistic  idea  that  all  materia  medica  products  under  the  same  names 
should  be  reduced  to  common  standards,  that  such  standards  should  be  main- 
tained by  manufacturers,  wholesale  and  retail,  and  that  those  refusing  to 
conform  with  standards,  should  be  punished  by  fines  and  imprisonment,  is 


3.36  THE  STANDARDIZATION  OF  MATERIA  MEDICA  TRODUCTS. 

repugnant  to  the  commercial  interests  of  a  large  number  of  manufacturers, 
including  both  retail  druggists  and  wholesale  manufacturing  houses.  Moreover, 
the  educational  interests  of  medicine  and  pharmacy  are  involved;  the  fate  of 
the  medical  and  pharmaceutical  press  is  influenced  by  tlie  development  of  tlie 
subject;  the  legal  fraternity  is  mightily  interested  because  of  the  relations 
wliich  the  patent  and  trade-mark  laws  bear  to  commerce  in  materia  medica  pro- 
ducts. Pressure  is  constantly  being  brought  upon  Congress  and  also  upon  the 
State  legislatures,  to  modify  laws  relating  to  adulterations  of  drugs  and  want 
of  conformity  with  established  standards.  The  question  of  laws  for  the  pro- 
tection of  the  public  from  unlicensed  practitioners  of  medicine  and  pharmacy 
who  are  practicing  at  wholesale  and  at  long  range  without  diagnosis,  is  also  a 
part  of  the  subject.  The  fraternity  engaged  in  this  kind  of  practice  is  wealthy, 
powerful  and  influential,  and  is  not  leaving  a  stone  unturned  to  confuse  the 
issue. 

Taking  these  facts  into  consideration,  I  have  chosen  an  excipicnt  for  the 
purpose  of  working  up  my  material  into  a  mass  and  making  it  into  sugar 
coated  pills  so  that  you  can  take  it  without  realization,  hoping  that  the  results 
may  be  beneficient  and  prove  of  value  to  the  public  by  stimulating  the  society 
to  use  its  gi-owing  influence  in  behalf  of  materia  medica  standardization. 

The  vehicle  I  have  chosen  is  in  the  form  of  a  personal  narrative  of  the 
experience  of  the  author  in  a  life  work  devoted  to  promoting  the  cause  of 
materia  medica  standardization. 

As  a  graduate  of  the  Philadelphia  College  of  Pharmacy,  class  1876,  and 
the  JcfTerson  Medical  College,  class  1879,  I  had  occasion  to  approach  the 
subject  of  materia  medica  standardization  from  both  commercial  and  profes- 
sional sides.  My  intent  upon  entering  the  medical  profession  was  to  make  a 
specialty  of  materia  medica  research,  publishing  the  results  of  investigation  for 
the  benefit  of  science,  and  securing  an  income  from  the  manufacture  and  sale 
of  materia  medica  products,  either  as  a  stockholder  in  a  corporation  estab- 
lished for  the  purpose,  or  through  the  agency  of  some  manufacturing  house 
already  in  the  field. 

The  plan  was  very  similar  to  the  one  taught  by  colleges  of  pharmacy, 
which  is  to  the  effect  that  pharmacists  belong  to  a  fraternity,  in  which  the 
inventions  and  discoveries  of  its  members  are  donated  to  the  common  good  of 
the  profession,  said  profession  of  pharmacy  to  practice  as  a  branch  of  the 
medical  profession,  and  in  harmony  with  its  professional  and  scientific  require- 
fiients. 

My  first  introduction  was  Pectal  Gelatin  Suppository  Capsules,  described 
in  my  graduation  thesis  and  afterwards  published  in  the  Medical  Eecord.  The 
capsules  were  not  patented,  and,  being  commercially  attractive,  were  immed- 
iately appropriated  by  the  manufacturers  without  giving  me  any  credit.  This 
was  a  lesson  in  favor  of  commercial  control  over  new  materia  medica  products. 

My  next  introduction  was  Desiccated  Bullocks  Blood,  which  brought  me  in 
contact  with  a  well-known  pharmaceutical  house  through  its  New  York 
agents.     I   introduced  this  product  to   science  through  the  columns  of  the 


THE  STANDARDIZATION  OF  MATERIA  MEDICA  PRODUCTS.  337 

Medical  Eecord,  and  the  Medical  and  Surgical  Eeporter.  The  house  referred 
to  introduced  it  to  commerce  througli  the  medium  of  its  house  organ,  detail 
force,  advertising  literature,  and  advertisements  in  the  medical  journals.  The 
proper  introduction  of  materia  medica  products  to  science  and  brands  of  the 
same  to  commerce  thus  became  a  subject  of  vital  personal  interest. 

After  making  arrangements  for  the  commercial  introduction  of  Desiccated 
Bullocks  Blood,  I  returned  to  New  York  City  and  went  into  the  practice  of 
medicine.  At  the  request  of  the  house  referred  to,  I  then  called  upon  some  of 
the  leading  physicians  of  the  City  with  their  samples,  literature  and  house 
organ.  The  house  was  making  a  specialty  of  introducing  new  drugs  commer- 
cially in  the  form  of  fluid  extracts,  and  the  literature  sent  out  consisted  of 
reprints  from  their  house  organ  of  articles  relating  to  the  therapeutic  action 
of  the  products  collected  by  their  detail  men  from  all  over  the  United  States. 
My  New  York  medical  friends  after  examining  the  literature  said  that  in  their 
estimation  it  represented  the  worst  form  of  quackery.  I,  therefore,  went  to 
Brookl}Ti  and  consulted  Dr.  Squibb  for  the  purpose  of  ascertaining  the  reason 
for  the  unsatisfactory  condition  of  affairs  existing  in  the  materia  medica  supply 
business.  Dr.  Squibb  gave  me  a  most  cordial  reception,  and  in  an  interview 
lasting  more  than  two  hours  opened  up  the  true  condition  of  affairs. 

I  found  that  Dr.  Squibb  was  engaged  in  the  practice  of  the  pharmac- 
ologic arts  for  money,  just  as  physicians  are  engaged  in  the  practice  of  thera- 
peutics for  money,  yet  he  was  practicing  his  profession  in  a  perfectly  professional 
manner.  Therefore,  the  ideal  I  had  set  up  for  myself  was  both  practical  and 
professional. 

"My  next  move  was  to  read  a  paper  on  this  subject  before  the  Tri-County 
Medical  Society,  at  Glen  Falls,  New  York,  and  I  afterward  accepted  an  invi- 
tation to  discuss  the  subject  before  the  Albany  Academy  of  Medicine.  I  then 
consulted  leading  scientists,  medical  editors,  and  professors  of  medical  and 
pharmaceutical  colleges.  Scientists  considered  the  subject  as  of  commercial 
interest  only,  and  therefore  outside  of  their  field  of  interest.  Publishers  pre- 
ferred things  as  they  were  for  obvious  reasons.  The  colleges  of  pharmacy  and 
retail  druggists  were  opposed  to  any  plan  likely  to  benefit  the  large  manufac- 
turing houses.  The  house  engaged  in  commercially  introducing  desiccated 
blood,  strongly  advised  me  to  let  sleeping  lions  alone.  However,  I  had  made 
up  my  mind  to  go  on  with  my  work,  and  therefore  consulted  Prof.  Charles  Pice, 
afterward  chairman  of  the  committee  for  ^e^^sing  the  Pharmacopoeia,  who,  at 
my  request,  devised  a  technical  name  for  Desiccated  Bullocks  Blood,  and  it  was 
placed  on  the  market  imder  the  title  "Sanguis  Bovinus  Exsiccatus." 

It  now  became  important  to  devise  a  system  for  the  scientific  introduction 
and  standardization  of  materia  medica  products,  and  their  commercial  intro- 
tion,  protective  alike  to  science  and  commerce.  I  found  that  the  field  of  com- 
mercial introduction  was  practically  under  the  control  of  the  so-called  proprie- 
tary medicine  business,  and  that  the  system  used  for  maketing  products  was 
diametrically  opposed  to  scientific  and  professional  requirements;  that  it  was 
a  misconception  of  the  patent  law,  an  abuse  of  (lie  trade-mark  law,  and  inim- 
icable  to  the  public  interests. 
4 


338  THE  .STANDARDIZATION  OF  MATEKIA  MEDICA  rKODDCTS. 

Judging  from  my  own  experience  with  the  Eectal  Capsules,  it  was  appar- 
ent that  some  system  should  be  adopted  for  the  protection  of  capital  invested 
in  the  medical  and  pharmacal  industries.  I  coiild  see  no  reason  wliy  Materia 
Medica  inventors  should  not  be  rewarded  with  patent  grants  just  as  medical 
writers  are  rewarded  with  coypright  grants,  provided  the  products  themselves 
were  open  to  competition  and  introduction  to  science  by  means  of  impartial 
discussion,  classification,  and  standardization. 

My  position  on  this  subject  was  the  same  as  that  of  Terrill  as  given  in  his 
treatise  on  Patent  Laws: — 

"Tlie  theory  upon  which  tliese  laws  rest  is  tliat  it  is  to  th«  interest  of  the 
commiuiity  that  persons  should  bo  induced  to  devote  their  time,  energies  and 
resources  to  original  investigation  for  the  furtherance  of  science,  the  arts,  and 
manufactures.  This  was  recognized  from  the  earliest  periods  which  can  pretend 
to  be  described  as  civilized.  It  is  to  the  advantage  of  the  whole  community  that 
authors  and  inventors  should  be  rewarded,  and  no  measure  of  reward  can  be  con- 
ceived more  just  or  equitable,  and  bearing  a  closer  relation  to  the  benefit 
conferred  by  the  particular  individual,  than  to  grant  him  the  sole  right  to  his 
"writing  or  discovery  for  a  limited  period  of  time." 

Vv'hile  studying  this  subject  I  was  invited  to  contribute  a  paper  to  th.e 
section  on  Materia  ]\Iedica  and  Therapeutics,  of  the  American  Medical  Associa- 
tion, on  the  "Materia  Medica  of  the  Future,"  to  be  read  at  the  Eichmond  Meet- 
ing in  Ma}'-,  1881.  After  reading  this  paper  Professor  Dunster,  of  the  Uni- 
versity of  Michigan,  offered  the  following  resolution  of  my  devising: — 

"Ifesolved,  That  it  is  contrary  to  the  spirit  of  the  code  of  ethics  for  a  phy- 
sician to  prescribe  a  remedy  controlled  bj'^  patent,  copyright  or  trade-mark.  This 
shall  except,  however,  a  patent  upon  a  process  or  machinery  for  manufacture, 
and  also  except  the  use  of  a  trade-mark,  provided  the  article  so  marked  is  accom- 
panied by  a  working  formula,  duly  sworn  to,  and  a  tecl)uical  name  under  which 
all  may  mauTifacture  and  sell  the  same  article." 

This  resolution  was  referred  to  the  Judicial  Council  and  rejected,  because 
it  recognized  Materia  Medica  monopoly  by  process  patents. 

I  have  no  reason,  after  a  study  of  this  subject  since  1880,  to  change  my 
mind  except  to  recognize  what  I  did  not  then  recognize,  the  necessity  of  keeping 
the  practice  of  the  pharmacologic  arts  under  professional  control  where  it  prop- 
erly belongs.  Granting  patents  to  imlicensed  practitioners  protecting  them  in 
carrying  on  a  business  in  medicine  conducted  in  competition  with  the  medical 
and  i^harmaceutical  professions,  and  using  misleading  methods  of  advertising 
to  create  a  demand  for  their  products,  is  inimicable  to  the  public  welfare. 

To  protect  the  practice  of  the  pharmacologic  arts,  the  following  legislation 
was  suggested  by  the  Supreme  Court  of  the  United  States  in  its  decision  in  the 
case  of  Wordcn  vs.  California  Fig  Syrup  Company,  No.  35,  October  Term, 
1902  :— 

"Most,  if  not  all,  the  States  of  this  Union  have  enactments  forbidding  and 
making  penal  the  practice  of  medicine  by  persons  who  have  not  gone  through  a 
course  of  appropriate  study  and  obtained  a  license  from  a  board  of  examiners; 
and  there  is  similar  legislation  in  respect  to  pharmacists.  And  it  would  seem 
to  be  inconsistent  and  to  defeat  such  salutaiy  laws,  if  medical  preparations,  often 


THE  STAKDATvDLZATIOK  01?  MATEEiA  iiiiJ>ICA  PRODUCTS. 


339 


and  \isually  containing  powerful  and  poisonous  drugs,  are  permitted  to  be  widely 
advertised  and  sold  to  all  who  are  willing  to  purchase.  Laws  might  properly 
l)c  passed  limiting  and  controlling  such  traffic  by  restraining  retail  dealers  from 
selling  such  medicinal  preparations,  except  when  prescribed  by  regular  medical 
practitioners." 

It  is  manifest  that  under  the  protection  of  proper  medical  and  pharmacal 
laws  to  protect  the  field  of  pharmacologj'  from  dishonest  commercial  exploita- 
tion, and  a  proper  etliical  code  for  the  guidance  of  physicians,  phannacists,  and 
manufacturers  in  their  relations  with  each  other,  and  with  the  public,  enforced 
by  a  board  of  control,  or  bureau,  representing  these  several  interests,  it  would 
be  safe  to  open  the  educational  channels  of  medicine  to  the  discussion  of  the 
newer  materia  medica.    I  therefore  commenced  to  advocate  such  a  plan. 

My  next  move  was  to  present  the  plan  above  mentioned  to  the  Smithsonian 
Institution.  This  occurred  mimediately  after  the  A.  M.  A.  meeting  in  1881. 
The  plan  as  presented  included  an  investigation  of  the  materia  medica  of  the 
world  under  the  auspices  of  the  United  States  Government,  aided  by  the  med- 
ical departments  of  the  Army,  the  Xavj-,  and  the  Marine  Hospital  Service.  It 
included  the  establishment  at  Washington  of  a  National  pharmacologic  labora- 
tory, the  organization  of  a  National  Pharmacologic  Society  of  physicians  and 
pharmacists,  and  the  founding  of  scientific  departments  by  the  great  commercial 
houses  engaged  in  the  chemical  and  pharmacal  industries  to  co-operate  with  the 
work. 

A  Bureau  was  to  be  established  under  the  control  of  the  Smithsonian  Insti- 
tution, and  experts  in  the  pharmacologic  arts  employed  for  carrying  on  the 
work.  Materia  Medica  products  were  to  be  collected  from  various  nations  and 
tribes,  and  placed  on  exhibition  in  the  National  Museum.  Those  foimd  worthy 
of  investigation  were  to  be  scientifically  examined,  and  the  information  thus 
evolved  issued  ])y  the  Bureau  to  the  medical  and  pharmaceutical  professions  and 
manufacturing  houses  in  the  form  of  Working  Bulletins,  accompanied  by  mate- 
rial for  a  collective  investigation  embracing  botany,  pharmacognosy,  pharmacy, 
pharmacodynamics,  and  therapyd}T3amic3. 

To  aid  in  this  work  it  was  proposed  to  publish  a  montlily  journal  and  an- 
nual report. 

The  plan  was  approved  by  the  Surgeon  Generals  of  the  Army,  Navy,  and 
:Marine  Hospital  Service,  also  by  the  President  of  the  National  Board  of  Health 
and  the  Director  of  the  Army  Medical  Museum.  It  was  endorsed  by  the  Alumni 
Association  of  the  Philadelphia  College  of  Pharmacy  in  1882,  and  favorably  dis- 
cussed by  the  Philadelphia  County  Medical  Society  in  1881. 

The  plan  was  again  approved  by  the  Smithsonian  Institution  in  1884,  but 
on  account  of  the  lack  of  funds  it  could  not  be  carried  out.  It  was  also  approved 
by  Prof.  H.  G.  Beyer,  Curator  of  the  National  Museum,  in  a  letter  written  to 
me  October  11,  1885,  in  which  he  said,  "I  think  your  conception  of  establishing 
a  Bureau  or  Department  of  Pharmacolog}'  under  the  Government  a  grand  one, 
and  no  doubt  one  that  ought  to  be  carried  out.  We  have  here  all  sorts  of  scien- 
tific Bureaus,  and  it  seems  to  me  not  one  which  is  calculated  to  bo  of  such 
immediate  benefit  to  mankind  as  a  Department  of  Pharmacology  would  be  to 


340  THE  STANDARDIZATION  OF  MATERIA  MEDICA  PRODUCTS. 

the  American  people,  not  to  speak  of  the  immense  scientific  value  it  would  be  to 
medicine  and  pharmacy.  I,  for  one,  should  certainly  hail  the  inauguration  of 
such  an  institution  with  great  delight;  it  is  exactly  what  I  have  been  having  in 
mind  for  the  last  year  and  a  half." 

In  1891  the  American  Medical  Association  memorialized  Congress  in  the 
following  words : — 

"To  five  Honoralle  Senate  and  House  of  Representatives  of  tha  United  States, 
in  Congress  assemtlcd — Greeting: 

"We,  the  officers  and  members  of  the  American  Medical  Association,  in 
pursuance  of  a  resolution  passed  at  a  session  of  tlie  annual  meeting  of  said 
association,  held  in  the  city  of  Washington,  D.  C,  May  8,  1891,  crave  the  atten- 
tion of  J  our  honorable  body  to  the  following  memorial : 

"Resolved,  That  the  Government  of  the  United  States  be  memorialized  by 
the  American  Medical  Association  in  favor  of  the  plan  proposed  by  Dr.  F.  E. 
Stewart,  whereby  the  valuable  work  of  the  laboratories  of  the  Army,  Navy, 
Marine  Hospital  Service,  Smithsonian  Institution,  Customs  Service,  Agricultural 
Department,  and  other  departments  of  the  public  service,  in  the  line  of  the 
identification  of  drugs,  may  be  facilitated  and  made  of  more  general  utility,  by 
the  publication  of  their  results,  so  that  the  information  thus  gathered  may  be 
disseminated  for  the  general  benefit  of  the  professions  of  medicine  and 
pharmacy. 

"Acting  in  accordance  with  the  above  resolution,  we  herewith  hand  your 
honorable  body  the  paper  of  Dr.  F.  E.  Stewart  referred  to,  hoping  that  you  will 
devise  some  means  whereby  the  valuable  suggestions  therein  contained  may  be 
carried  into  effect,  believing  tliat  they  are  calculated  to  promote  progress  in  tlie 
science  of  medicine  and  the  useful  arts  of  medicine  and  pharmacy,  and  thus 
prove  of  great  benefit  to  the  American  people." 

(Signed) 

Henry  0.  JIarcy, 
President  of  the  American  Medical  Association. 

W.  B.  Atkinson, 
Permanent  Secretary  of  the  American  Medical  Association. 

The  American  Pharmaceutical  Association,  in  189G,  appointed  a  connnittec 
on  national  legislation  to  consider  the  question  of  ]\Iateria  Medica  monopoly,  of 
which  I  was  Chairman  four  years.  The  reports  of  the  committee  were  published 
in  the  Troceedings  of  the  A.  Ph.  A.  for  1896-'97-'98,  and  '99,  and  contain  im- 
portant data  supplied  by  leading  members  of  the  bench  and  bar. 

As  a  result  of  this  work  a  document,  known  as  "Preamble  and  Resolutions," 
expressing  the  opinion  of  the  A.  Ph.  A.  on  the  subject  of  materia  medica 
monopoly,  was  adopted  and  sent  out  to  the  A.  M.  A.  This  document  embodied 
the  views  expressed  in  the  resolution  offered  at  the  Richmond  meeting  of  the 
A.  M.  A.  in  1881,  above  quoted. 

The  Journal  of  the  American  Medical  Association,  in  its  issue  for  April 
27,  1901,  published  my  paper,  entitled  "Proposed  National  Bureau  of  Materia 
Medica,"  and  editorially  endorsed  the  plan. 

In  a  letter  from  the  editor  dated  March  19,  1901,  he  says:  "I  have  just 
read  your  excellent  article,  and  I  must  say  that  I  am  surprised  and  delighted  at 
the  way  you  have  handled  the  subject." 


THE  ADRENAL  PRINCIPLE  IN  ANIMAL  EXTRACTS.  341 

An  association  of  physicians  and  pharmacists  was  organized  in  the  city  of 
Los  Angeles,  California,  October  14,  1901,  "to  promote  the  public  welfare  by 
establishing  a  National  Bureau  of  Materia  Medica,  to  be  supported  by  the  phy- 
sicians and  pharmacists  of  America,  by  means  of  a  National  Pharmacy  Com- 
pany, acting  as  manufacturers'  agents  or  manufactures,  and  dealing  in  medi- 
cines which  conform  to  the  standards  of  the  United  States  Pharmacopoeia,  and 
other  recognized  standards." 

The  bureau  was  then  incorporated  under  the  laws  of  New  Jersey  by  the 
Hon.  James  B.  Dill,  now  Judge  of  the  New  Jersey  Court  of  Errors  and  Appeals, 
under  the  name  "National  Bureau  of  Medicines  and  Foods."  The  National 
Phannacy  Company  wns  also  organized,  and  among  the  stockholders  were  some 
of  the  principal  physicians  and  pharmacists  of  the  Pacific  Coast. 

(To  he  concluded  in  our  next  issue.) 


THE  ADRENAL  PRINCIPLE  AS  THE  MAIN  ACTIVE  AGENT  IN 
PITUITARY,  TESTICULAR,  OVARIAN  AND  OTHER 
ANIMAL  EXTRACTS.* 

By  CHARLES  E.  de  M.  SAJOUS,  M.D., 

PHILADELPHIA. 

(Concluded  from  the  May  nurnbcr.) 

Beginning  with  the  pituitary,  the  prevailing  belief  that  it  is  the  source 
of  an  internal  secretion  has  led  to  the  therapeutic  use  of  extracts  of  this 
organ.  I  am  inclined  to  believe,  however,  that  it  does  not  secrete  anything 
and  that  all  the  phenomena  it  awakens  in  the  body  at  large,  are  provoked 
through  the  instrumentality  of  nerves  which  connect  it  with  the  adrenals,  the 
thyroid  and  the  vascular  system. 

In  a  ease  reported  by  E.  Wasdin,  of  the  Marine  Hospital  Service,''  a  fall 
had  caused  a  compound  fracture  of  the  left  maxilla.  Although  the  wound 
was  clean  and  normal  and  cultures  showed  that  no  bacteriamia  was  present, 
the  temperature  rose  to  104°  F.,  and  various  symptoms  appeared,  including, 
on  the  seventh  day,  bronzing  of  the  skin.  This  was  followed  by  death  on  the 
twenty-first  day,  its  direct  cause  remaining  obscure.  Having,  some  time  later, 
hecome  familiar  with  my  views  to  the  effect  that  the  pituitary  body  contained 
the  center  which  governed  the  adrenals,  Dr.  Wasdin  was  led,  by  the  bronzing, 
to  suspect  an  injury  of  the  pituitary.  On  consulting  the  records  of  the 
autopsy,  he  fouud  that  there  had  also  been  fract^^Te  of  the  sphenoid  involving 
the  sella  turcica,  the  pituitary  being  gangrenous  and  destroyed.  The  evi- 
dence in  favor  of  my  belief  that  tlie  pituitary  body,  in  man,  is  not  a  secreting 
gland,  hut  a  great  cpithelio-nervous  organ  which  controls  through  nerves  to 

•  Read  by  invitation  boforc  the  Medical  Society  of  Kings  County,  Brooklyn,  April 
20,  1909. 


342  THE  ADRENAL  PRINCIPLE  IN  AN13vLiL  EXTRACTS. 

the  adrenals  aud  thyroid,  general  oxygenation,  metabolism,  and  nutrition,  is 
sustained  ])y  considerable  evidence,  while,  conversely,  the  prevailing  view  that 
it  secretes  a  product  that  is  of  physiological  use  is  based  solely  on  the  fact 
that  pituitary  extracts  are  active.  But  these  effects  do  not  prove  that  the 
organ  is  the  source  of  a  specific  internal  secretion.  They  correspond  pre- 
cisely with  those  of  adrenal  extracts,  i.e.,  a  rise  of  blood-pressure,  slowing  and 
increased  power  of  the  heart-beats  and  diuresis.  The  dilatation  of  the  kid- 
ney observed  by  Schiifer  is  itself  nothing  but  the  result  of  the  intense 
hj'peraimia  of  these  organs,  the  result  in  turn  of  the  rise  of  blood-pressure  in 
the  body  at  large  caused  by  the  adrenal  substance  tlie  pituitary  extract  con- 
tains. Even  the  local  phenomena  of  the  adrenal  principle  are  obtained  with 
it.  Golla,^  for  example,  found  that  a  three-minim  solution  prepared  by  him, 
injected  into  the  buccal  mucosa,  caused  a  large  area  to  become  blanched  and 
to  remain  so  fortj^-five  minutes. 

The  therapeutic  use  of  pituitary  extract  has  not,  so  far,  given  results 
that  cannot  be  obtained  from  adrenal  extracts.  In  fact,  it  can  hardly  be 
considered,  as  yet,  as  possessed  of  any  clearly  defined  therapeutic  value.  We 
have  no  sound  clinical  criterion  upon  which  its  comparative  indications  can 
be  based.  This  applies  also  to  the  chemistry  of  the  pituitary  product  which 
has  so  far  received  but  little  attention.  ISTot  so,  however,  with  the  next  agent 
considered:   the  testicular  preparations. 

The  prevailing  opinion,  at  the  present  time,  is  that  these  agents  owe 
their  beneficial  effects,  not  necessarily  to  an  internal  secretion,  the  existence 
of  which  is  not  denied,  but  to  nucleo-albumins,  substances  that  are  rich  in 
phosphorus,  resembling  greatly  lecithins  aud  glycero-pliosphates.  This 
applies  mainly  to  the  extracts,  known  ujidcr  the  names  of  didymin,  orchitiu, 
etc.,  which  have  been  used  with  more  or  less  success  in  neuroses,  especially 
tabes,  neurasthenia,  impotence,  and  paralysis  agitans — all  disorders  in  which 
glycero-phosphates  and  the  like  have  given  good  results.  The  fact  that 
beneficial  efl'ects  have  also  been  noted  in  obesity,  eczcTua,  psoriasis  aud  other 
disorders  in  which  either  thyroid  and  adrenal  extracts  are  of  distinct  value, 
suggests  that  both  of  these  substances  are  present  in  testicular  preparations, 
besides  the  phosphorus-laden  nuclear  products  to  which  their  main  thera- 
peutic value  is  ascribed.  The  actual  presence  of  iha  adrenal  principle 
becomes  evident  when  the  identity  of  the  one  testicular  product  which  has 
given  the  best  therapeutic  results  is  sought. 

The  purest  of  testicular  products — that  known  as  spermin — was  isolated 
by  the  late  Professor  Toehl,  of  St.  Petei'sburg.  It  has  not  only  given  better 
results  than  the  ordinary  orchitic  preparations,  but  they  were  obtained  in  the 
same  disorders  as  those  in  M'hich  the  ordinary  extracts  had  been  employed. 

That  spermin  is  unquestionably  identical  to  the  adrenal  secretion  is 
shown  by^many  facts.  It  is  an  oxidizing  body  which  acts  catalytically,  it  gives 
the  guaiac  and  Florence's  ha^min  test,  thus  showing  that  it  is  a  constituent 
of  hemoglobin;  it  is  unaltered  by  boiling,  and  presents  other  characteristics 
of  the  adrenal  principle,  besides  producing  all  its  physiological  effects.     Proof 


THE  ADRE^iAL  rUlNCIPLE  IN  AlsiMAL  EXTllACTS.  343 

that  it  is  an  ubiquitous  constituent  of  the  organism  at  large  is  further  shown 
by  the  fact  that  it  is  found  in  the  blood  of  females  as  well  as  in  that  of  males. 
Finally,  the  class  of  disorders  in  which  it  has  been  employed  with  benefit 
have  all  been  such  as  would  be  equally  benefited  by  adrenal  preparations. 
Spermin,  in  fact,  is  now  regarded  in  Europe,  in  accord  with  the  views  of 
Trofessor  Toehl,  as  a  powerful  oxidizing  tonic. 

The  ovarian  preparations  indicate  as  clearly  their  dependence  for  their 
therapeutic  action  upon  the  adrenal  principle  they  contain.  Wilcox^  writes, 
referring  to  ovarian  extract:  "But  little  is  knowTi  of  its  pharmacological 
action.  Fresh  ovarian  extract  is  said,  when  injected  in  rabbits,  to  raise  the 
blood-pressure,  diminish  the  heart's  action  and  slow  the  respiration;  and 
when  administered  to  the  human  female  also  to  increase  the  arterial  tension. 
In  the  castrated  animal  it  is  found  to  increase  oxidation  to  somewhat  above 
the  normal  degTee."  I  may  add  that  removal  of  the  ovaries  in  sluts  lowers 
their  temperature,  while  the  adininistration  of  ovarian  extract  in  these  ani- 
mals restores  it  to  normal.  Moreover,  ovarian  preparations  enhance  metab- 
olism, increase  diuresis  and  the  excretion  of  urea  and  phosphoric  acid — all 
effects  also  produced  by  the  adrenal  products.  Finally,  their  action  has  been 
found  to  correspond  with  that  of  spermin. 

Therapeutically,  ovarian  preparations  have  been  used  with  more  or  less 
success,  mainly  in  disorders  attending  or  following  menopause,  and  in  those 
met  after  removal  of  the  ovaries.  We  have  seen  that  they  enhance  oxidation 
and  metabolism,  the  underlying  cause  of  the  morbid  phenomena.  This  is 
further  sho^m  by  the  fact  that  they  have  likewise  been  found  of  value  in  dis- 
orders due  to  deficient  catabolism,  such  as  obesity,  gout  and  epilepsy,  and  in 
the  anemias  characterized  mainly  by  deficient  hemoglobin  and  the  disorders 
of  menstruation  associated  therewith. 

These  few  examples  will  suffice,  gentlemen,  to  illustrate  the  general 
principle  I  wish  to  submit  to  you,  namely:  that  it  is  not  because  we  obtain 
physiological  effects  from  the  extracts  of  any  orgau,  that  we  must  conclude 
that  it  produces  a  specific  internal  secretion.  I  have  ascribed  this  preroga- 
tive to  two  sets  of  organs  only  so  far,  the  thyro-paratlm-oid  apparatus  and 
the  adrenals  (the  glycogenic  function  of  the  liver  and  the  production  of  pan- 
creatic ferments  being  deemed  other  than  internal  secretions),  because  these 
alone  present  the  true  attributes  that  warrant  their  being  considered  as  such. 
Their  true  secretions  have  been  traced  from  their  tissues  into  the  blood,  and 
their  role  therein,  if  my  labors  and  steadily  accumulating  confirmatory 
evidence  mean  anything,  has  been  clearly  cletorminod.  Their  presence  in 
every  tissue  endows  that  tissue  with  the  attributes  of  these  joint  secretions, 
and  what  efl'ects  are  produced  therefore,  seem  mainly  ascribable  to  what  pro- 
portion of  these  secretions  they  contain. 

We  do  not  witness  phenomena  which  can  be  ascribed  directly  to  the 
thjToid  secretion  it  is  true,  but  it  becomes  a  question  whether,  in  view  of  the 
other  fmictions  I  ascribe  to  this  secretion,  tlie  effects  we  obtain  from  what 
has,  until  recentl3%  been  termed  therapeutic  doses — the  so-called  average  dose 


344  THE  ADRENAL  PRINCIPLE  IN  ANIINIAL  EXTRACTS. 

of  4  grains  of  the  U.  S.  P.  for  example — do  not  in  reality  evoke  toxic  plie- 
nomena,  and  that  normally  such  a  thing  as  vasodilation  through  the  thyroid 
secretion  never  occurs.  This  involves  the  conclusion  that  we  must  look  upon 
the  small  proportion  of  thyroid  secretion  in  organic  extracts  as  having  hut 
one  purpose,  that  of  enhancing  the  oxidizing  property  of  the  adrenal  suh- 
stance. 

Admitting  with  me,  then,  that  the  purpose  of  the  adrenal  and  thyroid 
secretions  is  to  provide  for  and  sustain  metabolism,  what  general  phenomena 
we  can  expect  from  the  organic  extracts  are  precisely  those  witnessed.  In 
other  words,  we  ohtain  by  means  of  certain  organic  extracts  increased 
metabolic  activity  and  benefit  in  any  disease  in  which  metabolism  (both 
anabolism  and  catabolisra)  is  retarded,  simply  because  the  substances  which 
normally  sustain  it,  the  adrenal  and  thyroid  secretions,  are  artificially 
increased  in  the  blood.  In  this,  it  seems  to  me,  lies  the  secret  of  the  action 
of  organic  extracts. 

Of  course,  certain  extracts  are  far  more  active  than  others,  testicular 
and  ovarian  extracts  for  example.  But  special  provisions  are  made  for  these 
organs  in  order  that  they  may  be  amply  supplied  with  the  adrenal  principle. 
They  are  not  only  provided  with  special  cells  calculated  to  increase  the  pro- 
portion of  adrenal  product — owing  probably  to  the  importance  of  their  role 
in  iS^ature — but  a  close  homology  has  been  found  by  Schiifer  and  others  to 
exist  between  the  interstitial  cells  of  these  organs  and  the  corresponding  cells 
in  the  adrenals.  Moreover,  all  three  sets  of  organs,  the  ovaries,  testicles  and 
adrenals,  are  derived  from  the  Wolffian  body. 

I  have  taken  as  illustrations  the  three  most  prominent  organic  extracts. 
But,  I  may  add  that  spcrmin,  essentially  the  adrenal  oxidizing  substance  we 
have  seen,  gives  the  same  results  as  kidney  extracts.  Placenta  even,  can 
excite  metabolism;  but  as  Dixon^o  wrote  recently,  referring  to  investigations 
by  F.  Taylor  and  himself:  "AVe  have  shown  that  the  human  placenta  con- 
tains a  considerable  amount  of  a  substance  which  is  ...  .  unaffected 
by  boiling.  This  body  has  the  property  of  powerfully  constricting  blood- 
vessels, of  contracting  the  uterine  muscle,  and  of  raising  the  blood-pressure." 
.  .  .  .  "So  far  as  we  have  been  able  to  determine  this  body  has  all  the 
properties  of  adrenalin." 

On  the  whole,  it  seems  to  me  that  there  is  enough  evidence  available  to 
warrant,  at  least  as  a  working  proposition,  the  conclusion  that  certain  organic 
preparations,  of  which  the  piiuitary,  teslicnlar  and  ovarian  extracts  are  types, 
owe  their  therapeutic  activity,  not  to  any  specific  internal  secretion  derived 
from  the  organs  from  which  iJiey  are  obtained,  hut  to  the  presence  in  them  in 
relatively  large  quantities  of  substances  common  to  all  tissues:  the  adrenal 
and  thyroid  secretions.  As  these  substances  jointly  sustain  tissue  oxidation 
and  metabolism,  the  aninicd  extracts  containing  them  are  indicated  in  disorders 
due  to  inadequate  metabolic  activity. 

I  would  add  that  experience  has  shown  that  small  doses  of  the  above- 
m.entioned  animal  extracts  hasten  anabolism  and  thus  enhance  general  nutri- 


ADENOIDS,  NOCTURNAL  INCONTINENCE  AND  THE  THYROID  GLANDS.  345 

tion  and  the  activity  of  all  reparative  processes,  while  large  doses  enhance 
cataholism,  the  formation  of  waste  products  and  denutrition. 

Docs  this  mean  that  the  physiological  effects  I  ascribe  to  the  adrenal  and 
thyroid  secretions  are  to  be  considered  as  the  only  ones  obtainable  from  the 
various  organic  extracts  enumerated?  I  formulate  this  question  only  to 
emphasize  the  fact  that  it  must  be  left  suh  judice  and  as  an  object  for  further 
research.  All  I  have  tried  to  show,  is  that  the  gross  phenomena  evoked  by 
these  preparations,  and  doubtless  some  of  their  beneficial  effects  are,  in  all 
probabilit}^  due  to  the  products  of  the  essential  ductless  glands,  the  thyro- 
parathyroids  and  the  adrenals,  acting  jointly. 

BIBLIOGRAPHY. 
iReid  Hunt:     Amer.  Jour,  of  Physiol.,  Vol,  V,  p.  957,  1898. 
2  LUPINE:     La  semaine  mf'dicale,  Feb.  19,  1903. 
3CBILE:     Boston  Med.  and  Surg.  Jour.,  March  5,  1903, 
4IviNNAMAN:     Annals  of  Surg.,  Dec,  1903. 

SRoLLESTON:     Allbutt's  "Practice  of  Medicine,"  Vol.  V,  p.  540,  1897. 
6SAJ0DS:     "Internal  Secretions  and  the  Principles  of  Medicine,"  Vol.  I,  1903;    Vol.  II, 

1907;    and  New  York  Med.  Jour.,  Feb.  20-27,  1909. 
tWasdin:     Monthly  Cyclopaedia,  March,  1903. 
SGOLLA:     Lancet,  Feb.  15,  1902. 

9  Wilcox:     "Pharmacology  and  Therapeutics,"  seventh  edition,  p.  824,  1907. 
10 Dixon:     Brit.  Med.  Jour.,  Sept.  21,  1907. 


Cyclopaedia  of  Current  literature 


ADENOIDS,    NOCTURNAL  INCONTINENCE, 
AND  THE  THYROID  GLAND. 

Fifteen  cases  of  nocturnal  enuresis 
are  reported  by  the  writer.  Adenoid 
vegetations  can  no  longer  be  regarded 
as  a  cause  of  nocturnal  enuresis,  the 
adenoids  affording  some  measure  of  pro- 
tection from  nocturnal  accidents  of  this 
nature.  Wlicn  the  two  conditions  are 
associated,  which  they  often  are,  tliey 
are  both  due  to  a  common  cause — 
namely,  insufficiency  of  tlie  internal 
secretion  of  the  thyroid  gland.  This  in- 
sufficiency accounts  for  the  vast  major- 
ity of  cases  of  nocturnal  enuresis  in 
children,  as  shown  by  the  fact  that  the 
exhibition  of  thyroid  extract  will  in  a 
comparatively  short  space  of  time  effect 
not  only  a  cure  of  the  enuresis  but  a 


great  amelioration  of  many  coexisting 
evidences  of  ill  health.  In  the  author's 
cases  belladonna  and  hyoscyamus,  which 
constitute  the  sheet  anchors  of  the  text- 
books, have  not  played  any  part  in  the 
treatment.  Where  it  was  thought  desir- 
able to  employ  anything  in  addition  to 
the  thyroid  extract,  these  additions  have 
consisted  of  tonics  such  as  iron,  arsenic, 
and  iodine.  The  very  remarkable  im- 
provement in  the  general  health  of  his 
patients  under  treatment  for  enuresis 
by  thyroid  extract  induced  him  to  try 
the  effect  of  the  drug  on  two  or  three 
children  wlio  suffered  from  debility  due 
to  other  causes.  The  writer  found  that 
his  patients  who  had  not  suffered  from 
nocturnal  enuresis,  under  the  now  treat- 
ment with  thyroid  extract,  now  had  noc- 


346 


ArPENDIClTIS, 


EPILEPSY,  THE  DUCTLESS  GLANDS  IN. 


turnal  enuresis.  He  comes  to  the  con- 
elusiou  that  the  thyroid  secretion  is  a 
regulator  oi  the  mechanism  by  which 
urinary  incontinence  is  controlled,  an 
excess  of  the  secretion  being  abnost,  if 
not  quite,  as  deleterious  as  an  insuffi- 
ciency. In  the  treatment  of  enuresis 
by  thyroid  extract  the  question  of  dos- 
age is  therefore  not  only  of  paramount 
importance,  but  also  of  the  utmost  deli- 
cacy. It  is  essential  to  success  that  the 
initial  dose  should  be  very  small;  that 
this  dose  should  be  increased  very  cau- 
tiously, if  at  all;  and  that  the  minimum 
dose  which  experience  proves  to  be  pro- 
ductive of  good  results  should  be  s  tead- 
ily  persevered  with,  reinforced,  if  neces- 
sary, by  such  tonics  as  have  already 
been  mentioned.  Leonard  ^Yilliams 
(Lancet,  May,  1909). 

APPENDICITIS,   TPvEATSIENT   01?. 

It  is  difficult  at  tim-cs,  not  to  say  ijn- 
possible,  to  distinguish  accurately  and 
positively,  between  appendicitis  and  co- 
litis. In  som.e  cases,  McBurney's  point, 
rigidity,  blood-count,  symptomatic  ante- 
cedents, are  similar.  When  all  these  are 
identical  one  or  other  disease  may  exist 
alone.  It  is  frequently  the  case  here, 
as  elsewhere,  that  two  diseases,  so  far 
as  the  mere  organ  is  concerned,  may 
exist  together  just  as  is  found  elsewhere, 
notably,  in  uterus  and  ovaries;  in  larynx 
and  trachea.  Admitting  the  truth  of 
the  foregoing  to  be  "ndse  and  prudent, 
the  patient  should  be  treated  medically, 
in  what  seems  the  best  way  to  accom- 
plish a  cure.  This  treatment  should  be: 
Eest  in  bed,  which  means  little  or  no 
voluntary  movement  while  pains  are 
acute,  temperature  elevated,  and  other 
general  symptoms  threatening  or  grave. 
Ice  bag,  or  preferably  hot  water  bag,  or 
poultices,  or  stupes  with  hot  water  and 
oil  of  turpentine   and   s7)ap   liniment; 


flannel  covered,  or  not,  v^dth  oil  silk  or 
rubber  tissue.  Laxative  enema  with 
castor  oil  and  oxgall,  sometimes  a  little 
glycerin  being  added.  Flaxseed  tea 
should  preferably  be  the  menstruum  of 
the  enema.  A  moderate  amount  of 
codeine  every  hour  or  two,  by  mouth, 
if  pains  seem  to  require  it,  from  ^o  ^o 
"Ko  or  y^  grain.  In  rare  instances  only 
are  hypodermic  injections  of  morphine 
to  be  given,  and  then  only  for  excessive 
pain.  B.  liobinson  (New  York  Medical 
Journal,  May  1,  1909). 

EPILEPSY  AND  THE  BP.OSIIDES. 

The  writer  considers  that  the  value 
of  the  bromides  in  epilepsy  has  been 
greatly  overrated.  The  dosage  com- 
monly employed  is  not  only  excessive, 
but  deleterious  when  its  adininistration 
is  prolonged.  Small  doses  produce  as 
good  results  as  larger  ones.  Half  of 
the  favorable  cases  responded  to  treat- 
ment without  any  bromide  being  pre- 
scribed. When  employed  without  order- 
ing a  salt  free  diet  the  use  of  the  bro- 
mides is  almost  valueless.  Any  decided 
amount  of  ISTaCl  in  the  blood  acts  as  an 
irritant  to  the  cerebrum  and  increases 
the  frequency  and  severity  of  the  at- 
tacks. While  it  is  not  known  why  the 
exclusion  of  salt  from  the  patient's  diet 
is  so  beneficial  in  the  treatment  of  epi- 
lepsy, it  is  knoTvn  that  equally  brilliant 
results  are  obtained  by  its  prohibition  in 
chorea.  Less  than  10  per  cent,  of  all 
cases  of  epilepsy  are  curable,  and  only 
50  per  cent,  of  carefully  selected  cases 
were  benefited  by  prolonged  treatment. 
Wm.  Losem  (American  Medicine,  April, 
1909). 

EPILEPSY,  THE  DUCTLESS  GLANDS  IN. 

Eesults  of  an  examination  of  the  pit- 
uitary body,  supra renals  and  ovaries  in 
fifteen  cases  of  epilepsy  are  reported.     In 


HYI'OPJIYSrS  AND  OVAllIES. 


MASJJOlDITiS. 


34'i 


three  cases  the  pituitai-y  body  showed  a 
localized  area  of  sclerosis.  Capillary 
congestion  was  present  in  one.  From 
the  distribution  of  the  cellular  granules 
and  the  staining  reactions  of  the  cells 
and  the  increase  in  the  colloid  material 
in  the  above  three  cases,  a  hj'persecretion 
of  the  pituitary  body  is  suggested.  The 
pituitary  body  in  the  other  twelve  cases 
showed  histologic  evidence  of  a  decrease 
of  functional  activity.  In  all  cases  the 
suprarenals  were  smaller  than  normal. 
In  seven  cases  the  histolog^ic  picture  was 
distinctly  that  of  hypoiunctioual  activity. 
In  only  one  case  was  there  evidence  of 
h33)ersecretion  of  the  gland.  With  the 
ovary  the  changes  were  not  so  pro- 
nounced, and  their  significance  was  more 
difficult  to  determine.  The  ovaries  were 
small  and  unusually  poor  in  Graafian 
follicles.  An  examination  of  the  pan- 
creas, liver  and  kidney  revealed  nothing. 
Claude  and  Schmiergeld  (Comptes  ren- 
dus  societe  de  biologic,  vol.  Ixv.,  p.  ISG- 
199,  1908;  Journal  American  Medical 
Association,  March  13,  1909). 

HYPOPHYSIS  AND  OVAHIES,   RELATIONS 
BETWEEN. 

A  special  study  has  been  made  by  the 
writer  of  the  relations  beween  the  duct- 
less glands,  and  he  recently  reported  a 
case  in  which  a  tuinor  in  the  suprarenals 
was  accompanied  by  atrophy  of  the 
ovaries  and  male  characteristics  in  re- 
spect to  growth  of  hair,  bass  voice,  etc. 
In  a  case  described  in  detail,  the  loss  of 
ovarian  functioning  coincided  mth  the 
development  of  a  tumor  of  the  hypoph- 
ysis and  development  of  acromegal3\ 
The  patient  had  passed  through  a  nor- 
mal puberty,  had  married  at  21,  and 
soon  after  this  the  menses  became  ir- 
regular and  finally  ceased  altogether, 
probably  as  the  tumor  in  the  hypophysis 
began  to   develop.     The  first  sign    of 


trouble  was  hoarseness;  in  a  few  mouths 
vision  gi-ew  defective  and  iioentgen  ex- 
amination confirmed  the  assumption  of 
a  timoior  in  the  hypophysis.  The  symp- 
toms continued  a  progressive  course  un- 
der hypophysis  tablets,  but  after  a  few 
months  they  seemed  to  be  arrested  and 
the  patient  has  remained  in  compara- 
tively fair  condition  during  the  few 
months  since^  and  refuses  to  allow  any 
operation.  It  seems  evident,  the  writer 
thinks,  that  ovarian,  rather  than  hy- 
pophysis treatment  is  indicated  in  this 
and  similar  cases,  and  the  assumption 
seems  plausible  that  disturbances  result- 
ing from  excessive  ovarian  functioning, 
such  as  excessive  menstrual  haemor- 
rhage, nymphomania  and  other  psy- 
choses, might  be  combated  by  hypoph- 
ysis tablets.  The  pineal  gland  must  also 
be  considered  in  connection  with  the 
relation  between  the  glands  vsath  an 
internal  secretion.  Xot  merely  for  or- 
ganotherapy, but  also  for  physiology 
and  pathology  these  interrelations  will 
surely  prove  a  fruitful  field  for  re- 
search. L.  Thumim  (Berliner  klinische 
Wochenschrift,  April  5,  1909;  Journal 
of  the  American  Medical  Association, 
May  22,  1909). 

MASTOIDITIS. 

At  the  present  time  it  is  impossible 
to  reach  an  absolutely  certain  decision 
regarding  the  necessity  of  surgical  in- 
terference in  some  cases  of  affection  of 
the  temporal  bone.  In  most  cases  the 
groups  of  sjTuptoms,  and  in  many  cases 
the  presence  of  one  or  two  marked 
symptoms,  make  surgical  interference 
appear  imperative.  The  danger  of  gen- 
eral inhalation  anreslhcsia  in  any  opera- 
tion, especially  in  persons  suffering 
from  tuberculosis,  should  not  be  for- 
gotten. The  employment  of  local  anes- 
thesia might  bo  more  thoroughly  tested 


48 


PULMONARY  TUBERCULOSIS. 


RETINAL  HEMORRHAGES. 


a  eases  in  whieh  the  general  anajsthe- 
ia  is  contraindicated.  The  temporal 
lone  contains  numerous  groups  of  cells 
r'hich  may  come  into  consideration  in 
n  affection  of  the  same,  and  therefore 
he  term  "temporitis"  may  be  a  bet- 
er  name  than  "mastoiditis,"  which  is 
ometimes  misleading.  The  construc- 
ion  of  the  temporal  bone  is  such  that 
process  can  go  on  in  the  depth  with- 
ut  betraying  itself  by  very  plain  symp- 
oms;  marked  symptoms  may  appear 
uddenly,  and  in  some  instances  they 
ronounce  the  death  sentence  of  the 
atient.  Emil  Amberg  (Medical  Eec- 
rd,  April  17,  1909). 

ULMONARY      TUBEECULOSIS,       GRADU- 
ATED REST  IN. 

It  is  possible  to  give  the  lungs  ap- 
roximate,  not  complete  rest.  This  lat- 
er measure  should  be  prescribed  suffi- 
iently  early  and  for  sufficiently  long 
eriods.  All  patients  who  exhibit  even 
tie  smallest  sign  of  invasion  by  tuber- 
ulosis  must  be  treated  with  the  utmost 
igidity.  Eectal  temperatures  should 
e  taken  while  the  patient  is  in  bed  and 
3  long  as  there  is  any  fever,  bed  rest 
mst  be  maintained.  Such  cases  should 
ot  be  put  out  on  verandas  in  long 
hairs.  Absolute  silence  must  be  main- 
lined when  during  rest  in  bed,  the  tem- 
erature  rises  over  100.4  degrees  at  any 
ime  of  the  day.  If  this  limit  is  not 
xceeded,  the  patient  may  visit  the  lava- 
dTj  and  perform  the  usual  duties  of 
tie  toilet.  The  morning  temperature 
tiould  be  taken  before  breakfast,  and  it 
hould  fall  at  least  as  low  as  97.8  be- 
ore  the  patient  is  allowed  to  get  up. 
iases  commencing  with  an  initial  haem- 
ptysis  are,  as  a  class,  the  cases  which 
xhibit  the  least  fever,  and  consequently 
Bquire  the  least  rest,  but  all  require 


some  rest  in  bed  at  the  commencement 
of  the  bleeding.  Later  such  patients 
may  be  allowed  to  exercise  cautiously. 
Early  resting  prevents  acute  and  in- 
cipient cases  from  becoming  chronics. 
Patients  who  manifest  at  the  outset  the 
most  violent  constitutional  symptoms, 
if  they  eventually  survive,  ultimately 
make  the  most  perfect  recoveries.  All 
these  suggestions  apply  to  lar}Tigeal  le- 
sions with  double  force.  The  cough 
should  be  controlled  with  opium  deriva- 
tives, and  absolute  silence  must  be  main- 
tained for  a  period  of  even  months.  So 
soon  as  the  temperature  falls,  laryngeal 
patients  may  be  allowed  to  exercise.  E. 
E.  Prest  (Lancet,  April  3,  1909). 

RETINAL  HiEMORRHAGES, 

The  frequent  association  of  retinal 
hasmorrhages  with  disorders  of  the  cir- 
culatory system  emphasizes  the  close 
relationship  between  ophthalmology  and 
internal  medicine.  The  significance  of 
a  retinal  haemorrhage  extends  beyond 
the  disturbance  of  vision  produced  to 
some  profound  disturbance  of  the  bodily 
function.  The  earliest  definite  signs 
which  allow  one  to  diagnose  sclerosis 
are  three:  First,  the  corkscrew  appear- 
ance of  the  small  twigs  at  the  macula 
and  periphery;  second,  flattening  of  the 
veins  by  the  arteries,  and,  third,  the  dull 
red  congestion  of  the  nerve  head.  This 
last  sign  is  thought  by  Rebcr  to  indi- 
cate a  more  advanced  stage  of  the 
process.  Pctinal  haemorrhage  may  be 
grouped  into  four  types :  First,  simple 
haemorrhage  into  the  fiber  layer  of  the 
retina;  second,  ha?morrhagic  retinitis; 
that  is,  haemorrhage  with  some  cedema 
and  exudates  in  the  retina;  third,  sub- 
hyaloid,  a  haemorrhage  between  the  ret- 
ina and  the  hyaloid  membrane  covering 
the  vitreous ;  and,  fourth,  vitreous  haem- 


RHEUMATISM,  ACUTE. 


SYPHILIS,  INTRAMUSCULAR  INJECTIONS   IN.  349 


orrliage,  an  extravasation  sufficient  to 
burst  into  the  vitreous  humor. 

If  a  patient  in  middle  life  comes  com- 
plaining of  a  blur  of  sudden  onset,  he 
should  not  be  told  that  it  is  a  trifling 
affair  which  will  pass  off,  but  a  careful 
fvmdus  examination  should  be  made, 
best  with  a  dilated  pupil.  If  a  little  ex- 
travasation of  blood  or  any  evidence  of 
vascular  changes  be  found,  which  often 
can  be  detected  in  no  other  way  in  the 
early  stage,  the  case  should  be  thor- 
oughly studied  by  the  internist.  The 
examination  of  the  urine,  blood,  and 
especially  blood-pressure,  which  is  so 
easily  determined,  may  point  to  the 
necessity  for  medication  and  changes  in 
the  life  habits  which  may  spare  the  pa- 
tient serious  accidents  and  give  him 
many  years  of  life.  E.  M.  Blake  (Yale 
Medical  Journal,  April,  1909). 

RHEUMATISM,  ACUTE:     TREATMENT. 

The  writer  reports  favorable  results 
in  12  cases  of  acute  rheumatism  under 
the  following  routine  treatment:  The 
use  of  calomel  is  followed  by  Dorse/s 
magnesia  mixture  until  the  bowels  are 
freely  open,  then  they  are  kept  so.  The 
patients  should  drink  plenty  of  water. 
Thirty  grains  of  sodium  salicylate 
should  be  given  each  three  hours  until 
pain  is  relieved  or  there  are  unpleasant 
head  symptoms.  The  dose  is  then  de- 
creased to  twenty  grains,  and  when  the 
joints  can  be  used  freely  without  pain 
or  stiffness  the  dose  is  again  decreased 
to  fifteen  grains  four  times  a  day  for  one 
week.  When  the  patient  considers  him- 
self well,  ten  grains  are  given  three 
times  a  day  for  two  weeks.  Oil  of  win- 
tergreen  was  applied  to  the  joints  twice 
a  day,  and  they  were  dressed  in  cot- 
ton and  oiled  silk  or  rubber  sheeting. 
There  has  been  some  slight  deviation 


from  this  rule  to  meet  special  indica- 
tions in  individual  cases.  S.  E.  Earp 
(New  York  Medical  Journal,  May  1, 
1909). 

SMALL-POX,  DIAGNOSIS  OF. 

The  diagnosis  of  this  disease  must 
often  rest  wholly  on  the  objective  le- 
sions of  the  skin.     Except  in  rare  in- 
stances, and   only  in  the  presence  of 
an  epidemic,  is  the  positive  diagnosis  of 
small-pox  justified  before  the  appear- 
ance of  the  skin  lesions.     The  history 
of   pre-eruptive  illness   serves   only  to 
confirm  the  diagnosis  as  made  by  the 
senses  of  sight  and  touch.     The  small- 
pox   papule   has    characteristics   which 
make  a  positive  diagnosis  possible  within 
a  few  hours  of  its   appearance.     The 
papules    appear   first   on    the    exposed 
parts,    particularly    the    forehead    and 
flexor  surfaces  of  the  wrists.    They  are 
under  the  epidermis,  hard,  round,  flat- 
topped,     umbilicated,     rose-pink,     and 
waxy  in  appearance.    All  these  charac- 
teristics are  usually  present.     In  gen- 
eral, the  entire  course  of  evolution  of 
the  lesion  from  papule,  vesicle,  pustule, 
to  scab  formation  is  regular  and  charac- 
teristic.    The  lesions  vary  in  number. 
They  may  be  few,  or  so  numerous  as  to 
become    confluent,   but   the   individual 
characters  of  the  lesion  are  present  in 
all  cases.     J.  M.  Armstrong  (Archives 
of  Diagnosis,  April,  1909). 

SYPHILIS,  INTRAMUSCULAR  INJECTIONS 
IN  THE  TREATMENT  OF. 

After  having  given  or  been  ofiicially 
responsible  for  something  over  5,000 
injections  in  three  and  a  half  years,  the 
writer  is  convinced  of  the  following 
facts  and  advantages  in  this  method  of 
treating  syphilis: 

The  injection  method  of  treating  syph- 


550 


THYROID,  TRANSPLANTATION  OF. 


TONGUE,  CANCER  OF  THE. 


lis  is  the  most  efficient  of  all  methods. 
[t  keeps  the  patient  best  imder  control  of 
he  physician  because  he  must  return 
)nce  or  twice  a  week  for  his  injections 
ind  for  other  treatment  as  needed  by 
)erhaps  new  sjTnptoms.  Although  the 
uedicine  used  is  an  antiseptic,  the  injec- 
ion  is  a  surgical  procedure  and  as  such 
equires  the  usual  precautions  of  ster- 
lization  of  the  skin  and  of  all  instru- 
nents  used.  Eigid  asepsis  must  never 
e  neglected.  If  the  injections  are  slowly 
nd  gently  given  with  a  long  needle  and 
f  the  patient  is  in  the  proper  position  of 
claxed  glutei,  they  are,  in  most  cases, 
irtually  painless.  If  painful,  the  patient 
aay  be  told  that  they  are  exactly  like  a 
ruise  and  of  no  more  importance.  In 
he  bruise  the  extravasated  blood  is  the 
oreign  body  while  in  the  injection 
lie  medicine  is  the  foreign  body  causing 
he  slight  pain,  by  separation  of  the 
[luscle  fibres. 

Node-fonnation  of  longer  duration 
ban  two  or  three  days  is  very  rare  if  the 
ejection  is  gently  and  deeply  made  into 
he  muscle.  Abscess-formation  may  be 
otally  avoided  if  sterilized  fluid,  needle 
nd  skin  are  obtained.  Embolism  is  a 
eal  danger  but  is,  in  fact,  very  uncom- 
lon.  In  the  writei^'s  experience  a  little 
3SS  than  once  in  1,000  injections, 
^'oxic  accmnulation  is  hardly  excusable 
I  palpation  of  the  point  of  the  preceding 
ejection  is  made  at  each  visit,  before 
iving  the  next  injection. 

The  salicylate  of  mercury  appears  to 
e  so  ultimately  satisfactory  that  no 
ther  salt  need  be  considered.  The  terms 
3luble  and  insoluble  salts,  meaning,  as 
tiey  do,  the  laboratory  solubility,  are 
nfortunate.  The  soluble  salts,  of  which 
ichlorid  is  the  type,  give  a  very  prompt 
nd  extreme  reaction  during  the  first  8-1 
ours.  The  so-called  insoluble  salts, 
ith  the  salicylate  as  the  type,  give  a 


slower,  surer  and  more  prolonged  action, 
apparently  lasting  five  days. 

Continuation  of  the  injection  is,  as 
far  as  the  writer's  experience  is  con- 
cerned, necessary  for  the  usual  two  or 
tln-ee  years  with  one  to  two  months'  rest 
in  each  year.  Of  course,  the  patient's 
strengih  must  be  maintained  at  the  high- 
est possible  level  and  in  short,  the  disease 
must  be  managed  like  other  parasitic 
diseases  of  which  tuberculosis  is  a  type. 
Fresh  air,  good  food,  judicious  exercise 
and  hygienic  habits  are  indicated. 

If  the  foregoing  simple  principles  of 
employing  this  method  of  treatment  are 
studied  and  followed  the  writer  is  con- 
vinced that  a  larger  nmnber  of  physi- 
cians will  adopt  it  as,  in  every  way,  the 
best  means  of  treating  this  disease.  V. 
C.  Pedersen  (ISTew  York  State  Journal  of 
Medicine,  March,  1909). 

THYROID,  TEANSPLANTATIOW  OF. 

The  writer  has  been  experimenting  on 
rabbits,  the  results  encouraging  further 
attempts  to  supply  the  missing  function 
by  implantation  of  thyroid  tissue.  The 
best  results  will  certainly  be  obtained 
wdth  repeated  implantation  of  small 
scraps,  and  for  this  it  is  better  to  im- 
plant the  scraps  in  the  subcutaneous 
tissue  (Cristiani)  or  in  the  peritoneal 
tissue  (von  Eiselsberg).  H.  Salzer 
(Wiener  klinische  Wochenschrift,  March 
18,  1909;  Journal  American  Medical 
Association,  April  24,  1909). 

TONGUE,  CANCER  OF  THE. 

Beyond  the  fact  that  continued  irri- 
tation of  the  mucous  membrane  and 
consequent  ulceration  may  predispose 
to  cancer  of  the  tongue,  there  are  prob- 
ably no  recognizable  pre-eancerous 
stages.  It  is  either  cancer  or  not  can- 
cer, but  even  with  the  aid  of  the  micro- 


BOOK  REVIEWS. 


351 


scope  its  true  nature  may  not  be  evi- 
dent. Predisposing  conditions,  also  irri- 
tative, are  described  as  leucoplakia, 
iclithj^osis,  chronic  superficial  glossitis, 
etc.  All  warty  growths  and  thickenings 
of  the  surface,  or  ulcerations,  are  dis- 
tinctly siispieious,  and  while  they  may 
be  syphilitic  and  disappear  with  proper 
treatment,  excision  of  a  small  part  for 
diagnosis  is  advisable,  and  should  be  in- 
sisted on  in  every  case.  The  author  de- 
scribes the  methods  of  operation,  and 
says  that  prognosis  depends  very  much 
on  the  condition  of  the  patient,  and  the 
spread  of  the  disease  at  the  time  of  the 
operation.  The  operative  death  rate  in 
extensive  operation  has,  hitherto,  been 
excessive,  as  many  of  the  patients  have 
succumbed  to  such  preventable  causes 
as  septic  pneumonia,  local  sepsis  shock, 
and  haemorrhage.  The  deaths  due  to 
those  is  almost  85  per  cent.,  while  septic 


infection  causes  more  than  50  per  cent, 
of  the  immediate  fatalities.  If  one  con- 
siders that  much  more  extensive  opera- 
tions for  removal  of  tuberculous  glands 
can  be  done  with  an  almost  negligible 
mortality,  and  that  septic  pneumonia  is 
rare  after  nose  and  throat  operations 
and  dental  extractions  under  complete 
anassthesia,  one  is  forced  to  admit  that 
a  considerable  factor  must  be  the  weak- 
ened conditions  and  age  of  most  of  the 
patients  that  submit  themselves  to  the 
surgeon,  and  for  this  the  family  physi- 
cian is  much  to  blame.  "With  proper 
preparation  of  the  mouth,  and  good 
technique  during  the  operation,  the 
death  rate  should  be  reduced  to  below 
20  per  cent,  for  all  operations  offering  a 
fair  chance  of  complete  eradication  of 
the  disease  and  a  much  smaller  percent- 
age for  picked  cases.  Alexander  Don 
(Practitioner,  April,  1909). 


5ool<  F^eviews 


Glimpses  of  Medical  Eubope.  By  Ralph  Thompson,  M.D.,  Professor  of  Pathology,  St.  Louis 
University  School  of  Medicine.  Illustrated  from  Photographs  and  Drawings  by  Tom 
Jones.     Philadelphia  and  London:    J.  B.  Lippincott  Company,  1908. 

This  little  book  gives  the  reader  an  interesting  insight  into  the  medical  life  of  Europe, 
and,  in  a  way,  brings  him  in  close  contact  with  those  who  are  recognized  tliroughout  the 
world  as  masters  in  their  respective  branches.  It  is  of  these  men  and  their  clinics,  and  the 
influence  they  have  with  and  the  impression  they  make  upon  the  students,  that  the  author 
particularly  writes.  The  book  is  written  in  a  style  which  is  quite  interesting  and  entertain- 
ing, as  the  expected  dryness  of  such  a  subject  is  relieved  by  a  strain  of  humor  which  appears 
at  imexpccted  points.  Tlie  photographs  and  drawings  are  attractive  and  appear  to  fit  in 
well  with  the  various  descriptions.  While  the  author  made  no  attomj)t  to  provide  a  guide 
book  for  those  expecting  to  study  in  Etirope,  nor  even  expected  that  his  small  work  would 
assume  such  a  role,  there  are  many  suggestions  of  iindoubted  value  for  those  going  abroad  for 
scientific  study  and  for  a  more  liberal  education  in  the  various  branches  of  medicine. — R.  B.  S. 

PuLMONABY  TuBEHCULosis  AND  All  Its  CoMrLiCATioNS.  By  Sherman  G.  Bonney,  M.D., 
Professor  of  Medicine,  Denver  and  Gross  College  of  Medicine,  Denver.  Octavo  of  778 
Pages,  with  189  Original  Illustrations,  including  Twenty  in  Colors  and  Sixty  X-r.ay 
Photographs.  Phihadelphia  and  London:  W.  B.  Saunders  Company,  1908.  Cloth,  $7.00 
net;    Half-morocco,  $8.50  net. 

The  author  of  this  volume  is  to  be  congratulated  for  a  feature  which  stands  out  promi- 
nently throughout  its  pages,  viz.,  the  fact  tliat  it  embodies  to  a  great  extent  the  results  of 
personal  experience.     American  text-books  and  even  monographs  are  so  often  luerc  compila- 


352 


BOOK  REVIEWS. 


tiong.  not  of  the  literature  of  the  subject,  but  of  other  books  of  a  similar  class,  that  exceptions 
merit  special  recognition.  The  size  of  the  book,  778  pages  of  over  500  words  each,  indicates 
that  the  material  furnished  the  reader  is  not  scant;  this  fact  is  further  emphasized  by  the 
multiplicity  of  topics  covered,  which  include  chapters  on  tuberculosis  of  organs  other  than 
the  lungs— the  kidney,  bladder,  testes,  the  female  pelvic  organs,  the  upper  respiratory  tract, 
the  ear,  etc.,  and  also  the  relationship  of  other  conditions,  prcgancy  for  example,  or  diseases 
such  as  syphilis,  upon  the  morbid  process.  We  find  also  that  due  attention  has  been  given 
to  the  reciprocal  relations  of  consumptives  and  society,  subjects  such  as  compulsory  notifica- 
tion and  registration,  the  supervision  and  education  of  the  consumptive,  the  questions  of 
dissemination,  the  influence  of  predisposition,  of  intermarriage  of  tuberculous  individuals,  etc. 
Of  special  value  to  the  general  practitioner,  to  whom  the  work  is  especially  dedicated, 
are  the  cliapters  on  the  therapeutics  of  tlie  disease — the  open-air  method,  the  diet,  the  sana- 
torium, the  climate,  are  all  given  due  attention,  as  well  as  the  resources  available  for  the 
treatment  of  special  symptoms,  niglit  sweats,  hemorrhages,  etc.  Drug  therapy  and  the  more 
advanced  conceptions  as  to  the  use  of  tuberculin,  with  personal  observations  and  comments 
thereon,  are  all  considered  in  as  thorough  a  manner  as  is  compatible  with  the  purpose  of  the 
took— that  of  affording  practical  aid  to  its  readers.  On  the  whole,  we  heartily  recommend 
Dr.  Conney's  beautifully  illustrated  and  eminently  satisfactory  work, 

A  Text-Book  of  Operative  Surgery.  Covering  the  Surgical  Anatomy  and  Operative  Tech- 
nic  Involved  in  the  Operations  of  General  Surgery.  Written  for  Students  and  Practi- 
tioners. By  Warren  Stone  Bickham,  Phar.M.,  M.D.,  Visiting  Surgeon  to  Charity  and 
Touro  Hospitals,  New  Orleans.  Octavo  of  1206  Pages,  with  854  Illustrations,  entirely 
Original.  Philadelphia  and  London:  W.  B.  Saunders  Company,  1908.  Cloth,  $0.50  net; 
Half-morocco,  $8.00  net. 

In  the  third  edition  of  this  well-known  work  over  200  new  pages  and  300  new  figures 
have  been  added— an  indication  of  the  careful  revision  it  has  received.  The  broad  subject 
of  operative  surgery  is  covered  in  a  remarkably  complete  and  painstaking  manner.  The 
author  divides  the  operations  into  those  of  general  surgery  and  of  special  surgery.  The 
former  includes  the  procedures  used  in  connection  with  the  arteries,  such  as  ligation, 
arterial  suture,  and  aneurismorrhaphy,  together  with  the  operations  upon  the  veins,  lym- 
phatics, nerves,  bones,  joints,  muscles,  etc.,  and  the  amputations,  disarticulations,  and 
excisions  of  joints.  Part  II,  on  special  surgery,  includes  extensive  chapters  on  the  head, 
spinal  column  and  cord,  neck,  thorax,  abdomino-pelvic  region,  male  and  female  genital  organs, 
with  a  closing  section  on  the  herniae. 

The  work  is  devoted  almost  entirely  to  operative  technique  and  the  related  anatomical 
considerations,  the  clinical  aspect  having  been  limited  chiefly  to  brief  statements  of  the 
indications  for  the  various  procedures  described.  The  consideration  of  each  structure  begins 
with  a  section  on  surgical  anatomy,  setting  forth  concisely  the  relations  to  surrounding 
structures,  boundaries  of  surgical  spaces,  etc.  Detailed  description  of  the  operations  follows. 
Under  each  heading  a  general  statement  as  to  the  scope  of  the  operation,  then  the  position  of 
the  patient,  landmarks,  incision,  followed  by  the  details  of  the  technique,  the  successive  steps 
being  numbered. 

Clearness  and  ease  of  understanding  are  greatly  enhanced  by  the  numerous  well-executed 
illustrations,  some  showing  the  incisions  for  the  various  operations  with  their  relations  to 
the  bony  supports,  and  others,  dissections  of  the  underlying  structures.  There  are  also  cross- 
sections  of  the  limbs  at  various  levels,  etc.  The  extent  of  the  work  may  be  judged  from  the 
fact  that  200  pages  are  devoted  to  the  amputations.  Specially  well-executed  sections  of  the 
book  are  those  on  cranial  and  spinal  surgery,  the  thorax  and  its  viscera,  and  the  gastro- 
intestinal tract.  The  section  on  hernia}  is  rather  scant  in  comparison,  and  that  on  the  female 
genital  organs,  belonging  more  properly  to  gynaecological  works,  describes  but  four  operations. 
Otherwise  the  work  can  be  said  to  be  well-balanced,  devoting  due  space  to  the  operations 
most  commonly  performed.  Freedom  from  tyiJOgraphical  errors  is  a  noticeable  feature.  In 
clearness  of  description  the  text  could  hardly  be  improved  upon,  while  the  mechanical  execu- 
tion is  very  satisfactory.  The  work  will  undoubtedly  prove  useful  to  careful  operators  as  a 
complete,  but  not  unwieldy  exposition  of  the  subject. 


NTHLY      CvCLOPiEDIA 

AND 

Iedical   Bulletin 


Published  the  Last  of  Each  Month 


Medical  Bulletin  Section 


Vol.  II.  PHILADELPHIA,  JUNE,  1909.  No.  6. 


Clinical  Lecture 


PSORIASIS.* 


By  JOHN  V.  SHOEJIAKER,  M.D.,  LL.D., 

Professor  of  Materia  Mediea,  Therapeutics,  Cliuical  Medicine,  and  Diseases  of  the  Skin, 

in  the  Medico-Chirurgical  College  and  Hospital  of  Philadelphia. 


PHILADELPHIA. 


Gentlemen: — The  next  patient,  a  young  girl,  age  eighteen  years; 
nativity,  America;  occupation,  housework;  presents  typical  lesions  over  her 
entire  body  of  a  disease  which  you,  I  hope,  will  at  once  recognize.  Her  his- 
tory reads  as  follows: — 

Miss  S.  M,  Her  parents  are  living  and  well.  She  has  four  sisters  and 
two  brothers,  all  of  whom  are  in  good  health.  In  fact,  there  is  no  history  of 
anyone  in  her  immediate  family  having  ever  had  a  similar  affection,  nor  is 
there  a  history  of  cancer,  or  tuberculosis,  in  her  family.  Her  father  is  sub- 
ject to  occasional  attacks  of  rheumatism. 

As  a  child  she  had  measles,  scarlet  fever  and  diphtheria.  She  complains 
of  pain  in  her  knees  and  feet.  At  times  the  pain  is  so  severe  that  she  cannot 
walk  or  even  stand  on  her  feet.  She  states  that  there  is  never  any  evidence 
of  inflammation,  except  a  slight  swelling.  The  eruption  over  her  body  first 
began  on  her  scalp  eight  years  ago  as  small  red  papules  covered  Avith  whitish 
scales.  Some  of  the  papules  were  closely  united  together  and  coalesced,  form- 
ing large  infiltrated  and  desquamating  areas.  About  two  years  after  the  first 
appearance  of  the  papules  on  the  scalp,  similar  papules  appeared  on  the 
extensor  surfaces  of  the  forearms  and  on  the  back.  So  many  papules 
appeared  over  her  entire  body  that  they  coalesced  and  formed  during  the  past 
two  years  these  large  infiltrated  desquamating  areas,  covering  almost  her 


Delivered  in  the  Clinical  Amphitlieatre  Medico-Chirurgical  Hospital. 

(353) 


354 


PSORIASIS. 


entire  body  and  limbs.  Siie  complains  of  no  pain  or  itching  in  the  parts 
involved. 

The  physical  signs  are  negative,  except  the  condition  of  her  skin.  Her 
tongue  is  coated  heavily  with  a  yellowish  coat,  the  breath  is  offensive  and  she 
complains  of  chronic  constipation,  flatulence  and  eructation  of  gas  after 
meals. 

Diagnosis.— The  lesions  over  this  patient's  body  are  so  typical  that  the 
diagnosis  can  be  positively  made  at  a  glance  as  psoriasis. 

The  diagnosis  of  less  typical  cases  is  made  on  the  history  of  the  onset, 
the  small  red  papule  covered  with  whitish  scales  and  usually  appearing  on  the 
extensor  surfaces  of  the  arms  by  preference.  These  papules  are  followed  by 
similar  papules  closely  situated,  which  coalesce  and  form  thick,  iniiltrated 
desquamating  areas  of  skin. 

The  involved  skin  on  this  patient  is  raised  above  the  normal  skin,  is 
infiltrated  so  that  it  appears  almost  like  leather  and  desquamates  most  pro- 
fusely. The  lesions  are  sharply  defined,  which  is  another  characteristic 
symptom  of  the  disease. 

In  patients  with  less  typical  symptoms  of  psoriasis  than  are  present  in 
this  patient— the  disease  might  be  mistaken  for  eczema  squamosum,  squamous 
syphilis  and  seborrhoea  sicca.  The  tables  on  the  blackboard  will  clearly  point 
out  the  differential  points. 


Psoriasis. 

1.  The  primary  lesion  begins  as  a  papule 

covered  with  whitish  scales. 

2.  Itching  slight,  rarely  intense. 

3.  Affected  areas  sharply  defined. 

4.  Areas  occur,  both  large  and  small,  and 

are  usually  round. 

5.  Involves    with    preference   the    extensor 

surfaces. 

6.  The  lesions  often  remain  unchanged  for 

months. 

7.  Eruption  is  always  diy. 

8.  Areas    are    covered    with    many    white 

scales. 

9.  The  course  is  chronic. 

Psoriasis. 

1.  History  negative. 

2.  Tliatory  of  rheumatism,  gout  or  gastro- 

intestinal cntarrh. 

3.  Extensor    surfaces    of    arms    and    legs 

nearly  always  involved. 

4.  Lesions  regular  in  outline. 

5.  Scales    are    shining,    silvery-white    and 

abundant. 

6.  Itching  slight. 

Psoriasis. 
1.  Eruption  in  areas  of  entire  scalp. 


Eczema  Squamosum. 

1.  The  primary  lesion  begins  as  an  erythe- 

matous patch,   a    vesicle,  pustule  or 
moist  spot. 

2.  Itching  severe. 

3.  AflV'cted     areas     gradually     fade     into 

healthy  skin. 

4.  Areas  are  large  and  irregular. 

5.  Involves,  with  preference,  the  flexor  sur- 

faces. 

6.  The  lesions  rapidly  change. 

7.  Eruption  usually  is  moist. 

8.  Areas  are  covered  with  small  yello\\'ish 

scales  or  with  crusts. 

9.  The  course  is  either  acute,  subacute  or 

chronic. 

Syphilis  Squamosus. 

1.  History  of  primary  lesion. 

2.  History  of  sore  tliroat,  syphilitic  fever, 

and  other  concomitant  signs. 

3.  Extensor    surfaces    of    arms    and    legs 

rarely  involved. 

4.  Pol^Tuorphous  arrangement  of  lesions. 

5.  Scales  dirty,  yellow  and  few. 

6.  Itching  absent. 

Sehorrhcra  Sicca. 

1.  Eru.ption  usually  involves  the  scalp  over 
the  top  of  the  head  only. 


PSORIASIS.  355 

2.  Scales  dry  and  silvery  white.  2.  Scales  yellowish,  fatty  aud  greasy  to  the 

touch. 

3.  Scales  corisist  of  epithelial  cells.  3.  Scales  consist  of  dried  sebum. 

4.  Base  of  eruption  is  inHamniatory  and      4.  Base  of  eruption  is  anemic. 

infiltrated. 
6.  Eruption  also  present  over  the  body  and       6.  Ko  eruption  over  the  body, 
extremities. 

Pathology. — A  section  of  the  involved  skin  under  the  microscope  shows  a 
hyperplasia  of  the  mucous  layer,  and  of  the  normal  constituents  of  the  rete 
Malpighii.  The  increase  occurs  chiefly  in  the  intercapillary  portion  of  the 
layer,  which  growing  downward,  gives  the  appearance  of  increased  size  which 
is  not  found  to  be  increased  upon  close  examination.  In  the  advanced  stage 
of  the  affection  the  superficial  blood-vessels  of  the  corium  become  dilated, 
migration  of  the  white  corpuscles  follows,  and  the  connective  tissue  and  the 
blood-vessels  of  the  corium  become  the  seat  of  round-cell  infiltration,  which, 
together  with  effused  senim,  divides  the  connective  tissues  into  open  meshes. 
There  is  no  involvement  of  the  sebaceous  and  sudoriferous  glands,  but  there 
is  hyperplasia  of  the  external  root  of  the  hair,  extending  into  the  cutis. 

Etiology. — The  underlying  cause  of  the  psoriasis  in  this  young  woman  is 
rheumatism.  In  many  patients,  as  is  the  case  in  this  one,  it  appears  that 
the  rheumatic  condition  manifests  itself  in  the  form  of  psoriasis  instead  of 
severely  affecting  the  joints  or  muscles  of  the  body.  Gout,  rheumatism, 
gastro-intestinal  catarrh  and  irritation  of  the  skin  are  considered  predisposing 
causes  of  the  disease.  I,  however,  am  of  the  opinion  that  there  must  be  a 
peculiar  individual  diathesis  present  before  the  disease  wiU  manifest  itself. 
Psoriasis  is  as  common  among  the  wealthy  as  among  the  poor,  and  in  all  walks 
of  life.  Some  claim  it  to  be  hereditary  and  to  follow  scrofula,  syphilis  and 
other  constitutional  diseases,  which  leave  the  blood  in  an  impoverished  condi- 
tion. Again,  others  advance  a  microbic  theory  which,  in  my  opinion,  by 
experience,  I  cannot  warrant  the  belief. 

Treatment. — This  disease  is  constitutional  and  must  be  treated  accord- 
ingly. First,  it  behooves  us  to  ascertain  the  cause  and  remove  it  if  possible. 
Treat  the  cause,  whether  it  be  rheumatism,  gout  or  gastro-intestinal  catarrh. 

In  this  patient  I  believe  the  chief  cause  of  her  trouble  is  due  to  her  rheu- 
matism and  her  rheumatic  diathesis.  Her  gastro-intestinal  canal  is  in  a 
catarrhal  state,  as  evidenced  by  the  condition  of  her  tongue,  the  chronic  con- 
stipation and  flatulence.  Consequently,  we  will  first  treat  her  digestive 
organs  to  bring  about  better  digestion  and  assimilation.  Internally,  we  will 
prescribe  for  her  a  calomel  purge,  to  be  followed  by  a  saline,  after  which  we 
will  request  her  to  take  a  capsule  containing: — 

IJ  Extract!  hydrastis  gr.   y^. 

Extract!  nucis  vomicfe gr.  i^o- 

Extracti  rharani  purshianae   gr.  ss. 

Olei  mentliae  piperitso m  l^d- 

Extracti  taraxaci    &r.  j. 

Miace.     Fiat  capsula  No.  j.     Mitte  No.  xxx. 

Signa:    One  such  capsule  after  each  meal  and  at  bed-time. 

After  the  gastro-intestinal  catarrh  has  subsided  we  will  place  her  on  an 
antirheumatic  combination  containing : — 


356  co:nclusion  m  regard  to  tubercular  ureteritis. 

IJ  Olei  gaultlieria    f5j. 

Massu)  I'erri  carbonatis   3j. 

AibC'ui  trioxidi   g^"-  %• 

buiphuris  pra-oipitati, 

Pheuylis  saiicylaiii,  of  each   3j. 

Misce.     Eiant  capsuliie  Ao.  xxx. 

Signa:    One  capsule  after  each  meal  and  at  bed-time. 

Externally  we  can  at  once  give  her  a  stimulating  ointment  wliicli  will 
lessen  the  infiltration  and  desquamation.  Salicylic  acid,  in  comhination  with 
the  nitrate  of  mercury  in  the  form  of  an  ointment,  are  probably  the  best 
agents  at  our  disposal  for  this  purpose.  Therefore  the  ointment  contain- 
ing:— 

IJ  Olei   gaultheria    f5j. 

Acidi  salicylici   oiss. 

Uugueuti  hydrargyri  nitvatis, 

Unguenti  aquaj  ro^ai,  of  each    oj- 

Misce.     Eiat  uuguentum. 

Signa:    Apply  to  the  parts  affected  twice  daily. 

Hygienic  measure  and  diet  are  as  essential  in  the  successful  treatment 
of  this  disease  as  is  medicine.  The  functions  of  the  skin  must  be  kept  active 
by  bathing.  The  bran  baths  are  especially  valuable  in  psoriasis  to  soften  the 
skin  and  loosen  the  scales.  Three  to  four  pounds  of  bran  to  a  tub  half  full  of 
water  is  a  sufficient  quantity. 

The  diet  must  be  plain  and  consist  chiefly  of  vegetables.  Foods  rich  in 
nitrogen,  especially  those  from  the  animal  kingdom,  should  be  used  very 
sparingly.  Coffee,  tea,  alcoholic  beverages,  and  highly-spiced  foods  are  also 
interdicted. 

Prognosis. — Her  age  is  in  her  favor,  and  by  persistent  treatment  with 
a  careful  and  well-selected  diet  she  should  receive  a  cure  in  a  comparatively 
short  time.  The  disease  is  curable,  but  it  often  requires  months,  and  some- 
times years,  to  bring  about  desired  results. 


Original  Articles 


CONCLUSION  IN  REGARD  TO  TUBERCULAR  URETERIIIS. 

By  BYRON  ROBINSON,  B.S.,  M.D.,  LL.D., 

CHICAGO,  ILL. 

My  subject  is  tuberculosis ;  my  theme,  tuberculosis  of  the  ureter. 

Eiiology. — The  general  views  of  urologists  in  regard  to  reno-ureteral  tuber- 
culosis is :  that  it  is  a  circulatory  (hcemogenous  or  l^-mphogenous)  disturbance 
and  originates  unilaterally.  I  believe  from  years  of  personal  autopsic  obser- 
vation that  reno-ureteral  tubercular  infection  is  mainly  lymphogenous  in 
origin.  The  cause  of  reno-ureteral  tubercidosis  is  due  to  individual  predis- 
position, however.     Perhaps  fifty  per  cent,  of  adtilts  are  afflicted  with  tuber- 


CONCLUSION  IN  REGAED  TO  TUBERCULAR  URETERinS.      357 

culosis.  In  tiiberculosis  of  the  reno-iiretcral  tract  the  tubercle  bacillus  may 
arrive  at  the  tract  through  the  lymph  stream  travelling  in  a  retrograde  or 
abnormal  direction,  e.  g.,  from  the  lungs  through  the  diaphragmatic  lymph 
channels.  The  chief  rule  in  tubercular  ureteritis  is  a  distalward  moving 
infection  from  the  tubercular  kidney.  Haemogenous  origin  of  rcno-ureteral 
tuberculosis  does  not  explain  its  unilateral  beginning — lymphogenous  origin 
is,  perhaps,  a  more  rational  explanation.  The  kidney  in  children  may  be  the 
seat  of  a  miliary  tuberculosis  which  is  not  a  part  of  a  general  tuberculosis, 
hence,  was  probably  carried  to  the  kidney  by  the  renal  arteries  or  renal  lymph 
channels.  Septic  infarcts  in  the  kidney  may  be  a  mode  of  dispensing  tuber- 
cular infection. 

Pathologij. — Ureteral  tuberculosis  begins  in  the  vast  majority  of  subjects  in 
the  calyces  or  pelvis — which  derives  it  from  the  renal  parenchyma.     Tuber- 
cular  ureteritis   begins   mainly   in   the   mucosa.     The   rigid,    hypertrophied, 
non-flexible  ureter  is  due  to  periureteritis  and  mixed  infection.     Acute  miliary 
renal   tuberculosis  chiefly  prevailing  in   children   is   rapidly  fatal,  hence  is 
seldom  subject  to  operation.     Ulceration  of  the  apex  of  the  pyramid  may 
cause  dangerous  hasmaturia.     Advanced  reno-ureteral  tuberculosis   is  in  the 
majority  of   subjects   accompanied   by   mixed   infection.     The   pathology   of 
the  urinary  tract  in  the  dead   (through  autopsy)   and  the  pathology  of  the 
tuberculosis  of  the  urinary  tract  in  the  living  (through  cystoscopy)  have  joined 
hands  telling  the  main  story  that  tuberculosis  in  the  urinary  tract  is  a  distalward 
moving  process,  and  that  it  chiefly  arises  in  the  renal  parenchyma.     A  decade 
and  a  half  ago  the  general  opinion  was  that  tuberculosis  was  a  proximalward 
moving  disease  in  the  urinary  tract.     To-day  the  opinion  is  that  tuberculosis  is 
a  distalward  moving  disease  in  the  urinary  tract  (mainly  demonstrated  by  the 
cystoscope).     A  rational  principle  is  that  tuberculosis  of  the  urinary  tract  moves 
not  proximalward.  against  the  urinal  stream — but  accompanies  it  distalward. 
The  tubercle  bacillus  arrives  at  the  ureter,  infecting  it,  from  the  blood  stream, 
from  the  renal  parenchyma,  from  the  bladder,  from  adjacent  organs.     The 
chief  source  of  tubercular  ureteritis  is  from  the  renal  parench}Tna  through 
the  crihrum   lenedidum   or   apertures   of  the  renal   pyramidal   apices.      In 
autopsy  it  is  not  rare  through  longitudinal  incision  of  the  external  border  of 
the  kidney  to  observe  the  yellowish  tubercles  in  the  renal  parench}Tna.    The 
bladder   may   be   infected   by   tuberculosis    from   the   vesiculce   seminales   or 
epididymis  producing  ulceration  adjacent  to  the  ureteral  orifice  ending  in 
stricture  of  the  vesical  orifice  and  uro-ureter.     In  the  urinary  tract  the  kidney 
is  the  locus  minoris  resistentice  for  tuberculosis — which  may  be  engrafted  on  a 
debilitated  kidney.     Perhaps  five  per  cent,  of  subjects  afflicted  with  phthisis 
pulraonalis  sufl;er  from  tuberculosis  of  the  urinary  tract.      Tbe  reno-ureteral 
tuberculosis   is    a   secondary   process.     The    frequent   micturition   is    due   to 
vesical  disease,  ulceration  of  the  bladder  mucosa,  inflammatoiy  hypertrophy 
of  the  bladder  walls,  noncapacity  of  the  bladder  to  dilate  and  contract  except 
with  pain.    Tubercular  renal  inflammation  is  the  most  perfect  type  of  infec- 
tious nephritis.     Primary  tuberculosis  of  the  bladder  is  rare — hence  if  vesical 
tuberculosis  exists  its  source  must  be  sought  from  the  kidney,  uretera,  seminal 


358  CONCLUSION  IN  REGAED  TO  TUBERCULAE  URETERITIS. 

vesicles,  prostate,  epididymis — possibly  from  circulatory  disturbances  in  the 
hTiiph  or  blood  stream.  Pathologic  physiology  of  the  ureter — i.e.,  the  defect 
in  sensation,  peristalsis,  absorption  and  secretion  of  the  ureter — results  in 
defective  transportation  of  urine,  obstructing  the  normal  functions  of  the 
kidney  (which  are  sensation,  peristalsis,  absorption,  secretion).  The  chief 
essential  function  of  the  ureter  is  peristalsis. 

Symptoms. — The  dominating  symptoms  in  tuberculosis  of  the  ureter  are: 
haemorrhage,  pain  and  frequent  micturition.     Casper  advocates  that  persistent 
acid  pyuria  is  a  diag-nostic  feature  of  tuberculous  nephritis.     Whenever  pus 
is  discovered  in  the  urine  the  uterer  furnishing  pus  may  be  demonstrated, 
occasionally,  by  unilateral  ureteral  massage,  repetition  of  alternating  imilateral 
ureteral  massage  may  confirm  or  dispose  the  correctness  of  the  pyo-ureter  or 
pyo-uro-ureter.     The  right  ureter  is  attacked  more  frequently  than  the  left  in 
reno-ureteral    tuberculosis.     As    a    rule    reno-ureteral    tuberculosis    manifests 
tenderness  by  ureteral  pressure — at  the  three  ureteral  isthmuses,  proximal  (at 
distal  renal  pole)  ;    middle   (at  vasa  iliaca  communis)  ;    distal    (at  urinary 
vesical  wall).     Unilateral  pain  in  micturation  may  be  a  suspect  of  urinary 
tuberculosis.     An  inflamed  ureter  with  hj^ertrophic  parietes,  with  diminished 
lumen  and  length  may  functionate  with  pain.     In  reno-ureter  tuberculosis 
the  affected  kidney  may  be  at  first  smaller  or  second  larger  than  the  healthy 
kidney.     The  pain  in  tubercular  ureteritis  is  recurrent  (violent  ureteral  peri- 
stalsis,   accompanied,    perhaps,    by    ureteritis).     The    pain    may    be    due    to 
occlusion  of  the  ureter  by  blood-clots  or  from  the  peristalsis  of  an  inflamed 
ureter.     The  reaction  of  the  urine  is  in  the  incipient  stage  of  tuberculosis  of 
the  urinary  tract  acid,  in  the  advanced  stages  it  is  alkaline.     Hematuria  exists 
in  reno-ureteral  tuberculosis  from  ulceration   of  the  mucosa,   especially  the 
pyramidal  apex.     Pyuria  exists  in  tuberculosis  of  the  ureter,  from  the  sup- 
puration of  the  mucosa,  due  to  the  destructive  ulcer.     Persistent,  frequent  mic- 
turition or  vesical  tenesmus  painful  or  others  (notwithstanding  previous  gon- 
orrhoeal  attacks  and  catheter  infection),  should  be  considered  as  a  suspect 
for  ureteral  tuberculosis.     Subjective  pain  in  reno-ureteral  tuberculosis  may 
refer  to  the  healthy  or  diseased  organ — it  may  be  reflex  and  is  uncertain  as  to 
locating  the  disease.     Acute  inflammatory  processes  of  the  proximal  ureter 
(especially  the  calyces  and  pelvis)    produces  congestion  and  cedema  of  the 
distal  ureteral  orifice  with  eversion  of  the  ureteral  orifice.     The  degree  of 
ureteral  eversion  and  cedema  of  the  ureteral  orifice  is  in  accord  with  the  degree 
of  tubercular  ureteritis.     Profound  disturbances  of  the  proximal  ureteral  dila- 
tation as  circulatory,  inflammatory  or  ulcerative,  modifies  the  distal  ureteral 
orifice  in  the  form  of  congestion,  cedema,  eversion,  dilatation,  ulceration.     In 
other  words  the  circulation  of  the  ureter  is  so  compactly  and  solidly  anas- 
tomosed  from   calyces  to  trigone  that  what   effects   the   circulation   of   one 
extremity    of    the    ureter    will    correspondingly    effect    the    other.     In    both 
infectious  uretero-nephritis  and  (reno)  ureteral  tuberculosis  there  exists  pain, 
rise  of  temperature,  night  sweats  (from  sepsis).     Both  diseases  may  present: 
tender  kidney,  renal  hypertrophy,  diminishing  weight,  unfavorable  appetite, 
pus,  blood,  casts  and  epithelia  in  urine,  emaciation,  debility.     Eeno-ureteral 


CONCLUSION  IN  REGAUD  TO  TUBERCLTLAR  URETERITIS.  359 

tuberculosis  varies  in  its  effect,  rapidity  or  slowness  of  course,  similar  to  other 
germ  disease.  Some  are  markedly  chronic  and  some  are  markedly  acute — dura- 
tion averages,  perhaps,  three  years. 

Diagnosis. — The  presence  of  the  tubercle  bacillus  in  the  urine  is  one  of  the 
most  definite  signs  of  urinary  tuberculosis.  The  presence  of  the  tubercle 
bacillus  in  the  urine  is  not  conclusive  evidence  of  rcno-ureteral  tuberculosis  as : 
(a),  tubercular  ulcer  may  have  perforated  the  bladder;  (b),  the  bacillus  may 
be  projected  through  the  ejaculatory  duct  from  the  vesiculce  seminales;  (c), 
it  may  arise  in  glands  of  the  prostate;  (d),  the  bacillus  may  be  filtered  from 
the  blood  or  l}'mph  through  the  kidney  (from  extrarenal  tuberculosis).  If  the 
vesical  ureteral  orifice  on  one  side  be  normal  and  on  the  other  side  abnormal 
experience  dictates  that  the  reno-ureteral  disease  is  on  the  side  with  abnormal 
ureteral  orifice.  However,  crossed  ureters  should  not  be  forgotten.  Yet  most 
crossed  ureters  correspond  to  a  right  and  left  kidney  (especially  in  sigmoid 
kidney).  A  constricted  ureteral  orifice  evacuating  in  a  congested  cedematous 
area  indicates  an  acute  ureteritis  with  bladder  complications — and  persisting 
is  a  suspect  of  tubercular  ureteritis.  Limited  inflammation  and  hypertrophy  of 
the  ureteral  orifice  with  limited  congestion  of  the  adjacent  mucosa  may  indicate 
incipient  ureteral  tuberculosis,  pyoureteritis  or  nephritis.  A  lateralward  and 
proximalward  retracted  ureteral  orifice  may  indicate  a  diminishing  length  of 
the  ureter  from  cicatricial  ureteritis  or  proximalward  retraction  of  the  kidney 
from  paranephritis ;  however,  I  have  observed  these  identical  processes  may 
result  from  both  infectious  and  tubercular  processes.  A  marked  oedema  of  the 
ureteral  orifice  and  immediately  adjacent  mucosa  may  indicate  ureteral  tuber- 
culosis or  a  calculus  lodged  in  the  pelvic  segment  of  the  ureter.  If,  however, 
nodules  accompany  the  cedematous  ureteral  orifice  tuberculosis  is  at  least  a 
suspect.  In  ureteral  tuberculosis  grave  changes  are  practically  constant  in 
the  vesical  ureteral  orifice — not  so  always  in  renal  tuberculosis.  The  presence 
of  granulations  or  papillre  adjacent  to  the  vesical  ureteral  orifice  are  suspects 
of  reno-ureteral  tuberculosis.  If  the  bladder  presents  no  tubercular  symptoms 
bilateral  ureteral  catheterization  will  be  required  for  further  diagnosis.  Clari- 
fied urine  excludes  not  tuberculous  because  the  tubercular  ureter  may  be 
obstructed  or  obliterated.  A  danger  in  ureteral  catheterization  in  a  subject 
possessing  vesical  tuberculosis  is  that  the  catheter  may  transport  the  bacillus 
to  the  ureter,  with  possible  subsequent  ureteral  tuberculosis.  In  cystocopy  for 
tuberculosis  in  the  bladder,  ureter  or  kidney  it  may  be  well  to  remember  that 
the  tubercular  bacillus  may  be  injected  into  the  ureter  from  the  vesiculce 
seminales  or  prostate  gland.  Cystoscopy  and  ureteral  catheterization  are  the 
main  aids  to  diagnose  reno-ureteral  tuberculosis.  Cystoscopy  demonstrates 
the  condition  of  the  vesical  ureteral  orifice  and  its  relations  to  its  environments. 
Ureteral  catheterization  demonstrates  tlie  functional  capacity  of  both  kidncvs. 
When  the  vesical  ureteral  orifice  is  dislocated,  retracted,  drawn  lateralward 
and  proximalward  the  length  of  tlie  ureter  is  not  only  diminished,  but  its  lumen 
is  compromised,  hence,  the  urine  is  forced  through  the  ureter  with  difficulty 
and  frequently  with  pain.  Obstruction  in  the  reno-ureteral  function  proceeds 
swiftly  onward  and  swiftly  downward  to  final  destruction.     A  retracted  vesical 


360  CONCLUSION  IN  EEGARD  TO  TUBEECULAR  URETERITIS. 

ureteral  orifice  indicates  h}^Dertropliy  and  ureteral  contraction  of  the  ureter 
with  diminished  ureteral  lumen.  The  temperature  in  urinarv^  tuberculosis 
assumes  a  remarkable  variation — depending  on  the  conditions  of  mixed  infec- 
tion. Some  of  the  marked  changes  in  the  vesical  ureteral  orifice  observed  by 
the  cystoscope  during  reno-ureteral  tuberculosis  may  be  noted  as  the  following : 
If  the  ureteral  orifice  be  patent,  accompanied  by  adjacent  mucous  inflammation, 
tubercle  nodes  and  tubercle  bacillus  exists — it  is  a  suspect  of  tuberculosis.  Con- 
gestion and  oedema  of  the  vesical  mucosa  adjacent  to  the  ureteral  orifice,  aversion 
of  the  ureteral  orifice  indicate  acute  ureteritis — a  suspect  of  tubercular 
ureteritis.  Elongated,  everted,  cedematous  ureteral  orifice  with  redness  indi- 
cates violent  disturbances  (circulatory,  inflammatory,  ulcerative)  at  the 
proximal  ureteral  dilatation  (calyces  and  pelvis),  e.g.,  as  in  tuberculosis.  A 
dilated  ureteral  orifice  without  h3'pertroph3',  oedema  or  redness  indicates  a 
mild  disturbance  (circulatory,  inflammatory',  ulcerative)  as  in  lithiasis.  The 
diagnosis  of  reno-ureteral  tuberculosis  mainly  rests  on:  1,  Clinical  histor}^; 
2,  physical  examination;  3,  urinalysis;  4,  cystoscopy  and  separate  ureteral 
catheterization;   5,  tuberculin  test. 

Funciion. — In  tubercular  ureteritis  individual  catheterization  of  the 
ureters  is  required  to  determine  the  fimctional  capacity  of  each  kidney.  The 
functional  diagnosis  of  the  reno-ureteral  tract  must  be  determined.  From 
microscopic  examination,  from  cystoscopy,  from  ureteral  catheterization,  from 
the  percentage  of  urea,  from  the  phloridzin  test,  the  functional  capacity  of 
each  kidney  may  be  determined.  In  the  beginning  of  tubercular  ureteritis 
polyuria  may  exist,  but  in  advanced  stages  decrease  in  urine  occurs. 

Location. — The  rule  regarding  the  location  of  urinary  tuberculosis  is: 
(a),  renal;    (b),  ureteral;    (c),  vesicular. 

Obscure  Diagnosis. — Tuberculosis  of  the  ureter  may  be  mistaken  for 
lithiasis,  ureteritis.  There  is  more  hematuria  and  frequent  micturition  in 
ureteral  tuberculosis  than  in  ureteral  lithiasis.  Frequent  micturition  in  tuber- 
cular ureteritis  may  be  observed  day  and  night.  In  tubercular  ureteritis  there 
is  the  clinical  history,  family  history.  Eeno-ureteral  tuberculosis  is  fairly 
rapid,  cachexia  is  prompt.  Ureteral  lithiasis  presents  a  histor}'-  of  rheimiatism, 
gout,  lithsemia,  pain  in  dorsal  region.  In  ureteritis  tuberculosa,  tuberculosis 
may  be  noted  elsewhere.  Eeno-ureteral  tuberculosis  may  be  mistaken  for 
neoplasm  and  vice  versa.  Cachexia  distinguishes  ureteral  tuberculosis  from 
ureteral  lithiasis.  Ureteral  tuberculosis  generally  occurs  in  young  adults 
(under  forty).  Eenal  neoplasms  usually  occur  in  subjects  over  forty.  Eenal 
neoplasm  is  generally  palpated  with  facility  on  account  of  considerable  dimen- 
sion. Eeno-ureteral  tuberculosis  usually  presents  limited  dimension  for  pal- 
pation. Proximalward  moving  uretero-nephritis  is  the  most  easily  confounded 
with  reno-ureteral  tuberculosis.  Differentiation  of  these  two  diseases  is  diffi- 
cult, reqniring  skill,  time  and  repeated  observation.  The  souvenir  aids  to 
differentiate  between  infectious  uretero-nephritis  and  reno-ureteral  tuber- 
culosis are  the  cystoscope  and  the  microscope.  The  cystoscope  reveals  the 
condition  of  the  vesical  trigone,  the  l)ladder,  and  mucosa,  with  especially  the 
appearance  of  the  ureteral  orifices.     The  microscope  may  reveal  the  tubercular 


CONCLUSION  LN  IIEGAP.D  TO  TLI5ERCULAK  URETERITIS.  3^1 

bacillus — the  main  diagnostic  sign.  A  cystic  kidney  may  be  mistaken  for  a 
tubercular  kidney ;  however,  the  cystic  kidney  is  generally  larger,  more  indefinite 
in  contour,  more  mobile,  producing  slight  constitutional  symptoms. 

Surgery. — The  anaesthesia,  in  kind,  must  be  chosen  by  special  anesthetists. 
In  cases  of  reno-ureteral  tuberculosis  with  perireno-ureteral  abscess,  lumbar 
incision  (nephrotomy),  and  drainage  frequently  aids  as  a  preparatory  method. 
In  reno-ureteral  tuberculosis,  with  severe  involvement  of  the  urinary  vesical, 
infrapubic  cystotomy  may  relieve  pain  and  comfort  the  patient.  Neither 
tubercular  disease  in  the  other  sufficiently  functionating  kidney  nor  tuber- 
cular depredations  in  extrarenal  regions  is  a  contra-indication  for  neph- 
rectomy. If  the  functional  capacity  of  one  kidney  be  sufficient  to  support 
life,  the  other  may  be  removed  regardless  of  its  disease,  and  should  be 
executed  in  reno-ureteral  tuberculosis.  If  reno-ureteral  tuberculosis  be 
bilateral,  however,  the  functional  capacity  of  one  kidney  be  sufficient  to 
sustain  life,  the  other  tubercular  kidney  should  be  extirpated,  because 
subsequent  to  the  renal  extirpation  the  renal  hypertrophy  of  the  remain- 
ing organ,  from  necessit}',  will  be  supplied  by  an  extraordinary  volume 
of  blood,  which  may  cure  the  tuberculosis,  for  living,  flowing  blood  cures 
disease.  The  souvenir  remedy  (at  present)  for  reno-ureteral  tuberculosis  is 
nephrectomy  and  ureterectomy.  ISTeplirotomy  has  not  proved  satisfactory  in 
reno-ureteral  tuberculosis.  Nephrotomy  may  serve  the  purpose  of  a  prepara- 
tory aid  to  nephrectomy  by  drainiDg  extensive  renal  abscesses  and  infected 
areas.  Bilateral  reno-ureteral  tuberculosis  is  not  a  contra-indication  to 
nephrectomy,  if  one  kidney  be  able  to  assume  the  necessary  function  of  both. 
Subsequent  to  nephrectomy  for  tuberculosis  the  patient  should  lie  on  the 
dorsum  to  allow  maximum  drainage  of  the  wound.  The  patient  should  have 
continuous  proctoclysis,  eight  ounces  of  fluid  per  hour  entering  the  rectum 
and  sigmoid.  Also  as  much  hot  fluid  per  mouth  should  be  administered  as 
the  stomach  will  bear — two  to  four  ounces.  The  mortality  of  reno-ureteral 
extirpation  for  tuberculosis  is  marked — 10  to  40  per  cent.  The  pre-operative 
treatment  for  tubercular  reno-ureteral  surgery  is  visceral  drainage,  i.e.,  the 
patient  should  drink  eight  ounces  of  fluid  every  two  hours  for  eight  times 
(four  pints)  daUy  for  three  to  four  days  preceding  the  operation.  Medicated 
lavage  of  the  ureter  in  reno-ureteral  tuberculosis  is  a  rational  procedure,  allow- 
ing direct  medication. 

Prognosis. — Spontaneous  healing  of  reno-ureteral  tuberculosis  is  appar- 
ently extremely  rare — in  fact,  so  rare  that  it  should  not  be  expected.  Thera- 
peutic healing  or  reno-urteral  tuberculosis,  at  present  reports,  is  extremely 
rare.  Though  the  spontaneous  and  therapeutic  healing  of  reno-ureteral 
tuberculosis  is  extremely  rare,  yet  therapeutic  measures,  as  climactic,  dietetic, 
hygienic  should  be  employed  to  improve  the  general  condition  of  the  patient 
— to  lessen  suffering  and  prolong  life,  to  improve  digestion,  to  aid  sleep,  to 
increase  red  blood;  in  short,  to  improve  function.  It  is  probable  that  spon- 
taneous healing  of  the  tubercular  bladder  in  reno-ureteral  tuberculosis  is  due 
to  obliteration  of  the  tubercular  ureter  or  the  removal  of  the  tubercular  kid- 
ney.    It  would  appear  that  the  renal  parenchyma  is  such  a  favorable  nidus 


362  PRINCIPLES  OF  THE  MODERN  TREATMENT  OF  GONORRHCEA. 

for  the  thriving  of  the  tubercle  bacillus  that  it  becomes  progressive.  The 
duration  of  reno-ureteral  tuberculosis  after  marked  s3Tnptoms  averages  some 
three  years — the  patient  usually  dying  of  uraemia  and  cachexia.  Opinions 
are  divided  as  to  whether  pregnancy  damages  subsequent  to  nephrectomy. 


PRINCIPLES  OF  THE  MODERN  TREATMENT  OF  GONORRHOEA.* 

By  JOSEPH  L.  BOEHM,  PuG.,  M.D., 
Professor  of  Diseases  and  Surgery  of  the  Genito-Urinary  Organs,  St.  Louis  College  of 

Physicians  and  Surgeons. 

In  this  advanced  era  of  pathology  and  bacteriology,  it  may  seem  rather 
puerile  and  elementary  for  one  to  address  a  medical  assembly  on  the  treat- 
ment of  gonorrhoea.  It  is  the  fii"m  conviction  of  the  writer,  that  too  much 
cannot  be  written  or  spoken  about  the  treatment  of  this  universally  prevalent 
disease,  and  that  it  is  a  sad  commentary  on  our  American  literature  to  peruse 
most  of  our  text-books  on  genito-urinary  diseases  and  read  some  of  the  anti- 
quated methods  of  treatment  of  urethral  gonorrhoea.  Ofttimes  more  stress 
is  laid  on  some  particular  favorite  drug  of  the  author,  than  on  a  thorough 
consideration  of  the  correct  principles  of  treatment,  in  which  all  drugs  are 
of  minor  importance. 

Almost  every  drug  in  the  pharmacopoeia  or  dispensatory  has,  at  some 
time  or  other,  been  used  or  recommended  as  valuable  in  the  treatment  of  this 
disease.  Notwithstanding  the  arrogant  claims  of  many  pharmaceutical  chem- 
ists: There  is  no  specific  drug  or  treatment  for  the  cure  of  gonorrhoea. 
There  is  no  drug  or  chemical  that  can  be  applied  to  every  urethra  with 
equally  good  results. 

It  is  our  purpose  in  this  paper  to  deal  with  the  principals  of  treatment, 
and  not  dwell  on  any  specific  remedial  agent  or  method  of  treatment. 

It  is  of  minor  importance  what  drug  or  chemical  is  used  or  what  method 
of  application  is  resorted  to,  provided  the  cardinal  principle  is  adhered  to, 
embodied  as  follows: — 

The  successful  treatment  of  gonorrhoea  consists  in  the  proper  under- 
standing and  use  of  the  surgical  principles  of  rest  and  free  drainage,  and  the 
methodic  use  of  certain  classes  of  drugs  and  bactericidal  agents  primarily, 
and  secondarily  endeavoring  to  repair  as  well  as  possible  any  damage  to  the 
urethral  mucosa  and  adnexa,  resulting  from  the  proliferation  and  growth  of 
the  gonococcus. 

Remember  that  each  urethra  has  a  distinct  individuality;  some  are 
leathery,  others  are  intolerant  and  irritable.  According  to  Eobinson,  "The 
gonococcus  is  the  king  of  beasts  among  germs,  as  it  practically  prepares  the 
road  for  all  the  pathogenic  germs  by  trauma  of  the  mucosa,  producing  atria 
for  infection." 


•Read  in  the  Symposium  on  Gonorrhoea,  at  meeting  of  the  St.  Louis  Medical 
Society,  May  1,  1909. 


PRI]^CIPLES  OF  THE  MODElUs   TllEATMEJ^T  OF  GONORRHCEA.  363 

Analyzing  this  cardinal  principle,  we  must  then  consider  as  the  elements 
of  treatment  the  following:  Prophylaxis,  free  drainage,  rest,  bactericidal 
agents,  repair  and  regeneration  of  destroyed  and  damaged  mucosa,  abnor- 
malities of  urine,  as  hyperacidity,  oxaluria,  phosphaturia,  etc. 

DEAINAGE. 

Evacuate  all  pus  from  the  urethra  by  free  drainage,  not  by  the  intro- 
duction of  any  foreign  material  into  the  urethra,  as  gauze,  etc.,  but  between 
the  intervals  of  micturition  the  penis  should  be  suspended  in  a  comfortable 
position  in  a  dressing  retainer  and  fresh  cotton  applied  to  the  glans  after 
each  urinary  act.  A  congenitally  narrow  meatus  is  an  obstacle  to  free  drain- 
age. By  no  means  should  the  filthy  tobacco  pouch  be  used  where  the  meatus 
and  glans  is  kept  constantly  bathed  in  the  pus  exuding  from  the  urethra  into 
the  cotton  at  the  bottom  of  the  pouch.  No  bandage  should  be  applied 
directly  to  the  penis  that  is  constricting  in  any  sense.  The  pus  of  gonorrhoea 
is  as  essential  to  and  symptomatic  of  this  diseased  condition  as  pyrexia  is  in 
typhoid  or  pneumonia.  When  the  typhoidal  temperature  is  temporarily 
reduced  with  cold  and  hydrotherapy,  it  does  not  signify  that  the  disease  is 
cured,  but  we  also  endeavor  to  eliminate  the  typhoid  bacillus  in  the  gall, 
urinary  bladders  and  bowels  to  the  best  of  our  ability.  Strange  to  say,  we 
often  lose  sight  of  the  fact  that  the  suppuration  and  secretion  of  the  urethra 
in  gonorrhoea  is  quite  essential;  it  is  nature's  method  of  eliminating  the 
inflammatory  detritus,  together  with  the  destroyed  gonococci  and  epithelium, 
the  result  of  phagocytosis. 

Therefore  we  must  not  be  too  desirous  of  promoting  the  patient's 
happiness  and  peace  of  mind,  by  attempting  too  quickly  to  stop  the  urethral 
discharge.  You  may  dress  a  varicose  ulcer  with  a  bismuth  powder  and  have 
a  scab  form  over  it  very  quickly,  but  this  would  not  necessarily  indicate  that 
the  ulcer  is  healing.  Kemove  the  scab  and  often  a  collection  of  pent  up  pus 
will  be  found  beneath  it.  Just  so  in  acute  primary  gonorrhoea;  attempt  to 
stop  a  suppurating  urethra  quickly,  which  can  often  be  done  by  astringent 
mixtures,  and  you  only  delay  healing,  while  the  gonococci  penetrate  the  sub- 
mucosa  and  museularis  layers  of  the  urethra.  There  has  existed  a  so-called 
abortive  treatment  for  many  years,  with  the  chief  idea  of  destroying  the 
gonococci  quickly  by  an  initial  application  of  some  strong  silver  solution,  etc. 
Many  authorities  agree  that  the  abortive  treatment  is  useless  forty-eight 
hours  after  the  beginning  of  symptoms.  Patients  must  be  seen  a  few  hours 
after  the  itching  and  burning  of  the  urethra  starts,  and  a  slightly  purulent 
discharge  exists.  "We  often  hypnotize  ourselves  with  the  phantom  of  abortive 
treatment  that  seldom  is  a  reality.  It  is  never  successful  when  the  inflamma- 
tory process  has  penetrated  below  the  surface  layer  of  the  epithelium. 

BEST. 

This  is  of  paramount  importance;  physical  rest  of  the  whole  body  in  a 
reclining  posture  as  much  as  possible,  during  the  acute  stage,  thus  reheving 


364         PRllN'CIPLES  OF  THE  MODERJS'  TKEATMEKT  OF  GONORRnCEA. 

all  tendency  to  pelvic  congestion.  licst  the  posterior  urethra  by  keeping  the 
rectum  unloaded  of  all  fascal  contents,  by  at  least  one  daily  bowel  action, 
which  relieves  all  tendency  to  all  pressure  on  the  prostate,  because  there  is  a 
direct  anastomosis  of  the  hemorrhoidal  and  prostatic  circulations.  liest  the 
penis  and  scrotal  contents  by  wearing  a  bandage  for  both ;  the  Modified  Sup- 
port Bandage  and  Dressing  Eetainer,  such  as  the  writer's,  manufactured  by 
Seabury  &  Johnson,  of  New  York,  which  also  has  the  advantage  of  keeping 
all  dressings  to  the  penis  in  position,  and  preventing  soiling  of  the  linen  by 
infectious  discharges. 

BACTERICIDAL   AGENTS. 

Many  of  the  elements,  in  various  organic  and  inorganic  combinations, 
have  been  used  from  time  to  time,  as  mercury,  thalimn,  silver,  manganese, 
potassium,  copper,  sodium,  iodine,  bismuth,  zinc,  lead,  etc.  The  most  com- 
monly used  to-day,  as  bactericidal  agents,  are  the  organic  and  non-organic 
silver  sails.  In  the  Transactions  of  the  x^merican  UrologJcai  Association, 
Volume  II,  1D08,  are  recorded  my  views  on  the  new  silver  preparations,  in 
which  is  stated  that  these  newer  preparations  are  not  in  all  cases  equally  as 
efficient,  nor  can  they  fully  replace  the  older  silver  nitrate. 

Astringents  must  never  be  used  in  early  treatment,  until  all  evidence  of 
gonocoeci  is  negative.  Many  prefer  not  to  use  them  at  all  because  of  the 
possibility  of  sealing  up  or  enveloping  in  the  tissues  some  latent  germs.  No 
one  can  intelligently  treat  a  gonococcal  infection  of  the  urethra  without  fre- 
quent use  of  the  microscope  to  examine  urethral  secretion,  urinary  shreds  and 
I'ilaments.  This  is  of  absolute  necessity,  aud  is  a  compass  that  guides  and 
directs  our  course  of  treatment. 

In  applying  local  medication  to  the  urethra,  which  is  at  times  highly 
inflamed  and  cedematous,  discretion  must  be  used  so  as  not  to  use  bactericidal 
solutions,  which  smart  and  irritate  the  urethral  mucosa.  It  is  often  advisa- 
ble to  wait  for  several  days  before  beginning  local  medication,  especially  if 
there  should  be  slight  capillary  ha}morrhage  from  the  mucosa  at  each  urinary 
act.  If,  for  some  reason  local  medication  is  attempted  at  this  time,  it  is 
advisable  to  precede  such  antiseptic  solution  with  an  aneesthetic  as  alypin, 
novocain,  cocain  and  adrenalin.  It  matters  not  in  what  manner  antiseptic 
solutions  are  ap|)lied  to  the  urethra;  whether  in  lavage  with  a  large  volume 
of  fluid  for  copious  irrigation,  or  the  use  of  a  large  piston  syringe,  provided 
we  remember  that  where  the  infection  is  limited  to  the  anterior  urethra,  as 
it  is  during  the  very  early  part  of  an  acute  inflammation,  force  and  pressure 
with  a  syringe  or  irrigation  apparatus  may  quickly  disseminate  the  infection 
to  healthy  portions  of  the  urethra,  even  to  the  bladder  by  direct  continuity 
of  tissue.  We  must  remember  that  we  have  virtually  two  urethras:  the 
anterior  and  posterior,  and  that  it  is  more  simple  to  treat  the  former  than 
the  latter. 

Abnormalities  of  urine  must  be  considered  because  an  oxaluria,  phospha- 
turia  and  excess  of  uric  acid  crv^stals  or  hyperacidity  will  irritate  the  inflamed 
mucosa.     These  urinary  conditions  indicate  the  necessity  for  proper  dietetic 


PRINCIPLES  OF  THE  UODERN  TREATMENT  OF  GONORRHCEA.         365 

aud  internal  medicinal  treatment;  and  the  use  of  demulcents,  antacids,  seda- 
tives and  diuretics.  We  cannot  too  vigorously  condemn  the  use  of  any 
medium  except  warm  sterile  water  or  glycerine  as  a  vehicle  for  the  gonococco- 
cides,  in  tlieir  application  to  the  acutely  inflamed  urethra.  Therefore  avoid 
inserting  gauze,  saturated  with  antiseptics,  medicated  bougies  or  supposi- 
tories and  ointments  during  the  acute  stage. 

Never  introduce  any  instrument  or  foreign  hody  into  an  acutely  inflamed 
and  suppurating  urethra,  unless  there  is  some  special  emergency  necessitating 
it.  A  case  of  genuine  gonococcal  urethritis,  in  contradistinction  to  the  sev- 
eral forms  of  simple  urethritis,  is  never  absolutely  cured  in  three  days. 
Classical  cases  require,  as  a  rule,  at  least  six  or  eight  weeks  of  careful 
methodic  treatment.  The  practice  of  treating  an  infected  urethra  solely  by 
the  use  of  internal  medication  with  urinary  antiseptics,  balsamics,  etc.,  has 
been  relegated  to  oblivion  long  ago.  Gonoeocei  can  only  be  destroyed 
by  attaelviiig  them  in  situ,  in  the  urethra  or  aduexa  by  direct  bactericidal 
medication. 

EEPAIR   OF   DESTROYED   AND  DAMAGED   MUCOSA   AND   ADNEXA. 

The  adnexa  most  commonly  complicated  in  urethral  gonorrhoea  are  the 
prostate,  seminal  vesicles  and  epididjmii.  When  this  occurs  it  indicates  that 
the  disease  has  infected  the  posterior  urethra,  because  the  ejaculatory  ducts 
of  the  vesicles  and  the  prostatic  ducts  are  directly  continuous  with  the 
prostatic  urethral  mucosa,  also  the  lymphatics  are  in  direct  continuity.  The 
prostate  is  of  paramount  importance,  and  when  acutely  infected  Avith  gonor- 
rhoea, bids  fair  to  run  a  long  chronic  course,  covering  weeks,  months,  years, 
and,  possibly,  incurable.  The  so-called  gleet  and  morning  drop  of  chronic 
gonorrhcea  is  commonly  dependent  on  an  infected  prostate,  that  may  have 
escaped  detection  and  received  no  treatment;  a  similar  state  of  affairs  may 
exist  with  diseased  seminal  vesicles,  where  only  too  commonly,  when  acutely 
infected,  they  escape  detection  and  treatment.  Recurrent  epididjniiitis, 
neuralgic  pains  of  the  spermatic  cord  and  testes,  are  commonly  caused  by  a 
chronic  gonorrhoeal  prostatitis  or  vesiculitis.  Gonoeocei  may  lie  dormant  for 
}"cars  in  the  prostate  and  urethral  follicles,  and  in  coitus  when  there  is  con- 
gestion and  hypersecretion  of  the  urethra,  prostate  and  vesicles,  all  mixed 
together  with  the  seminal  elements,  we  can  readily  understand  how  gono- 
coccal semen  is  deposited  in  the  vagina,  then  follows  the  tragic  recital  of  pus 
tubes,  laparotomy,  etc. 

Formerly  most  text-books  advised  eliminating  all  urethral  treatment 
when  acute  epididymitis  occurs.  I  believe  this  is  an  antiquated  superstitious 
tradition,  not  founded  on  logical  facts,  and  therefore  advise  continuing 
treatment  of  the  posterior  urethra,  with  proper  precautions.  Schindleri 
advocates  puncture  as  a  therapeutic  method  in  treatment  of  gonorrhoeal 
epidicIjTnitis.  EpididjTnotomy,  or  puncture  find  incision  of  the  epididymis  in 
gonorrhoeal  inflammation, 'is  now  universally  practiced.     There   is  no   good 


1  Deutsch.  Mpd.  Woch.,  1907. 


366         PRINCIPLES  OF  THE  MODERN  TREATMENT  OF  GONORRHffiA. 

reason  why  it  should  not  be  done  wherever  feasible,  although  many  patients 
object  to  the  knife  for  such  a  simple  thing  as  "swollen  testicles,"  as  they  call 
it.  Bazet  has  a  record  of  sixty-five  cases  with  good  results,  and  advises 
operative  procedure  as  soon  as  the  diagnosis  is  made.  Hagner  says:  "The 
operative  treatment  of  gonorrhoeal  arthritis  was  the  procedure  that  suggested 
to  me  the  surgical  intervention  in  these  cases  of  gonorrhceal  epididymitis." 
We  all  know  the  intense  pain  in  acute  epididymitis  when  all  patients  only  too 
eagerly  go  to  bed.  The  advantage  of  epididymotomy  is  vanishing  of  pain 
almost  immediately  after  operation,  reduction  of  temperature,  elimination  of 
the  constant  danger  of  recurrent  attacks  of  acute  reinfection  due  to  retained 
infection  in  loco  for  years. 

Belfield2  refers  to  gonorrhoeal  epididymi  as  pus  tubes  in  the  male;  he 
regards  this  condition  as  far-reaching  as  pyosalpinx,  and  advises  surgical 
treatment,  free  drainage  and  evacuation  of  all  pus.  Bilateral  or  unilateral 
occlusion  of  the  vas  deferens  is  very  common  following  an  epidid}Tnitis  with 
a  consequent  sterilit3^  G}mecologists  must  not  lose  sight  of  the  bearing  of 
this  condition  on  the  question  of  propagation  of  species,  when  consulted  by 
women,  who  never  suspect  the  husband  as  the  cause  of  their  sterility,  when 
examination  of  him  may  show  indurated  areas  in  one  or  both  functionless 
epidid}Tfii.  Bier's  method  of  artificial  hypergemia  in  acute  epididymitis 
according  to  reports  is  not  markedly  successful. 

In  referring  to  regeneration  of  destroyed  and  damaged  mucosa,  we  con- 
sider the  conditions  resulting  from  the  destructive  action  of  the  gonococci 
at  which  time  they  may  have  apparently  disappeared  and  the  purulent  secre- 
tion of  the  urethra  diminished  or  ceased,  and  instead  a  urethral  catarrh 
exists.  This  is  the  chronic  stage  of  urethritis,  and  should  be  treated  by 
primarily  inspecting  the  anterior  and  posterior  urethras  with  the  urethro- 
scope, by  ocular  inspection.  This  is  done  to  determine  the  exact  seat  and 
location  of  the  lesion.  In  this  stage  instrumental  treatment  in  some  form  or 
other  is  not  only  indicated,  but  of  absolute  necessity  for  a  cure.  Permit  me 
to  say  that  urethral  instrumentation  as  recklessly  practiced  by  many  is  only 
an  abuse  of  the  patient,  and  may  result  in  much  injury  to  the  healthy  parts 
of  the  urethra.  The  urethroscope  is  commonly  used  as  a  toy  to  the  delight 
of  the  patient  who  marvels  at  the  introduction  of  an  electric  light  into  the 
urethra.  Any  novice  can  insert  a  urethroscope,  but  urethroscopy  to  be 
understood  requires  as  much  practice  and  experience  as  proficiency  in  the  use 
of  the  ophthalmoscope.  Chronic  gonorrhoea  demands  in  order  to  cure  it, 
destruction  of  gonococci,  remaining  as  a  latent  condition  from  the  acute  stage, 
especial  attention  to  destroyed  or  denuded  areas  of  mucosa,  infected  follicles, 
the  removal  of  new  growths  by  chemicals  or  electric  cauterization,  treatment 
of  diseased  prostate  and  vesicles.  Of  less  common  occurrence  is  infection  of 
the  lower  urinary  tract,  as  acute  exacerbations,  from  chronic  gonorrhoeal 
pyelitis.  If  chronic  gonorrhoeal  pyelitis  or  prostatitis  exists  never  hope  to 
cure  the  urethra  until  these  diseased  foci  are  respectively  treated.     One  or 


2  Joiir.  Amer.  Mpd.  Assn.,  1905. 


PRINCIPLES  OF  THE  MODERN  TREATilENT  OF  GONORRHCEA.  367 

both  kidney  pelves  may  be  treated  by  urethral  catheterization  and  pelvic 
lavage  of  the  kidney  with  the  same  antiseptic  solutions  as  are  used  for  the 
urethra. 

Paraurethritis,  where  the  infected  focus  is  entirely  outside  of  the  urethra, 
possibly  in  the  glans  penis,  may  cause  recurrent  gonorrhea  of  the  urethra  of 
years  standing.  Such  condition  is  reported  by  me  in  the  American  Journal 
of  Dermatology  and  Genito-urinary  Diseases,  in  April,  1909. 

THE  VACCIXE  OR  BACTERIN  TREATMENT. 

This  is  the  most  modern  innovation  in  the  treatment  of  gonorrhoea  and 
its  complications.  The  work  of  Wright  in  opsonic  investigation  has  made 
gonorrhoeal  vaccine  a  possibility.  That  vaccine  has  a  diagnostic  as  well  as 
a  therapeutic  value  cannot  be  doubted,  but  on  this  point  those  who  have 
reported  its  use  do  not  fully  agree,  in  all  phases  of  the  subject.  Personally, 
I  have  found  that  in  some  cases  it  will  arouse  latent  gonococci,  but  does  not 
act  exactly  similar  to  tuberculin,  in  regard  to  uniformity  of  results,  as  a 
diagnostic  means.  It  is  common  to  observe  a  rise  of  temperature  after  the 
initial  injection  subcutaneously,  or  observe  a  zone  of  hyperi3emia  around  the 
site  of  the  needle  puncture  for  several  days  after  the  injection.  In  my 
record  of  twenty-four  cases  treated  by  vaccine  seldom  was  pain  complained 
of.  In  one  case  marked  furunculosis  of  arm  and  neck  followed  the  initial 
injection,  with  enlargement  of  axillary  glands.  If  urethral  gonorrhoea  and 
prostatitis  is  complicated  with  pus  germs,  which  is  only  too  common,  the 
gonococcus  vaccine  must  be  fortified  with  injection  simultaneously  of  mixed 
strains  of  the  staphylococcus  vaccine.  This  fact  must  not  be  lost  sight  of. 
To  date  there  is  no  mixed  or  combined  gonococcus  and  staphylococcus  vaccine 
on  the  market,  and  the  Department  of  Experimental  Medicine  of  Parke- 
Davis  &  Company,  of  Detroit,  are  kindly  experimenting  in  this  line  according 
to  my  suggestion.  Future  experimentation  may  make  such  a  mixed  vaccine 
a  possibility.  I  believe  vaccine  and  biologic  therapy  should  be  used  only  as 
an  adjunct  in  treatment  at  the  present  time,  and  in  no  sense  as  a  total  sub- 
stitute for  local  and  internal  medication.  Gonorrhceal  prostatitis  requires 
in  addition  to  injection  of  vaccine,  massage  treatment  of  the  posterior 
urethra  and  intema,l  administration  of  drugs  as  correctives  for  urinary  abnor- 
malities. 

Aronstrom^  reports  fifty-four  cases  of  acute  and  chronic  gonorrhoea  and 
complications,  in  which  vaccine  was  used  with  favorable  results  in  the  acute 
stage,  and  he  is  somewhat  skeptical  about  its  efficiency  in  many  of  the 
chronic  stages  of  gonorrhoea.  I  am  not  enthusiastic  about  the  use  of  vaccine 
in  the  acute  stage,  but  have  had  better  results  with  it  in  the  chronic.  Irons* 
observed  thirty-one  cases  of  infection,  and  goes  into  some  detail  about  the 
results,  which  is  very  interesting.  He  says:  "The  reliability  of  the  clinical 
gonococcus  reaction  as  a  diagnostic  procedure  will  be  determined  after  many 


8  Jour.  Amer.  Med.  Assn.,  1908. 
4  British  Medical  Journal,  1908. 


368         PRINCIPLES  OF  THE  MODEPvN  TREATMENT  OF  GONORRHCEA. 

tests.  There  may  well  be  eases  of  gonococcus  infection  that  do  not  respond." 
The  good  results  that  I  have  observed  viitli  gonococcus  vaccine  v/ere  in 
chronic  cases,  with  articular  and  prostatic  complications.  That  the  gono- 
coccus, in  pure  culture  is  found  in  the  circulation  is  an  established  fact. 
i\Iany  cases  arc  reported  corroborating  this  statement.  I  reported  a  case  in 
the  Courier  of  Medicine  nine  years  ago,  with  joint  and  heart  complications  in 
a  boy  of  seventeen  years  old,  in  which  the  gonococcus  was  cultivated  from 
blood  from  the  median  basilic  vein.  At  that  time  the  opsonic  treatment  was 
unborn,  and  we  could  not  take  advantage  of  using  vaccine,  as  there  was  none 
on  the  market.  Vaccine  therapy  is  still  in  its  infancy,  and  to  date  accounts 
of  treatment  with  it  in  acute  urethral  gonorrhoea  are  at  variance,  and  are 
not  in  harmony  as  to  the  ultimate  results  and  benefits  derived  therefrom. 

I  believe  that  only  too  commonly  acute  urethral  gonorrhoea  is  a  mixed 
infection,  in  which  the  staphylococcus,  in  mixed  strains,  plays  a  prominent 
role.  It  may  be  possible,  therefore,  since  this  is  the  case  of  mixed  infection 
in  this  disease,  that  the  gonococcus  vaccine,  when  used  alone,  does  not  give 
satisfactory  results.  Therefore  at  some  future  time  I  may  be  able  to  report 
what  progress  is  made  in  the  treatment  with  the  mixed  staphylococcus  and 
gonococcus  vaccine.  I  have  asked  the  Biological  Department  of  Parke-Davis 
&  Company  to  make  one  cubic  centimeter  bulbs,  each  holding  400  million 
staphylococci  and  100  million  gonococci,  combined.  I  have  used  both  these 
vaccines  as  they  are  on  the  market  to-day  uncombined.  The  advantage  of 
combining  them  in  a  single  solution  is  that  one  injection  need  be  given, 
instead  of  two  punctures  being  made  for  two  separate  vaccine  injections, 

THE    CURE   OF   GONORRHCEA. 

When  is  an  acute  case  of  gonorrhoea  cured  ?  This  is  a  mooted  question. 
Extremists  of  the  German  school,  typified  in  ISToegerrath,  claim  that  gono- 
cocci in  the  male,  as  well  as  in  the  female,  persists  for  life  in  the  organs  of 
generation,  notwithstanding  the  apparent  cure  of  the  acute  infection.  This 
statement  is  influenced,  and  possibly  prompted  by  the  fact,  that  of  women, 
who  have  fatal  diseases  of  the  uterus  and  adnexa,  80  per  cent,  have  been 
found  to  succumb  to  gonorrhceal  infection,  llany  patients  dismiss  them- 
selves from  treatment  before  they  are  cured,  only  desiring  cessation  of  the 
urethral  discharge.  On  the  other  hand,  many  cases  are  considered  chronic, 
which  are  virtually  long  continued  acute  cases  withstanding  the  element  of 
time.  A  red,  swollen  meatus,  a  profuse  purulent  discharge,  no  matter  how 
long  it  has  existed,  must  be  treated  as  acute  gonorrhtea.  Fuller^  believes 
that  the  systemic  infection  in  the  male,  due  to  imcured  gonorrhoea,  enters 
from  a  special  focus,  chiefly  the  seminal  vesicles.  He  excised  the  seminal 
vesicles  twenty-three  times  for  the  cure  of  gonorrhceal  arthritis. 

When  all  secretion  and  discharge  has  ceased  from  tlie  urethra,  or  cannot 
be  expressed  therefrom  by  stripping  it,  and  the  meatus  is  not  glued  together, 
especially  in  the  morning  on  arising,  and  there  are  no  shreds  in  the  freshly 

6  New  York  Med.  Jour.,  1908. 


REVISION  OF  LAWS  RELATING  TO  CHILD  LABOR.  359 

voided  urine,  it  is  a  common  teaching  to  regard  a  ease  as  cured.  The  urine  is 
not  always  an  index  of  existing  conditions  in  the  deep  urethra.  I  have  known 
of  many  cases  of  chronic  posterior  urethritis,  with  ulceration,  etc.,  and  espec- 
ially chronic  prostratitis,  when  the  urine  passed  in  two  or  three  glasses,  was 
macroscopically  crystallinely  clear  and  apparently  normal.  At  this  time  the 
patient  should  he  put  on  a  liberal  allowance  of  malt  and  spirituous  liquors, 
especially  beer,  for  several  successive  days  and  indulge  in  moderate  exercises, 
as  a  test  to  determine  if  any  recurrence  happens. 

The  acme  of  all  treatment  should  be  to  keep  gonorrhoea  a  local  urethral 
disease  and  prevent  if  possible  its  dissemination  and  metastasis  by  the  lymph- 
atic and  circulatory  systems  to  remote  parts  and  organs  of  the  body,  when  it 
becomes  a  systemic  infection,  endangering  life  and  much  worse  in  some  of  its 
ultimate  consequences  than  syphilis. 

Neisser,  one  of  the  benefactors  of  humanity,  the  discoverer  of  the  Gonococ- 
cus,  says :  "Although  I  am  always  advocating  that  every  medical  man  should 
be  taught  how  to  treat  acute  gonorrhoea  efficiently  from  every  point  of  view, 
the  estimation  of  the  chronic  cases  of  urethritis  requires  such  special  tech- 
nicality and  practice  as  cannot  possibly  be  possessed  by  every  practitioner, 
quite  apart  from  the  circumstances  that  not  every  medical  man  can  have  at 
his  disposal  the  laboratory  arrangements,  required  for  the  preparation  of  cul- 
tures, etc."  I 

715  North  Eighth  St. 


THB  REVISION  OF  THE  LAWS  RELATING  TO  CHILD  LABOR  BY  MEANS 
OF  THE  ROENTGEN  RAY.* 

By  THO.MAS  MORGAN  ROTCH, 
Professor  of  Pediatrics,  Harvard  University. 

In  studying  the  great  wave  of  reform  in  connection  with  child  labor, 
which  has  lately  been  spreading  all  over  the  country,  we  are  at  once  struck 
by  the  evidence  of  possibly  an  unwise  legislation  resulting  from  this  move- 
ment. In  certain  States  there  is  no  doubt  but  that  the  laws  in  regard  to 
labor  have  been,  and  even  now  are,  not  only  ^vrong  and  pernicious,  but  unwise 
and  blind.  These  laws  have  been  mostly  based  on  chronologic  age.  In 
South  Carolina  the  age  at  which  a  child  is  allowed  to  work  in  a  mill  has,  for 
years,  practically  been  placed  at  ten,  with  the  proviso  that  if  the  child's 
parents  are  dependent  the  child,  shall  be  allowed  to  work.  Although  many 
attempts  have  been  made  to  change  this  law  in  the  interests  of  the  child,  yet 
these  attempts,  up  to  the  present  time,  and  especially  latel}^  have  proved  to 
be  a  signal  failure.  Resulting  from  this,  the  philanthropic  public,  especially 
those  who  are  interested  in  this  reform  in  connection  wnth  child  labor,  have 
jumped  at  the  conclusion  that  to  improve  the  law  a  later  age  than  that  pro- 
scribed by  the  States  should  be  fought  for. 


Delivered  at  the  Jefferson  Medical  College.  Philadelphia,  December  28,  1008. 


370 


REVISION  OF  LAWS  RELATING  TO  CHILD  LABOR. 


Although  the  intentions  of  the  child  labor  reformers  and  enthusiasts  are 
more  than  good,  for  their  devotion  to  the  cause  and  their  self-sacrificing 
interests  are  evidenced  everywhere,  yet  their  energies  are  being  directed  on 
lines  which  are  really  contrary  to  the  true  interests  of  early  life.  It  would 
be  well,  therefore,  for  these  thousands  of  advocates  and  friends  of  children 
to  investigate  a  little  further  this  question  of  chronologic  age,  and  in  doing 
this  to  make  use  of  the  knowledge  on  this  subject  which  has  evolved  from  the 
careful  investigations  of  the  medical  profession,  and  which  has  long  ago 
proved  that  chronologic  age  as  a  guide  to  and  an  index  for  the  grading  of 
children  for  labor  in  mills  and  other  sources  of  income  for  their  parents,  or 
for  themselves,  is  a  delusive  one. 

The  number  of  years  that  a  child  has  been  born  does  not  necessarily 
mean  that  a  group  of  children  can  be  given  the  same  amount  of  work  with 
its  consequent  physical  fatigue.  At  least,  if  this  is  done,  some  of  this  group 
of  children  will  inevitably  suffer.  Twenty  boys,  whose  chronologic  age  may 
all  be  eleven  years,  may  differ  very  materially  in  the  degree  of  their  develop- 
ment, which  indicates  their  strength  and  their  ability  to  perform  cer- 
tain kinds  of  work. 

For  some  especial  piece  of  work,  some  of  these  boys  may  be  entirely 
unfit,  while  others,  again,  may  be  well  fitted  for  work  even  more  arduous. 
Some  of  these  boys  of  eleven  years  may  only  show  the  stage  of  development 
which  corresponds  to  nine  or  ten  years,  while  others  may  present  that  of 
twelve  or  thirteen  years.  It  is,  therefore,  manifest  that,  so  far  as  work  is 
concerned,  these  boys  should  be  graded  according  to  their  physical  develop- 
ment, rather  than  to  their  chronological  age.  Resulting  from  this,  if  the 
laws  are  to  be  changed  and  improved,  these  laws  should  be  based  upon 
degrees  of  development,  and,  instead  of  saying  that  a  child  should  be  allowed 
to  "work  in  the  mills  at  a  certain  age  chronologically,  it  should  be  stated  that 
they  should  be  allowed  to  work  in  the  mills  when  their  especial  stage 
of  development  indicates  that  they  are  able  to  do  this  work  without  harm^  to 
their  health.  In  this  way  the  work  can  be  properly  done  without  our  having 
thrown  on  our  hands  citizens  who  have  been  weakened  and  in  that  sense 
crippled,  both  in  body  and  mind,  by  an  unwise  le.gislation  which  has  not 
looked  out  for  the  health  and  vigor  of  our  future  citizens.  Of  course,  we 
must  consider  the  educational  side  of  this  question.  Education,  however, 
should  work  hand-in-hand  with  the  rules  for  good  hygiene  and  general  phys- 
ical development.  Unless  this  is  done  the  rules  for  education  will  simply 
hamper  the  production  of  strong  and  healthy  brains,  and  will,  inevitably, 
defeat  their  own  purposes. 

In  regard  to  the  laws  connected  with  child  labor,  we  should  consider  not 
only  how  we  can  best  influence  our  legislators  to  carry  out  the  necessary 
reforms  in  connection  with  early  life,  but,  after  the  laws  have  been  revised 
and  changed,  how  we  are  to  aid  in  the  determination  of  the  best  and  the 
surest  way  to  carry  out  these  laws.  This  can  be  accomplished  by  a  knowledge 
of  the  means  which  the  Roentgen  ray  has  given  us  to  determine  the  degree 


PRACTICAL  ANALYSIS  OF  THE  GASTRIC  CONTENTS.  37 1 

of  physical  development  present  in  each  individual  child.  By  means  of  the 
Eoentgen  ray  this  can  be  accomplished  very  rapidly,  in  perhaps  one  or  two 
seconds  for  each  child.  After  a  careful  study  for  a  number  of  years  of  the 
development  of  young  children  in  respect  to  the  development  of  their  bones, 
I  have  found  that  such  development  can  best  be  determined  by  the  progres- 
sive changes  which  take  place  in  connection  with  the  growth  of  their  joints. 
A  still  further  study  has  shown  me  that,  in  all  probability,  the  best  index  to 
this  growth  is  represented  in  the  development  of  the  bones  of  the  wrist. 
Still  further,  that  the  most  exact  information  can  be  obtained  from  a  com- 
bination of  the  growth  of  the  carpal  bones  with  the  lower  epiphyses  of  the 
radius  and  ulna.  The  greater  the  number  of  these  bones  present,  the  more 
advanced  their  ossification,  and  the  more  they  are  massed,  the  greater  is  the 
possibility  for  anatomic  strength  in  the  wrist  and,  resulting  from  this  as  a 
possible  index,  we  may  be  able  to  determine  the  general  development  and 
strength  of  the  individual. 

In  making  laws,  therefore,  for  the  grading  of  children,  it  would  be  far 
safer  to  determine  what  work  each  child  is  fitted  for  by  grouping  them  in 
divisions,  for  instance,  A,  B,  C,  and  in  this  way  the  law  will  not  permit  a 
child  to  perform  certain  labor  until  it  is  fitted  to  perform  such  physical  labor 
without  harm. 


PRACTICAL  ANALYSIS  OF  THE  GASTRIC  CONTENTS. 

By  EDWARD  C,  HILL,  M.D., 
Professor  of  Chemistry,  Denver  and  Gross  College  of  Medicine, 

For  a  test  breakfast  it  is  my  custom  to  have  the  patient  take  a  full  pint 
of  hot  water  and  one  shredded  wheat  biscuit,  without  butter,  sugar  or  cream. 
The  gastric  contents  are  removed  one  hour  later  with  the  ordinary  tube. 
The  quantity  obtained  in  this  way  is  normally  from  60  to  90  cubic  centi- 
meters. Above  90  cubic  centimeters  indicates  gastric  atony  or  pyloric 
obstruction  (differentiated  by  palpation,  percussion  and  succussion).  Less 
than  60  cubic  centimeters  points  to  pyloric  insufficiency  ("achylia  gastrica"). 
Organoleptic  evidence  as  to  odor  (may  be  putrid  in  carcinoma),  color  and 
viscidity  particularly,  is  of  equal  value  with  chemic  tests.  The  specimen 
should  be  filtered  for  the  chemic  tests,  using  preferably  a  large  funnel  and 
filter  paper  to  correspond. 

The  reaction  is  tested  with  litmus  paper,  and  should  be  frankly  acid. 
To  distinguish  mineral  (HCl)  from  organic  (lactic,  acetic,  butyric)  acidity,  I 
use  a  1:1000  aqueous  Congo  red  solution,  adding  two  or  three  drops  of  this 
to  one-third  test-tubeful  of  water,  and  then  a  few  drops  of  the  gastric  filtrate. 
Free  mineral  acid  gives  a  sky-blue  color;  organic  acids  show  violet.  In  case 
of  doubt,  I  resort  to  Boas's  or  Giinzburg's  reagent,  evaporating  with  the 
filtrate  carefully  on  the  water-bath,  watching  for  the  red  or  purple  line  (posi- 
tive for  HCl)  as  the  fluid  dries. 


372  PRACTICAL  AtTALYSIS  OF  THE  GASTRIC  CONTENTS. 

Uffelmann's  reagent  (10  per  cent,  ferric  clilorid  sojution)  still  appears 
to  me  Lest  for  lactic  acid,  using  a  tulje  of  distilled  water  for  comparison  with 
the  gastric  filtrate  and  dropping  ihe  test  fluid  alternately  into  either  tube. 
In  this  connection  one  should  not  mistake  the  brownish  color  due  to  much 
swallowed  saliva  for  the  lemon-yellow  hue  of  ferric  lactate.  The  test  is  made 
more  delicate  by  shaking  out  lactic  acid  (if  present)  with  ether,  agitating  the 
ethereal  extract  with  distilled  water,  and  adding  one  or  two  drops  of  the 
ferric  chlorid  solution.  Lactic  acid  is  not  volatile,  whereas  acetic  and  butyric 
acids  are  volatile  and  can  be  detected  by  heating  some  of  the  gastric  filtrate 
in  a  test-tube,  at  the  same  time  holding  a  slip  of  moistened  blue  litmus  paper 
in  the  mouth  of  the  tube. 

The  quantitative  estimation  of  the  various  acid  factors  is  readily  effected 
by  the  Toepfer  method,  for  which  four  reagents  are  required:  1.  Decinormal 
sodium^  hydrate.  2.  A  l-per-cent.  alcoholic  solution  of  phenolphthalein,  to 
indicate  total  acidity.  3.  A  1-per  cent,  aqueous  solution  of  sodium-alizarin 
sulphonate,  to  indicate  all  acids  except  loosely  combined  HCl.  4.  A  0.5-per- 
cent, alcoholic  solution  of  dimethyl-ami do-azobenzol,  to  indicate  free  HCl 

only. 

A  10-cubic-centimeter  buret  is  filled  to  the  mark  vrith  the  alkaline 
reagent.  Five  or  10  cubic  centimeters  of  the  gastric  filtrate  are  placed  in  a 
small  beaker,  one  or  two  drops  of  the  phenolphthalein  indicator  added,  and 
the  liquid  titrated  wdth  the  decinormal  solution  till  a  permanent  red  color  is 
produced.  To  another  equal  portion  of  filtrate  a  few  drops  of  alizarin  solu- 
tion are  added,  and  the  whole  titrated  with  the  alkaline  solution  until  a  pure 
violet  color  is  attained.  A  third  portion  of  filtrate,  to  which  a  few  drops  of 
the  dimethyl-amido-benzol  have  been  added,  is  titrated  with  the  alkali  until 
the  red  color  due  to  free  HCl  (if  present),  turns  yellow.  By  multiplying  the 
number  of  cubic  centimeters  of  ^\  alkali  required  for  each  step  of  the 
procedure  by  10  or  20  (according  as  10  or  5  cubic  centimeters  of  the  filtrate 
are  employed),  we  get  the  alkaline  equivalents  per  100  cubic  centimeters  of 
filtrate  for  each  item. — normally  (when  the  patient  takes  a  full  pint  of  water) 
40.(^0  for  total  aciditv,  and  20  to  35  for  free  HCl,  the  remainder  being  chioflv 
combined  HCl;   acid  phosphates,  for  practical  purposes,  can  bo  disregarded. 

Hyperchlorbydria  obtains  in  gastric  ulcer  (which  sometimes  precedes 
cancer),  gastrosnccorrhfra  (with  large  amount  of  flnid).  r;nd  rarolv  in  benign 
irritative  pyloric  obstmction.  Hypo-  or  anachlorhydria  is  observed,  with 
converse  amount  of  lactic  acid,  in  gastric  cancer  and  also  in  asthenic  gastritis 
and  pernicious  anremia.  Neuroses  are  marked  by  great  variations,  from 
anachlorhydria  to  hypcrchlorhydria,  in  the  chemistry  of  the  gastric  contents. 

For  pepsin  determination  I  employ  a  freshly  prepared  aqueous  filtered 
solution  (about  1:1000)  of  egg  albumin.  To  10  cubic  centimeters  of  this 
solution  in  each  of  two  beakers  one  drop  of  strong  HCl  is  added.  Then  to 
one  beaker  5  cubic  centimeters  of  distilled  water  are  added;  and  to  the 
other,  5  cubic  centimeters  of  the  gastric  filtrate.  The  two  beakers  are  kept 
at  about  98°  in  the  incubator  for  one  hour,  when  a  part  of  the  contents  of 


THE  MILK  SUPPLY  OF  CITIES.  373 

each  is  centrifugated  for  three  minutes  with  twice  as  much  Esbach's  solution. 
The  dili'ercnce  in  the  readings  of  the  ppts.  now  observed  represents  the 
action  of  pepsin.  For  example,  if  the  tube  without  gastric  filtrate  shows 
0  per  cent,  by  volume  of  albumin  sediment,  while  that  containing  said  fluid 
yields  2  per  cent,  of  sediment,  pepsin  (or  pepsinogen)  is  GO  per  cent,  of  the 
par  value,  which,  however,  it  seldom  quite  reaches.  The  estimation  of 
ehymosin  (or  chymosinogen)  is  of  no  great  practical  value,  but  is  easily 
eifected  b}''  keeping  a  mixture  of  equal  volumes  of  neutralized  milk  and 
neutralized  gastric  juice  at  body  temperature  for  fifteen  minutes,  when,  if 
rennin  secretion  is  normal,  complete  coagulation  takes  place.  These  two 
cliief  ferments  of  the  stomach  are  notably  diminished  only  in  malignant  or 
non-malignant  atrophy  of  the  glands. 

An  idea  of  the  relative  digestive  action  of  the  saliva  and  the  gastric 
secretion  can  be  had  by  making  the  biuret  test  with  a  little  of  the  gastric 
filtrate  (peptones  and  albumoses,  pink;  less  digested  protein  products,  violet), 
and  by  adding  a  drop  of  Gram's  solution  to  another  portion  of  filtrate — blue 
or  violet,  unless  excessive  amjdolysis  (no  color  except  that  of  iodine),  due  to 
deficient  inhibition  by  HCl. 

Microscopic  examination  of  the  solid  portions  of  the  removed  gastric 
contents  is  of  a  certain  confirmatory  value.  The  presence  of  the  large  club- 
shaped  Oppler-Boas  bacilli  (readily  stained  with  gentian  violet),  at  one  time 
regarded  as  pathognomonic  of  cancer,  indicates  merely  a  favorable  medium 
for  their  growth,  i.e.,  lactic  acid.  Yeasts  and  sareinse  are  found  commonly  in 
non-malignant  fermentive  conditions,  as  in  dilated  stomach.  Certain  moulds 
may  give  to  the  specimen  a  green  appearance,  which  is  usually  due,  however, 
to  bile  aspirated  through  an  atonic  pylorus.  Pus  is  seldom  seen,  as  gastric 
abscess  is  rare,  but  blood  is  not  uncommon  in  slight  amount  from  the  irrita- 
tion of  the  tube.  Considerable  dark,  foul-smelling  blood  is  strongly  sugges- 
tive of  cancer.  Mucus  and  swallowed  saliva  are  very  common  ingredients  of 
the  gastric  specimen.  Pavement  epithelia  from  the  throat  are  much  more 
frequently  observed  than  the  columnar  cells  of  the  stomach.  While  atrophic 
and  ulcerating  tissues  in  general  are  more  subject  to  abrasion  than  when  nor- 
mal, yet  t5T)ical  nests  of  cancer  cells  are  hardly  ever  encountered  in  the 
routine  examination  of  the  crastric  contents. 


Editorials 


THH  MILK  SUPPLY  OP  CITIES. 

The  milk  supply  of  cities  is  a  matter  of  great  importance  as  regards  the 
purity  and  healthfulness  of  the  milk.  It  is  a  problem  that  grows  more  complex 
and  difficult  as  the  centers  of  population  become  more  crowded.  The  careless 
handling  by  the  dealer  and  in  restaurants  often  renders  it  unfit  as  a  food. 
The  care  of  the  cows,  the  sanitary  conditions  of  the  stables  and  the  precautions 


374  THE  MILK  SUPPLY  OF  CITIES. 

taken  in  milking  are  likewise  matters  of  importance  as  regards  its  purity. 
Too  many  fanners  know  not  how  to  properly  obtain  and  care  for  the  milk. 
While  they  appear  and  endeavor  to  be  cleanly,  yet  they  know  not  the  first  prin- 
ciples of  sanitation  and  hygiene.  In  case  of  sickness  among  them  they  exercise 
very  little  precaution  against  the  spread  of  the  disease,  and  with  the  many 
dealers  to  consider,  it  is  almost  impossible  to  trace  the  source  of  a  particular 
sample.  In  fact,  we  are  obliged  to  depend  largely  upon  chemical  and  micro- 
scopical tests  to  ascertain  the  purity  and  quality  of  the  supply. 

Various  experiments  have  been  devised  in  order  to  modify  the  purity  of  the 
milk  as  it  is  found  on  the  market.  Pasteurization  is  practically  of  no  value 
except  that  it  m.aj  check  the  fermentative  process,  and  pathogenic  micro-organ- 
isms are  not  affected  in  the  least.  The  nutritious  quality  of  milk  is  also  of 
immense  importance  to  a  vast  number  of  invalids,  in  addition  to  infants,  who 
are  obliged  to  subsist  more  or  less  absolutely,  more  or  less  continually,  upon 
a  milk  diet. 

While  this  city's  milk  supply  is  fairly  satisfactory,  yet  there  is  still  much 
room  for  improvement  and  at  a  special  meeting  held  at  the  College  of  Physi- 
cians a  few  weeks  ago,  it  was  suggested  and  argued  out  that  the  milk  supply 
would  not  be  bettered  until  the  price  to  the  consumer  was  advanced  one  cent 
per  quart  and  the  small  dealer  wijjed  out.  This  would  undoubtedly  be  a  step 
in  the  right  direction  and  would  insure  better  sanitary  conditions  on  the  farms 
and  a  more  careful  handling  of  the  milk  by  persons  healthy  and  free  from 
contagious  diseases.  Nature  teaches  us  directly  and  unmistakably  what  is  the 
best  food  for  the  young  babe.  This  is  milk  as  it  flows  from  the  clean  breast 
or  udder — fresh,  pure,  uncooked,  unsterilized,  unpasteurized.  Such  is  Nature's 
supply  upon  which  man  cannot  improve.  Much  money  has  been  expended  by 
the  noble  generosity  of  individuals  in  the  attempt  to  purify  the  milk  of  dealers 
and  especially  of  those  whose  trade  lies  in  the  poorer  districts.  Nevertheless, 
no  amount  of  pasteurization  is  capable  of  purifying  an  impure  milk.  If  it 
becomes  contaminated  with  putrefactive  bacteria  or  with  such  that  are  specific 
for  certain  diseases,  it  should  be  totally  rejected.     It  cannot  be  renovated. 

This  problem  needs  to  be  attacked  with  more  hope  of  success  from  its  other 
end — the  origin  of  the  milk  and  scrupulous  care  in  its  transit  from  the  dairy 
to  ultimate  destination  in  the  city.  This  phase  of  the  matter,  we  believe, 
should  be  controlled  by  the  strict  enforcement  of  mimicipal  and  State 
supervision  of  the  industry  from  beginning  to  end.  Under  the  authority  of 
well-conceived  laws,  regulation  of  the  milk  trade  could  be  thoroughly  and 
satisfactorily  accomplished  at  comparatively  little  cost.  With  a  pure  supply 
there  is  no  need  for  artificial  purification  or  rather  attempted  purification. 

The  care  of  the  cow  as  regards  food  and  hygiene;  the  grooming  of  the 
animal;  cleanliness  of  the  stable;  dairymen  and  utensils;  the  vessels  in 
which  the  supply  is  collected  and  stored  for  transmission  to  market;  the  rigid 
supervision  in  other  words,  of  every  step  in  its  progi-ess  toward  the  consumer. 
Such  methods  would  be  productive  of  pure,  wholesome,  nutritious  milk  and  still 
further  lower  the  infant  mortality  from  intestinal  disorders. 


EDUCATION  FOR  DEFICIENT  CHILDREN.  375 

We  are  waiting  with  hope  for  the  day  when,  by  the  collaboration  of  city 
and  State,  unadulterated  milk  will  be  furnished  at  reasonable  cost  to  the  poorest 
inhabitant. 


EDUCATION  FOR  DEFICIENT  CHILDREN. 

Educators  and  physicians  all  over  the  country  have  long  felt  the  need 
of  a  better  system  for  the  education  of  mentally  deficient  and  backward  children 
in  this  country.  At  the  same  time  provision  should  also  be  made  for  those 
inclined  to  disease,  especially  tuberculosis.  In  some  of  the  foreign  countries 
great  effort  is  being  made  to  provide  for  the  education  and  physical  develop- 
ment of  these  unfortunate  little  ones.  Much  can  undoubtedly  be  done  for  them 
individually  and  at  the  same  time  the  spread  of  tuberculosis  among  school 
children  be  decreased.  Little  provision  for  the  education  of  these  children  has 
thus  far  been  made  in  America,  but  we  hope  to  see  the  day  soon  dawn  when 
every  city  and  town  in  this  land  may  have  a  special  public  school  to  nurture 
and  care  for  them. 

Too  many  of  the  children,  especially  those  of  the  poorer  classes,  are  con- 
sidered mentally  deficient,  but  very  often  it  is  found  that  these  imfortunate 
ones  are  not  deficient  by  virtue  of  lack  of  brains,  but  because  they  are  chronic 
sufferers  of  either  defective  sight,  hearing  or  difficult  breathing,  owing  to 
adenoids  and  enlarged  tonsils.  Correction  of  these  infirmities  would  undoubt- 
edly result  in  mental  activity  and  progress,  and  for  this  very  reason  our  larger 
cities  have  regularly  appointed  physicians  who  visit  the  schools  and  carefully 
examine  all  the  pupils  for  any  infirmities.  Such  vigilance  not  only  is  pro- 
ductive of  mental  power  but  largely  lessens  the  number  of  contagious  diseases 
existing  among  the  school  children. 

The  government  of  California  has  probably  done  more  along  this  line  of 
education  than  any  other  State  in  the  Union.  Dr.  Walter  Lindley,  of  Los 
Angeles,  who  has  been  appointed  commissioner  by  the  government  of  California, 
to  investigate  the  subject,  spent  some  months  in  Europe,  mainly  in  Paris  and 
London,  to  study  the  system  of  education  of  the  mentally  deficient  and  back- 
ward children.  He  said,  "I  have  been  most  impressed  by  the  schools  in  Lon- 
don, of  this  kind.  London,  in  this  respect,  is  far  in  advance  of  any  American 
city,  and  has  established  out-door  schools  which  I  consider  most  beneficial  for 
children  of  the  poor  who  are  weak,  abnormally  backward  or  inclined  to  disease. 
I  can  speak  only  with  thg  utmost  admiration  of  such  schools  as  that  in  Lord- 
ship Lane,  Stoke  Newington,  where  ninety  unfortunate  little  ones  are  given 
most  only  mental  instruction,  but  taught  gardening  and  other  out-door  work. 

*T?hey  receive  a  wholesome  and  hearty  luncheon  at  school,  and  before  they 
return  to  their  homes  are  made  to  lie  down  and  rest  two  hours  in  the  afternoon, 
either  on  cots  or  on  the  ground  according  to  the  bodily  condition.  The  effect 
is  to  correct  morbid  physical  tendencies  and  strengthen  the  body,  gradually 
inuring  it  to  fatigue  and  exposure,  and  stimulate  mental  action  at  tlie  same 
time."  Similar  methods  should  be  adopted  in  America  and  we  feel  sure  tliat 
such  efforts  would  be  most  productive  of  good  results. 


376      ADRENALIN  IN  ILEMORRHAGE. 


ADRENALIN;    ACTION  ON  SKIN. 


Jlaterla  Jledlca  and  Therapeutics 


ADRENALIN  IN  INTESTINAL  H^ffllilOR- 
EHAGE. 
Dr.  C.  J.  Wiggers,  Detroit  has  per- 
formed a  number  of  experiments  witli 
this  drug  and  has  arrived  at  the  fol- 
lowing conclusions: — 

1.  Large  doses  of  adrenalin  (0.05  to 
0.1  mg.)  cause  a  short  preliminary  in- 
crease in  ha?morrhagc,  followed  quickly 
by  a  decrease  or  cessation  of  bleeding. 
On  account  of  the  great  preliminary  loss 
of  blood  they  are  always  contraindi- 
cated. 

2.  Small  doses  of  adrenalin  (0.01- 
0.025  mg.)  cause  little  or  no  preliminary 
increase,  but  shortens  the  course  of 
ha}morrhage.  As  they  save  the  red 
blood  cells  in  every  way,  they  are 
therapeutically  desirable. 

3.  The  method  of  introducing  adre- 
nalin determines  the  effect  of  blood- 
pressure  and  haemorrhage.  The  subcu- 
taneous administration  does  not  give  any 
results.  A  slight  elevation  of  pressure 
and  a  simultaneous  checking  of  the 
haemorrhage  can  be  obtained  by  continu- 
ous intravenous  injections  of  weak  solu- 
tions. This  may  also  be  accomplished 
by  intramuscular  injection, 

4.  Adrenalin  is  not  indicated  in  all 
intestinal  haemorrhages.  The  condition 
of  the  blood-pressure  is  the  criterion  for 
its  use.  In  ha3morrhages  of  short  dura- 
tion when  the  pressure  has  not  fallen  to 
any  extent,  a  judicious  use  of  nitrites 
proves  of  more  benefit  than  adrenalin. 
When  the  bleeding  has  been  profuse, 
however,  and  a  low  pressure  already  ex- 
ists, it  becomes  vital  that  haemorrhage 
should  be  checked  without  further  re- 
duction of  pressure.  Adrenalin  is  then 
very  useful. 


5.  The  use  of  adrenalin  should  always 
be  closely  followed  by  blood-pressure  ob- 
servations. The  pressure  should  be 
carefully  estimated  after  a  dose  below 
the  safety  limit  has  been  tried.  If  no 
rise  occurs,  gradually  increasing  doses 
may  be  injected  until  a  slight  elevation 
of  pressure  is  present,  in  which  case  we 
may  be  certain  that  enough  has  been 
introduced  to  effect  ha:)morrhage,  and  at 
least  no  significant  preliminary  increase 
has  resulted.  (Archives  of  Internal 
Medicine,  March  15,  1909.) 


ADRENALIN;    ITS  ACTION  ON  THE  SKIN. 

Dr.  G.  Sardou  discusses  the  remark a- 
])le  benefits  to  be  derived  from  painting 
the  skin  with  adrenalin.  His  results 
are  based  upon  the  results  obtained  in 
54  eases  during  the  last  six  years. 
Among  the  conditions  treated  were 
toxic  erythemas,  urticaria,  acne,  sun- 
burn, bee  sting,  eczema,  pruritus,  nevus, 
contusion,  inflamed  chilblains,  headache, 
and  congestion  of  the  face  from  indiges- 
tion, sciatica  without  neuritis,  arthral- 
gia, arthritis,  varices,  etc.  The  adre- 
nalin applied  to  the  skin  is  rapidly  ab- 
sorbed and  acts  on  the  vessels  in  the 
region.  Durable  vasoconstriction  is  ob- 
tained by  a  moderate,  graduated  apijli- 
cation  of  the  adrenalin,  renewed  accord- 
ing to  the  effects  produced.  Too  large  a 
dose,  at  first,  paralyzes  the  reaction. 
Haemorrhoids  are  benefited  vrhen  mod- 
erate and  recent,  unless  they  are  the 
result  of  portal  h}^ertension.  The 
measure  may  also  fail  on  account  of 
sclerosis  and  paresis  of  the  walls  of  the 
vessels.  The  effects  of  the  adrenalin 
are  similar  to  those  of  constriction  hy- 
perasmia.     When  applied  locally  it  re- 


ARTIFICIAL  PNEUMOTHORAX. 


BRONCHIAL  AFFECTIONS. 


377 


enforces  the  local  defenses  without  wait- 
ing for  general  reactions,  the  outcome 
of  which  it  is  impossible  to  foresee.  The 
adrenalin  is  able  to  act  in  the  depths  of 
the  tissues  and  to  aid  their  defensive 
efforts,  or  the  adrenalin  may  arouse 
them  to  more  effective  resistance.  (An- 
nales  generales  de  Medecine,  Paris, 
February,  1909.) 


ARTIFICIAL  PNEUMOTHORAX  IN  THE 
TREATMENT  OF  CHRONIC  TTIBER- 
CULOTIS  EMPYEMA. 

Dr.  Wenckebach  states  that  remark- 
able results  were  derived  by  introduc- 
ing air  into  the  closed  chest  and  thus 
evacuating  the  pus.  He  aspirated  by 
means  of  this  method  as  much  as  two 
h'ters  in  patients  who  were  in  a  threat- 
ening condition.  The  rubber  tube 
through  which  the  fluid  was  aspirated 
was  closed  with  a  stopcock;  the  tube 
was  plugged  with  sterile  cotton,  the 
stopcock  opened  and  air  allowed  to 
enter  the  chest.  As  the  oppression  and 
pain  ceased  the  patients  breathed  with 
a  sigh  of  relief.  The  puncture  hole  was 
then  closed.  The  absorption  of  the  air 
left  a  partial  vacuum  and  the  negative 
pressure  resulting  was  sufficient  to  draw 
out  the  lung,  so  that  it  expanded  finally 
and  the  patients  were  practically  cured. 
He  commends  this  simple  technique  to 
every  physician,  as  often  an  effectual 
means  of  treating  chronic  tuberculous 
empyema,  transforming  the  pyothorax 
into  a  pyopneumothorax,  repeating  the 
injection  of  air  at  intervals  of  from 
three  to  six  weeks.  By  the  end  of  eleven 
weeks  in  his  first  case  there  was  no 
furtlier  trace  of  either  the  pyothorax  or 
pneumothorax,  as  also  after  fifteen 
months  in  the  other  case.  There  is  no 
necessity  for  a  mutilating  operation  or 
complicated  apparatus,  and  air  answers 


the  purpose  just  as  well  as  oxygen.  In 
the  third  case  which  he  reports,  the  re- 
sults were  less  favorable,  and  the  ex- 
perience with  this  case  indicates  that 
success  depends  on  the  lung  being  in 
contact  at  some  point  with  the  chest 
wall.  (Mitteilungen  aus  den  Grenz- 
gebieten  der  med.  und  Chir.,  Jena., 
]909.)  

BRONCHIAL  AFFECTIONS,  RAISING  THE 
FOOT  OF  THE  BED  IN  THE  TREAT- 
MENT OF. 

Dr.  P.  Schafer  reports  the  experiences 
at  Quincke's  clinic,  at  Kiel,  with  the  slop- 
ing position  suggested  by  Quincke  to 
utilize  the  force  of  grarity  to  promote  ex- 
pulsion of  bronchial  secretions.  The 
patients  lie  flat  in  bed,  on  the  back,  the 
head  turned  to  one  side  to  be  able  to  ex- 
pectorate more  readily.  "W^ien  they  have 
learned  to  do  this,  the  foot  of  the  bed  is 
raised  from  8  to  12  inches  for  two  or 
three  hours  every  morning,  before  9  a.  :m., 
and  again  in  the  evening  if  desired.  It 
is  astonishing  to  observe  the  amounts  of 
secretion  which  are  expelled  at  times 
under  these  conditions,  the  patients  being 
relieved  so  that  they  are  free  from  cough 
and  expectoration  for  the  rest  of  the  day, 
and  fever  from  the  retained  secretions 
rapidly  subsides.  In  the  29  cases  related, 
benefit  was  pronounced  whenever  it  was 
possible  to  influence  the  accimiulated 
secretions  by  force  of  gravity.  The 
method  is  especially  useful  for  all  cases  of 
snc-shaped  and  cylindrical  bronchiectasia 
of  the  lower  lobes,  accompanied  by 
clironic  cough  and  expectoration.  It  is 
also  useful  in  catarrhal  conditions,  witli 
acute  onset  but  long  protracted  course, 
especially  in  elderly  people  with  their  loss 
clastic  thorax  and  bronchi.  The  method 
is  also  valuable  for  locating  the  source  of 
the  secretion  by  the  success  or  failure  of 
the    measure.     (Deutsche    Archiv.    fiir 


378 


CARBONIC  DIOXIDE  SNOW. 


EMPYEMA  OF  NASAL  SINUSES. 


Klinische  Medizin,  Leipsic,  February  13, 
1909.)  

CAEBONIC  DIOXIDE  SlfOW,  USES  OF. 

Dr.  M.  L.  Heidingsfeld  says  that  this 
carbon  dioxide  snow  is  specially  well 
adapted  for  the  removal  of  pigmented 
and  selected  types  of  vascular  nevi.  In 
removing  tattoo  marks  it  is  not  partic- 
ularly efficacious  and  possesses  a  doubt- 
ful and  rather  negative  value  in  the 
successful  treatment  and  penuanent 
cure  of  lupus  erythematosus.  It  com- 
mends itself  for  certain  forms  of  senile 
keratoses  and  degenerations  of  the  skin. 
It  is  still  a  remedy  of  too  tentative  a 
character  to  commend  itself  as  the 
method  of  choice  in  epitheliomata,  com- 
mon and  venereal  warts,  lupus  vulgaris, 
leucoplakia,  lichen  planus  and  a  host  of 
other  cutaneous  affections.  Carbon 
dioxide  snow,  however,  is  an  agent  that 
commends  itself  to  every  dermatologist 
as  a  therapeutic  agent  of  unques- 
tioned merit,  worthy  of  an  indispensable 
place  in  dermatologic  practice.  (Lancet 
Clinic,  January  30,  1907.) 


irrigator  and  rinsing  out  the  pleural 
cavity  with  hot  water  or  a  solution  of 
potassium  permanganate.  These  rins- 
ings are  repeated  once  or  twice  daily, 
closing  the  stopcocks  in  the  interim  at 
first.  Later  it  may  be  an  advantage  to 
apply  suction  to  one  of  the  drains.  This 
technique  avoids  the  danger  of  thorac- 
otomy and  sudden  pneumothorax.  It 
does  not  require  general  ansesthesia  or 
assistance,  but  can  be  done  under  ethyl 
chlorid,  and  the  patients  can  be  up  and 
about  at  once.  It  thus  avoids  the  shock 
of  an  extensive  operation  just  when 
they  are  least  fitted  to  stand  one. 
(Deutsche  medizinische  Woehenschrift, 
Berlin,  February  25,  1909.) 


EMPYEMA,   TREATMENT   OF,   BY  FLUSH- 
ING AND  SUCTION. 

Dr.  W.  Pust  discusses  a  simple  modifi- 
cation of  the  present  techniques  of 
draining  empyema  of  the  pleura.  A 
curved  trocar  with  a  number  of  openings 
is  introduced  just  below  the  upper  limit 
of  the  empyema  and  another,  curving 
upward,  just  above  the  lower  limit, 
has  a  stopcock  and  each  is  fastened  in 
place  with  strips  of  adhesive  plaster. 
ITnder  control  of  the  pulse  the  stopcock 
is  opened  in  the  lower,  and  then  in  the 
upper  trocar.  If  the  pus  flows  out 
readily,  as  much  is  allowed  to  escape  as 
the  patient  can  tolerate.  The  flow  can 
be  promoted  by  change  of  position  or  by 
connecting  the  upper  trocar  with   an 


EMPYEMA  OF  THE  NASAL  SINUSES, 

TREATMENT  OF. 
Dr.  Mortens  describes  a  suction  appara- 
tus of  his  own  construction,  which  he 
claims  is  of  great  aid  in  the  diagnosis  of 
suppuration  of  the  ethmoidal  cells  and 
the  sphenoidal  and  frontal  sinuses.  This 
apparatus  is  especially  valuable  in  diag- 
nosing suppuration  of  the  ethmoidal 
cells.  The  apparatus  consists  of  a  suc- 
tion pump  to  which  a  muck  nasal  tip  is 
attached  by  means  of  hose  with  a  van- 
kumeter  intervening  to  register  the  suc- 
tion power.     Suction  being  continuous. 

With  the  apparatus  in  motion  and  10 
to  15  cm.  mercury  pressure  registered, 
the  muck  tip  is  placed  into  one  of  the 
nostrils  of  the  patient.  The  patient  is 
then  instructed  to  repeat  the  word  "Tik" 
to  bring  about  the  shutting  off  of  the  naso 
from  the  oral  phar}Tix.  The  patient's 
other  nostril  is  then  closed  by  applying 
pressure  with  the  finger.  The  lateral 
opening  of  the  nasal  tip  is  closed  with  the 
physician's  finger,  thus  suction  is  brought 
about  in  the  nasal  cavity.  Fifteen  to 
twenty-five  centimeters  applied  for 
three  to  five  minutes   suffices  usually 


EPILEPTIC  PSYCHOSIS. 


HYDROCEPHALUS. 


379 


to  draw  pus  from  the  sinuses  into  the 
nasal  cavity,  when  it  exists.  If  apply- 
ing suction  pus  appears  in  the  nose 
previously  free  from  purulent  discharge, 
the  diagnosis  of  empj^ema  is  made.  Not 
only  is  this  method  valuable  for  diag- 
nosis, but  also  for  therapeutics.  Bid- 
ding the  cells  of  pus  frees  the  mucous 
membrane  and  favors  restoration.  The 
suction  applied  causes  hyperemia  of  the 
tissues,  which,  according  to  the  Bier 
theory,  tends  to  healing.  (Deutsche 
Med.  Woch.,  January,  1909.) 


EPILEPTIC  PSYCHOSIS,  TREATMENT  OF. 

Dr.  Siemerling  states  that  certain  cases 
of  epileptic  psychosis  are  observed  to  end 
in  recovery,  in  the  absence  of  special 
therapeutic  procedures,  while  the 
amenability  of  these  conditions  to  treat- 
ment is  a  subject  still  open  to  discussion. 
There  is  no  doubt,  however,  but  that  a 
favorable  effect  can  be  exerted  upon  the 
course  of  the  epilepsy,  and  therapy  upon 
the  epileptic  psychosis,  through  certain 
remedies,  more  particularly  prophylac- 
tics, for  the  control  of  the  attacks,  by 
means  of  abstinence  from  alcohol,  a 
suitable  diet  (restriction  of  meat,  in 
favor  of  milk,  vegetables,  fruit)  ;  im- 
provement of  the  digestion,  regulation  of 
the  patient's  entire  mode  of  life;  atten- 
tion to  cardiac  or  vascular  disturbances 
and  other  organic  affections.  In  a  num- 
ber of  cases,  a  threatened  attack  may  be 
aborted  by  the  administration  of  large 
doses  of  bromides  (10  to  14  Gm.  daily). 
The  bromides  are  at  the  same  time  the 
sovereign  remedy  for  the  epileptic  dis- 
turbances. It  is  useful  to  combine  the 
remedy  with  the  ingestion  of  large  quan- 
tities of  water.  When  bromism  or  acne 
make  their  appearance,  the  use  of  the 
remedy  should  be  interrupted  for  some 
time.     In  the  presence  of  cardiac  dis- 


turbances, the  simultaneous  administra- 
tion of  adonis  vemaLis,  strophanthus,  or 
digitalis,  as  advisable.  No  particularly 
favorable  results  have  been  found  to 
attend  a  salt-free  diet.  Other  procedures 
entering  into  consideration  for  the  con- 
trol of  the  excited  states,  besides  the 
customary  measures  (isolation,  baths, 
packs)  consist  in  sedatives,  such  as  large 
doses  of  bromides,  amylen  hydrate, 
cliloral  hydrate,  isopral;  injections  of 
duborsin-hyoscyamin;  and  chloral  hy- 
drate enemata.  (Berliner  klin,  Woch., 
No.  1,  January,  1909.) 


KYDSOCEPHALUS,  CHRONIC  IDIOPATHIC 
INTERNAL,  CURED  BY  DRAINAGE 
OF  THE  VENTRICLE. 

Dr.  Halben  states  that  all  the  main 
symptoms  have  retrogressed  since  the 
operation  done  by  Payr  last  October. 
The  patient  was  a  girl  of  sixteen;  Payr 
introduced  into  the  right  lateral  ven- 
tricle a  piece  of  an  artery  about  2 
millimeters  in  diameter  taken  from  a 
calf.  The  artery  had  been  hardened  in 
formalin  and  dipped  in  paraffin,  and 
was  fastened  to  allow  communication 
between  the  ventricle  and  the  epidural 
and  subdural  space  at  the  top  of  the 
head.  The  headaches,  choked  disc, 
n5^stagmus,  abducent  paralysis  and 
tremor  all  vanished  once  or  by  the  end 
of  a  month,  and  vision,  which  had  been 
y^  on  each  side,  was  5f,  and  %  when  the 
patient  was  discharged  two  weeks  after 
the  operation.  Slight  headache  at 
times  is  the  only  trace  left  of  the  former 
trouble,  except  that  the  papilla  looks  a 
little  dirty.  The  patient  had  always 
suffered  more  or  less  from  headache,  but 
the  otber  symptoms  first  developed 
about  five  months  before  the  operation. 
(Deutsche  medizinische  Wochenschrift, 
Berlin,  March,  1909.) 


3S0 


IIS' GROWN  TOE- JS' AILS. 


INTRAORAL  CANCER. 


INGROWN  TOE-NAILS,  TREATMENT  FOR. 

Dr.  W.  Stoeckel,  Marburg,  describes 
the  operation  as  follows:  Twenty-four 
hours  previous  to  the  time  of  opera- 
tion the  foot  and  toes  are  thoroughly 
scrubbed  with  tinctnre  of  green  soap, 
after  which  the  nail  is  trimmed  straight 
across  its  free  border  and  the  surface 
exposed  and  thoroughly  cleansed.  Tinc- 
ture of  iodin  is  now  applied  around  the 
entire  margin  of  the  nail  and  a  1-2000 
bichlorid  of  mercury  dressing  applied. 
At  the  time  of  operation,  the  parts  are 
again  scrubbed  thoroughly.  Hsemor- 
rhage  is  controlled  by  a  rubber  band 
aronnd  the  base  of  the  toe  and  local 
anaesthesia  obtained  by  injection  of  a 
weak  cocaine  solution.  With  a  sharp 
scalpel  the  nail  is  split  down  its  center 
and  to  the  bone;  the  next  step  is  the 
freeing  of  the  matrix  and  lateral  border 
of  the  nail  by  an  iucision  down  to  the 
nail  almost  three-sixteenths  of  an  inch 
from  the  lateral  border  extending  back 
beyond  the  base.  The  scalpel  is  carried 
along  tlie  outer  border  which  is  lifted 
up  and  the  scalpel  is  directed  close  to 
the  bone,  under  the  matrix,  to  within 
one-quarter  of  an  inch  of  the  median 
line.  The  freed  lateral  border  is  then 
elevated  with  the  handle  of  the  scalpel 
and  the  matrix  beneath  is  removed  and 
the  sides  elevated  are  allowed  to  rest  on 
the  healthy  tissues.  A  strip  of  gauze  is 
inserted  underneath  the  edge  and  a  wet 
dressing  of  magnesium  sulphate  applied. 
For  a  few  days  the  foot  should,  not  be 
used.  The  advantages  of  the  operation 
seem  to  be  that  of  simplicity,  radical 
cure,  minimum  tissue  destruction  and 
decreased  suffering  from  pain,  rapid 
restoration  of  the  normal  condition  of 
the  tissues  and  short  period  of  con- 
valescence. (New  York  Medical  Jour- 
nal, February  20,  1909.) 


INTRAORAL  CAITCER,  OPERATIVE 
TREATMENT  OF. 

Dr.  C.  P.  Childe  draws  the  following 
conclusions  from  an  experience  of 
thirty-nine  cases:  The  neck  should  al- 
ways be  attacked  first,  with  ligature  of 
the  lingual  and  facial  arteries  on  one  or 
both  sides.  This  manoeuvre  reduces  the 
excision  of  the  primary  growth,  pro- 
vided that  it  can  be  extirpated  without 
division  of  the  jaw,  to  an  insignificant 
and  bloodless  operation,  which  can  con- 
sequently be  frequently  performed 
without  danger  immediately  after  the 
neck  operation.  It  enables  the  primary 
growth  to  be  removed  with  great  pre- 
cision. It  does  away  with  all  necessity 
for  preliminary  laryngotomy  and  tra- 
cheotomy. It  cuts  off  the  blood  supply 
to  the  tumor  in  the  interval,  if  tlie 
operation  has  to  be  divided  into  tv/o 
stages.  It  will  possibly  starve  cancer 
cells  which  may  be  left  behind  after  at- 
tempted extirpation  of  the  disease.  In 
my  experience  it  is  the  key  to  the  opera- 
tion. 

The  second  principle  is  that  a  com- 
munication between  the  mouth  and  the 
large  wound  in  the  neck  should  always 
be  avoided  where  possible.  Unless  the 
disease  be  situated  in  the  tonsil  or  its 
neighborhood,  and  except  the  patient 
insist  on  a  single  operation,  this  can  al- 
ways be  accomplished  by  dividing  the 
operation  into  two  stages  in  those  cases 
in  which,  for  the  satisfactory  removal 
of  the  disease,  the  lower  jaw  requires 
division.  The  neck,  as  before,  is  at- 
tacked first,  and  the  lingual  and  facial 
arteries  are  tied.  When,  in  a  fortnight, 
the  large  wound  in  the  neck  is  healed, 
the  jaw  is  divided  and  the  primary 
growth  is  excised,  as  before,  bloodlesslj''. 
In  conclusion,  as  regards  final  results, 
early  diagnosis  is  the  only  hope.  With 
this  view,  the  therapeutic  test  of  cancer. 


MAXILLARY  REAJDJUSTMEJST. 


JMENINGOCOCCAL  SERUM. 


381 


iodide  of  potassium,  should  be  relegated 
to  the  limbo  of  dangerous  playthings. 
Immediate  microscopic  examination  of 
a  piece  of  the  growth  should  be  the  only 
test,  and  the  therapeutic  test  should 
never  be  employed,  unless  the  micro- 
scopic report  is  doubtful.  It  should 
then  be  pushed  rapidly,  and  its  effects 
not  watched  too  long.  (British  Medical 
Journal,  January  3,  1909.) 


MAXILLARY  READJUSTEIENT. 
Dr.  G.  V.  I.  Brown,  Milwaukee,  Wis., 
explains  and  illustrates  the  method  of 
exercising  direct  pressure  on  the 
maxillse  originated  by  him,  and  de- 
scribes its  advantages.  He  thinks  that 
probably  too  much  stress  has  been  laid 
on  local  factors,  adenoids,  etc.,  in  the 
etiology  of  palatal  deformities,  and  that 
a  general  tendency  to  irregailar  develop- 
ment must  be  reckoned  with,  as  a  chief 
cause  in  most  of  these  cases.  The  ap- 
pliance used  by  him  for  separating  the 
maxillge  consists  of  bands  attached  to 
the  cuspids  and  molar  teeth  on  each 
side,  so  Joined  that  when  a  bar  with 
screw  and  nut  is  attached  across  the 
palate  in  the  bicuspid  region,  the  force 
applied  by  turning  the  nut  wiU  cause 
pressure  against  all  the  teeth  on  each 
side  of  the  dental  arch.  Only  very  gen- 
tle pressure  is  used,  and  very  little  pain 
or  inconvenience  is  caused  in  producing 
a  marked  separation  of  the  maxillae  in 
this  way.  The  relief  of  the  contracted 
nasal  conditions  is  at  once  apparent,  and 
it  is  a  curious  fact  that  children  suffer- 
ing from  nervous  symptoms  attributable 
to  nasal  obstructions,  almost  imme- 
diately become  less  nervous,  have  better 
appetites,  and  otherwise  show  improve- 
ment, even  while  the  appliance  is  still 
fixed  in  their  mouths.  Brown  believes 
that  this  treatment  can  be  made  of 
great    value    in    safeguarding    against 


tuberculosis.  There  are  thousands  of 
children  who  are  unquestionably  more 
susceptible  to  pneumonic  and  bronchial 
affections  on  account  of  imperfect 
breathing,  and  methods  to  improve  this 
function  will  be  a  factor  deserving  con- 
sideration. In  case  of  harelip  and  cleft 
palate,  compression  methods  are  called 
for,  and  his  methods  for  this  purpose 
have  been  described  in  former  articles. 
(Journal  of  the  American  Medical  Asso- 
ciation, March  18,  1905,  and  March  2, 
1907.)  In  his  summary  Brown  says: 
"In  otherwise  normal  cases  the  maxilla 
should  be  separated  to  improve  con- 
tracted nasal  conditions,  and  the  earlier 
this  may  be  done  the  better  the  result 
In  infants  with  harelip  and  cleft  palate, 
the  parts  should  be  readjusted  by 
gradual  methods,  care  being  taken  not 
to  disarrange  more  than  may  be  act- 
ually necessarj'-,  those  structures  which, 
though  invisible,  are  nevertheless  in 
course  of  development.  In  cases  in 
which  very  wide  fissure  actually  exists, 
the  width  of  the  fissure  should  be  re- 
duced and  the  form  of  the  palate  cor- 
rected before  plastic  operation  for 
closure  is  attempted.'*  The  benefit  to 
health  and  general  development  of 
growing  children  thus  cared  for,  he 
thinks,  can  not  be  overestimated. 
(Journal  of  the  American  Medical  Asso- 
ciation, March  27,  1909.) 


MENINGOCOCCAL  SERUM  IN  EPIDEMIC 
MENINGITIS. 
Dr.  Lange  has  studied  the  figures  of 
two  epidemics  of  epidemic  meningitis, 
during  which  eighty-five  cases  were  ad- 
mitted into  the  Augusta  Hospital  at 
Cologne.  In  each  case  the  diagnosis  was 
confirmed  by  the  discovery  of  Weichsel- 
baum's  meningococcus.  During  the  first 
and  the  more  severe  epidemic,  between 
March  and  September,  1907,  fifty-seven 


382 


MOLES  AND  NEVI. 


NEUROPEIN  IN  NERVOUS  DISEASES. 


cases  were  admitted.  Fourteen  of  these 
were  not  with  serum  at  all;  of  these, 
thirteen  died  (92.8  per  cent.),  four  of 
which  were  dying  on  admission.  Thirty- 
seven  were  treated  with  serum,  but  not 
systematically;  of  these,  twenty-three 
(62.1  per  cent.)  died,  of  which  one  was 
dying  on  admission,  one  died  from 
septic  infection  of  a  puncture  wound, 
and  two  from  hydrocephalus;  if  these 
four  are  excluded  the  mortality  is  re- 
duced to  51.3  per  cent.  During  the 
second  epidemic,  between  December, 
1907,  and  October,  1908,  twenty-eight 
cases  were  admitted.  Of  these,  twenty- 
four  were  treated  systematically  with 
large  doses  of  serum  (adults  30  to  40 
cubic  centimeters,  children  10  to  20 
cubic  centimeters),  on  an  average  every 
other  da}'',  but,  if  necessary,  more  often. 
The  injections  were  intradural.  Of  the 
twenty-four  nine  died  (37.5  per  cent). 
Lange  considers  the  numbers  too  small 
to  show  definitely  whether  an  early 
resort  to  serum  would  give  better  re- 
sults than  when  the  serum  is  given  late ; 
but  the  figures  given  suggest  that  this 
may  be  so.  No  harmful  effects  of  the 
serum  injections  were  observed.  The 
low  mortality  of  the  cases  in  the  second 
epidemic  is,  at  any  rate  in  part,  ac- 
counted for  by  the  milder  nature  of  the 
epidemic.  (Med.  klin.,  February  21, 
1909.)  

MOLES  AND  MORE  OR  LESS  EXTENSIVE 
NEVI,  TESLA  CURRENT  IN  THE 
TREATMENT  OF. 

Dr.  Aspinwall  Judd  recommends  the 
application  of  the  Tesla  current  for  the 
extirpation  of  selected  nevi.  This 
method  does  not  favorably  affect  the 
large  and  extremely  vascular  or  deep 
nevi  with  smooth  skin  over  them.  How- 
ever, those  with  flat,  pigmented,  hair 
growths,  or  those  only  moderately  vas- 


cular, the  results  have  been  uniformly 
good.  His  technique  is  as  follows:  The 
patient  holds  one  electrode  in  the  hand. 
The  other  electrode  consists  of  a  hollow 
glass  rod,  bent  to  any  desired  angle, 
with  insulated  handle,  through  which  is 
drawn  a  copper  wire,  projecting  one- 
sixteenth  of  an  inch  beyond  and  sealed 
into  the  end  of  the  tube.  This  held  far 
enough  from  the  surface  of  the  nevus 
to  produce  a  heavy  bombardment  spark 
from  an  eighth  to  a  quarter  of  an  inch 
in  length.  The  size  of  the  spark  is  con- 
trolled by  the  spark  gap  and  the  am- 
perage behind  the  current  used.  This 
spark  is  played  upon  the  surface  of  the 
nevus  for  from  one  and  one-half  to 
three  and  one-half  minutes.  The  treat- 
ment is  not  especially  painful,  and 
usually  needs  repetition  about  twice  a 
week  for  from  three  to  twelve  treat- 
ments, depending  upon  the  size  of  the 
spark  and  the  size  and  vascularity  of 
the  nevus.  The  treatment  converts  the 
nevus  into  a  dry  slough,  which  separates 
at  the  end  of  from  two  to  six  weeks  and 
leaves  a  smooth,  somewhat  reddened 
epithelial  surface  beneath.  This,  it 
may  be  safely  assumed,  will  become 
whitened  within  a  few  months.  This 
treatment  is  applicable  to  keloid  (al- 
though in  this  class  of  cases  it  must  be 
continued  over  a  longer  period  of  time 
and  with  a  very  hot  spark) ;  to  localized 
gangrene,  where  it  is  desirable  to  get  a 
rapid  line  of  demarcation;  to  per- 
forating ulcers  due  to  obliterating  en- 
darteritis, and  for  the  reduction  of 
enlarged  tonsils,  superficial  epithelioma 
and  warty  growths.  (Post  Graduate, 
January,  1909.) 


NEUROPRIN  IN  NERVOUS  DISEASES. 
Dr.  Eoasenda  has  observed  good  re- 
sults in  the  treatment  of  certain  con- 
vulsive   types    of    nervous    disease    by 


SCOrOLAMIN^MOKPHlN. 


VAGINAL  AND  CiESAEEAN  SECTlOxNT. 


383 


means  of  neuroprin  which  is  an  extract 
of  nervous  tissue,  and  has  been  com- 
pared to  digitalis,  as  far  as  its  tonic 
action  on  the  nervous  system  is  con- 
cerned— as  digitalis  is  a  cardiac  tonic, 
so  neuroprin  is  a  specific  nerve  tonic. 
The  author  has  used  the  drug  with  suc- 
cess in  epileptics,  in  epileptoid  attacks, 
in  neurasthenia  (especially  when  marked 
by  insomnia,  mental  and  physical  ex- 
citability followed  by  speedy  exhaustion), 
in  Graves's  disease,  and  in  one  case  of 
paralysis  agitans.  From  his  experience 
he  believes  that  neuroprin  is  a  good 
nerve  sedative  and  tonic,  and  may,  in 
certain  cases,  prove  a  usefid  substitute 
for  the  bromides  and  other  cortical 
sedatives.  He  has  not  observed  any  ill 
effects  from  its  use.  (Gazz.  degli  Osped., 
No.  21,  February,  1909.)  i 


SCOPOLAMIN-MORPHIN  AN.a:STHESIA. 

Dr.  C.  M.  Nicholson,  St.  Louis,  re- 
ports his  experience  with  six  hundred 
and  fifty  cases  of  anaBsthesia  with  scopo- 
lamin-morphin,  used  as  a  preliminary  to 
general  anaesthesia  with  chloroform  or 
ether.  He  reviews  the  published  cases 
of  fatalities  with  this  method  and  con- 
cludes that  in  no  one  of  them  can  the 
death  be  attributed  to  the  injection  of 
scopolamin.  His  own  experiments  on 
animals  are  summarized,  and  he  finds 
that  they  bear  the  drug  well.  His  con- 
clusions are  stated  as  follows:  "(1)  The 
effects  of  the  injection  of  scopolamin 
and  morphin  into  animals  is  similar  to 
that  of  morphin  when  given  alone,  with 
the  exception  of  the  injection  into 
kittens,  in  which  excitement  instead  of 
sleep  was  produced.  (2)  Continued  re- 
peated daily  injections  produce  no  de- 
generation of  the  heart,  liver  or 
kidneys,  the  physical  condition  is  not 
impaired  so  long  as  the  injections  are 


given  at  such  intervals  as  not  to  inter- 
fere with  the  animal's  nutrition.  Daily 
injections  of  from  one  to  three  times 
the  dose  given  to  patients  produce  no 
pathologic  changes  in  animals.  (3)  The 
toxic  dose  of  scopolamin  and  morphin 
in  my  experiments  correspond  very 
closely  to  that  of  morphin  alone  for  the 
animals  used.  (-4)  The  autopsy  findings 
in  animals  which  succumb  to  a  toxic 
dose  are  the  same  as  those  for  morphin, 
i.e.,  congestion  of  the  viscera.  (5)  My 
animals  seemed  to  acquire  a  tolerance 
for  the  drugs  on  long  continued  daily 
administrations.^'  Death  after  opera- 
tion with  scopolamin  is,  he  considers, 
most  likely  due  to  loss  of  blood,  sepsis 
or  shock.  It  is  very  Kttle  toxic  for  ani- 
mals, and  certainly  jjroduees  no  degen- 
eration of  the  heart,  liver  or  kidneys. 
He  has  used  it  by  injection,  %oo  of  ^ 
grain  of  scopolamin  and  34  of  a  grain 
of  morphin,  three  quarters  of  an  hour 
before  giving  ether,  in  650  cases,  avoid- 
ing the  extremes  of  life.  In  6  per  cent, 
of  the  cases  there  was  practically  no  re- 
sult, but  in  the  remaining  94  per  cent, 
the  patients  were  quieter  before,  during 
and  after  the  angssthesia.  There  was 
an  absence  of  mucus  in  the  throat,  no 
post-operative  vomiting,  and  a  diminu- 
tion of  50  per  cent,  in  the  amount  of 
ether  used.  (Journal  of  the  American 
Medical  Association,  April  3, 1909.) 


VAGINAL  AND  CESAREAN  SECTION, 
TECHNIQUE  AND  INDICATIONS  FOR 
THE. 

Dr.  A.  Diihrssen  gives  the  technique 
of  the  vaginal  Csesarean  section  as  fol- 
lows: The  operation  is  preceded  by  an 
injection  of  ergotin,  an  incision  is  then 
made  on  the  right  side  of  the  vagina 
through  the  perineum  large  enough  to 
admit  the  fist  of  a  full-sizod  man.     The 


384  BOOK  REVIEWS. 

cervix  is  now  grasped  with  forceps,  and  tlie  foot  of  tlie  foetus  is  grasped,  and  the 

the  posterior  lip  spUt  up  to  the  roof  of  child   extracted.      The   indications   for 

the  vagina;   by  prolonging  this  incision  this  operation  are  eclampsia,  in  which 

backward  the  cul-de-sac  of  Douglas  is  better    results    are    obtained    by    this 

opened,  and  the  peritoneum  separated  method   than  by  any  other;    placenta 

from  the  uterus.     The  anterior  lip  and  pra^via,  when  the  cervix  is  not  widely 

vaginal  junction  are  split  in  the  same  dilated  enough  to  allow  of  the  use  of  a 

way,  and  the  urinary  bladder  separated  rubber  balloon,  and  combined  version,  or 

in  a  similar  manner;   thus  the  anterior  when  the  delay  would  destroy  the  life  of 

and  posterior  walls  of  the  body  are  ex-  the  child.     The  author  has  never  seen 

posed  for  a  distance  of  six  centimeters,  lesions  of  the  bladder  produced  by  this 

and  this  is  now  quickly  incised  with  a  operation.     In  cases  of  danger  to  the 

pair  of  scissors,  the  resulting  opening  child  alone  with  undilatable  cervix,  the 

shows  the  amniotic  sac  large  as  a  man's  vaginal     section    is    indicated.      (Gyn. 

fist.     A  hand  is  pushed  into  the  utenis,  Eund.,  Jahr.  II,  Heft  22.) 


5oo!{  R^evleivs 


Department  of  Commerce  an^d  Labor,  BrEEAU  of  the  Cexsus.  S.  N.  D.  North,  Director. 
Mortality  Statistics,  1907.  Eighth  Annual  Report.  Washington:  Government  Printing 
Office,  1909. 

In  this  report  all  the  mortality  statistics  concerning  the  registration  area  of  the  United 
States  for  1907  are  given. 

The  arrangement  of  t!iis  report  follows  the  usual  division  into  three  parts,  namely:  (1) 
Text  and  text  tahle,  discussing  tiie  more  important  feature  of  the  returns  of  deaths  for  the 
year  1907,  and  making  comparisons  between  the  returns  and  the  returns  of  preceding  years; 
(2)  summary  and  rate  tables,  presenting  series  of  death  rates  for  the  registration  area  and 
its  subdivisions  for  the  year  1907  and  the  four  preceding  years  of  registration;  and  (3) 
general  or  primaiy  tables,  showing  the  detailed  results  of  registration  for  the  year  1907. 
The  work  is  admirably  arranged,  and  will  prove  of  immense  interest. 

New  axd  Nox-Official  Remedfes  for  1909.  Containing  descri])tions  of  the  Articles  which 
have  been  Accepted  by  the  Council  on  Pharmacy  and  Chemistry  of  the  American  Medical 
Association,  prior  to  January  1,  1909.  Chicago:  Press  of  the  American  Medical  Asso- 
ciation, 103  Dearborn  Avenue,  1909. 

This  small  book  contains  the  descriptions  of  such  proprietary  articles  which  have  not 
been  found  to  conflict  with  the  rules  of  the  Council.  The  quantity  of  each  active  medicinal 
ingredient,  the  general  composition  of  the  vehicle,  the  alcoholic  percentages,  are  furnished 
under  the  mixtures  described.     Also  the  tests  for  identity,  purity,  etc. 

PBOCEEniNGS    OF   THE  ACADEMY   OF   NATURAL   SCIENCES    OF    PlIILAUEtPnTA,   Vol.    LX,    Part   III, 

July  to  December,  1908.     The  Academy  of  Natural  Sciences  of  Philadelphia,  1909. 

This  volume  consists  of  the  proceedings  of  the  meeting  and  a  number  of  problems  in  the 
field  of  natural  sciences.  These  articles  are  very  interesting,  and  will  prove  of  extreme  value 
to  special  students.     Thus,  some  of  the  articles  are:  — 

"Notes  on  the  Distribution  of  Colorado  ]\Tamnials,  with  a  Description  of  a  New  Species 
of  Bat  (Eptesicus  Pollidus)  from  Boulder";  "The  Directive  Influence  of  Light  on  the  Growth 
of  Forests  Plants";  "Recent  Additions  to  Our  Knowledge  of  the  Flora  of  Southern  New  Jer- 
sey";   "A  New  Species  of  Cymatopleura";    "On  the  Teeth  of  Hawaiian  Species  of  ITelieina." 

The  articles  are  treated  in  a  scientific  manner,  and  some  of  them  are  illustrated  by  a 
number  of  plates. 


Monthly    CvcLOPiEDiA 

AND 

Medical   Bulletin 


Published  the  Last  of  Each  Month 


Monthly  Cyclopaedia  Section 


Vol.  II.  PHILADELPHIA,  JULY,  1909.  No.  7. 


Original  Articles 


Department  in  charge  of  J.  MADISON  TAYLOR,  A.M.,  M.D. 


VARIATIONS  IN  THE  MEDICINAL  THERAPY  OF  PNEUMONIA  IN  THE 
LAST  HALF  CENTURY.* 

By  A.  JACOBI,  M.D.,  LL.D., 

NEW    YORK. 

The  therapeutics  of  Hippocrates  was  symptomatic  and  palliative.  He 
was  not  guided  by  pathological  anatomy,  which  did  not  then  exist,  but  by  the 
complaints  of  the  patient  and  distinct  symptoms,  such  as  fever,  pain,  dyspnoea, 
and  the  presence  or  absence  of  expectoration.  He  taught  us  to  watch  and 
follow  nature,  to  support,  and  to  do  no  harm.  Fomentations,  blood-letting, 
bathing,  and  glutinous  or  mucilaginous  substances — few  in  number  compared 
with  the  vast  array  of  substances  known  to  and  utilized  or  abused  by  us — were 
his  armamentarium  in  pneumonia  and  other  feverish  diseases.  Two  thousand 
years  after  him  Sydenham  followed  the  same  rules. 

Without  any  increase  of  positive  knowledge,  Asclepiades  and  the  Arabs 
cut  loose  from  the  teachings  of  simple  clinical  experience.  Particularly  the 
latter  built  up  a  confused  mass  of  therapeutic  measures.  Their  numberless 
old  and  new  medicinal  internal  and  external  aids  and  appliances  remind  us  of 
the  detrimental  activity  displayed  by  the  worst  class  of  our  wholesale  nostrum 
vendors  and  the  frauds  of  modern  meretricious  practice. 

One  of  the  greatest  men  of  medicine,  Albertus  von  Haller,  was  the  innocent 
cause  of  a  nefarious  change  in  therapeutic  practice  about  the  end  of  the 
eighteenth  and  the  beginning  of  the  nineteenth  century.  His  theory  of 
irritability  and  his  assumption  of  a  general  vital  force  subjacent  to  and  con- 
trollicg  every  local  function,  gave  rise  to  two  systems  of  therapy  which  reigned 

*  Read  before  the  American  Climatological  Association,  June  4,  1909. 

3  (385) 


386  THE  MEDICINAL  THERAPY  OF  PNEUMONIA. 

supreme  in  many  decades;  viz.,  those  of  John  Brown,  in  England,  and 
Giovanni  Easori  in  Italy.  Both  believed  that  local  diseases,  such  as  pneumonia, 
were  manifestations  of  a  general  affection  and  required  no  local  or  especial 
treatment.  According  to  Brown,  whose  teaching  was  not  adopted  by  the 
practical  common  sense  of  his  own  countrjTiien  but  attained  supremacy  ia 
Germany,  and  through  the  writings  of  Benjamin  Eush  in  America,  all  diseases 
depended  either  on  depressed  or  on  excited  vital  force,  mainly  the  former,  which 
required  stimulation,  while  the  latter  demanded  depression.  Meat,  alcohol, 
opium,  camphor,  musk,  ammonia,  were  his  main  remedies.  While  most  of 
Brown's  diseases  were  asthenic,  they  were  sthenic  with  Easori.  Tartar  emetic 
and  venesections  were  his  principal  resorts  in  pneumonia.  His  methods  were 
adopted  over  a  large  part  of  Europe  into  the  second  half  of  the  nineteenth 
centur}\  The  great  Cavour  was  treated  for  his  malaria  with  interminable 
blood-lettings  until  this  saviour  and  hope  of  modern  Italy  was  killed  by  his 
physicians.  Easori's  teaching,  which  was  also  that  of  Peschier,  was  obeyed 
in  the  best  medical  schools  of  Europe.  Under  the  orders  of  my  revered 
teacher,  Friedrich  Nasse,  at  Bonn,  in  1849-1851,  and  the  supervision  of  his 
clinical  assistant.  Doctor,  now  Sir,  Hermann  V/eber,  of  London,  I  treated  in 
1850  old  Abraham,  78  years  old,  with  large  doses  of  tartar  emetic  and  two 
venesections,  one  on  the  cephalic,  one  on  the  saphena,  until  he — survived. 

After  1853,  I  did  the  same  things  in  New  York  practice.  Most  of  my 
pneumonia  patients  were  bled,  some  on  the  saphena.  To  my  credit,  I  may 
add  that  after  a  few  years  I  became  less  sanguinary,  though  Payne  of  the 
University  Medical  CoUege  was  still  alive  and  teacliing.  Gradually  both 
Brownianism  and  Easoriism  underwent  slight  modifications.  Easori  relied 
mainly  on  antimony — its  oxysulphuret  was  the  subject  of  one  of  my  first  New 
York  publications — emetics,  narcotics,  and  digitalis,  which  he  considered  to  be 
a  sedative;  Brown  on  nutrients  and  tonics,  stimulant?  and  analeptics. 
Amongst  the  latter,  warmth  or  heat,  and  digitalis  held  a  high  rank. 

By  and  by,  imiversal  vital  force  was  no  longer  the  underlying  general  sup- 
port or  danger  of  everything  in  physiology  and  nosology;  its  presence  or 
absence  was  considered  in  its  local  influence  on  the  heart,  the  nerves,  and 
the  blood.  Weakness  of  tlie  heart  was  treated  with  alcohol,  digitalis,  camplior, 
and  cold  bathing,  and  narcotics  and  nervines  found  their  ready  indications. 

The  therapeutical  nihilism  of  Vienna  was  the  result  of  tlie  observation  of 
unsuspected,  and  in  part  incredible,  changes  found  at  autopsies.  A  hepatized 
lung  was  not  believed,  when  found  at  the  autopsy  to  have  ever  been  accessible 
to  treatment  or  to  improvement  during  life.  Laennec's  teaching  at  the  same 
period  was  still  anatomic,  but  anatomic  lesions  were  found  during  life  and 
not  only  after  death,  and  not  only  they  but  the  rapidity  of  their  changes  were 
appreciated.  As  these  changes  were  known  to  take  place  spontaneously,  so 
they  were  believed  to  be  accessible  to  treatment,  both  internal  and  external. 
Abscesses  and  gangrene  became  amenable  to  interference,  and  resolvents, 
evacuants,  and  derivants  reconquered  their  former  standing.  Inflammations 
and  fever,  however,  became  parts  of  the  disease;  unfortunately,  in  the  eyes 
of  too  many  even  the  disease  itself,  and  antipjrresis  and  antiphlogosis  became  the 


THE  MEDICINAL  THERAPY  OF  PNEUMONIA,  387 

gospels  and  the  guides  of  medical  consciences.  In  1S61  Ernst  Brand  intro- 
duced cold  water  treatment  in  typhoid  fever.  Neither  he  nor  Currie  was 
the  first  to  propose  it,  but  it  so  happened  that,  about  the  same  time,  the 
clinical  thermometer  conquered  the  field  of  diagnosis.  The  reduction  of 
temperature  came  to  be  looked  upon  as  a  general  duty.  That  was  accomplished 
by  chemical  aids  when  water  did  not  suflBce  or  was  not  selected  for  that  purpose. 

In  1820  Pelletier  and  Carenton  dissociated  quinine.  As  it  cured  the  fever 
in  malaria,  it  was  introduced  into  the  realm  of  pneimionia.  Later  on,  the 
coal  tar  preparations,  one  after  the  other,  were  credited  with  effects  unknown 
and  unknowable.  Antipyrin  was  introduced  by  Knorr  in  1884;  acetanilid,  the 
joy  of  the  antikamnia  mercenaries  and  the  shame  of  the  Commission  of  the 
United  States  Pharmacopoeia,  of  what  was  called  1900  and  was  1905,  by 
Cahn  and  Hepp  a  few  years  later.  And  so  on,  ad  infinitum.  Old  vegetable 
remedies  did  not  lose  their  standing.  Digitalis  was  often  replaced  by  strophan- 
thus,  which  was  eulogized  by  Livingstone  and  Kirk  in  1865,  and  strongly 
recommended  by  Th.  K.  Eraser.  Veratrum  and  mercury  came  into  their  own 
again,  and  all  the  other  important  and  unimportant  therapeutic  measures. 

It  is  quite  true,  however,  that  the  course  of  the  pathologic  process  was  not 
disturbed  much,  and  was  not  shortened  by  treatment;  that  is  the  dogmatic 
dose  always  given  us  when  we  resort  to  physical  or  medicinal  treatment.  We 
are  always  told  that  all  our  medication,  because  it  cannot  improve — so  they  say 
— anatomical  conditions,  is  useless.  That  is  silly,  for  it  should  not  be  neces- 
sary to  prove  that  a  strong  heart  or  a  weak  heart,  an  active  splanchnic  circula- 
tion, or  a  hepatic  obstruction,  act  differently  in  the  process  of  pulmonary 
circulation  and  of  absorption.  After  all,  it  is  on  these  that  the  life  of  a 
patient  may  depend  in  a  pneumonia.  Finally,  I  wonder  why  we  should  be  pre- 
vented from  keeping  the  man  alive  who  owns  the  lung,  and  why  we  should 
take  our  hands  off  the  lung  because  it  cannot  be  directly  influenced,  at  least 
they  say  bo. 

As  late  as  the  middle  of  the  last  century  pneumonia  was  a  disease  resulting 
from  some  internal  disposition,  whose  nature,  according  to  Choqiel  and  many 
others,  was  unknown.  It  originated  from  mucus  in  the  blood,  from  bilious  or 
thin  blood,  angina,  pleurisy  or  suppressed  menstrual  or  ha3morrhoidal  bleeding. 
Now  and  then  a  local  lesion,  a  pharyngeal  wound,  was  mentioned  as  a  cause  of 
pneumonia.  Centuries  before,  Paracelsus  had  said :  "The  body  has  been  given 
us  without  venom.  Whatever  makes  man  sick  is  a  venom  that  gets  into  his 
nature  from  outside."  That  was  forgotten.  Even  the  many  ailments  and 
accidents  resulting  from  poisons  were  not  utilized  to  correct  the  old  theories; 
they  lost  their  nosological  dignity  and  were  exiled  to  special  books  on  toxi- 
cology. Semmelweiss,  who  learned  from  Paracelsus  and  his  own  observations, 
was  ridiculed  and  driven  crazy;  even  Lister  was  looked  on  askance  for  his 
innovations.  Still  the  study  of  wound  infections  had  its  influence  on  internal 
medicine,  and  in  imitation  of  the  aseptic  measures  of  surgical  practice  other 
clinicians  looked  for  internal  antisepsis  to  fight  internal  disease.  As  that 
proved  useless,  the  hunt  after  more  antiseptics  was  continued,  the  Greek 
dictionaries  were  exhausted  in  the  search  for  new  names ;  the  doctors  were  dis- 


388  THE  MEDICINAL  THERAPY  OF  PNEUMONIA. 

appointed,  but  never  hopeless,  the  manufacturers  got  rich,  or  tried  to  get  rich, 
quick.     Pneumonia,  however,  was  not  treated  any  better  or  more  successfully. 

Therapy  has  always  been  dependent  on  or  connected  with  certain  path- 
ological doctrines.  Its  results  are  in  due  proportion  to  our  ignorance,  or 
knowledge,  and  to  the  difficulties  to  be  surmounted.  What  little  I  could  say  of 
the  trifling  influence  we  appear  to  have  in  the  different  forms  of  pneimionia, 
seems  to  prove  it.  Better  than  mere  empiricism  is  the  proving  of  the  effects  of 
drugs,  of  which  there  are  examples  in  Galen.  Storck  (1731-1803)  made 
systematic  researches  in  that  line.  He  studied  mainly  narcotics,  such  as 
cicuta,  colchicum,  hyoscyamus,  pulsatilla  and  stramonium.  It  has  been  said 
that  Hahnemann  was  the  first  to  embark  in  that  sort  of  study.  That  is  a  mis- 
take. The  most  important  progress  in  pharmacology  was  made  by  experi- 
mentation at  the  hands  of  the  men  just  named. 

During  the  anatomic  era,  initiated  by  Bichat  and  elaborated  by  Laennec 
the  master,  and  the  Vienna  school  of  Rokitansky  and  Skoda,  it  was  possible 
to  distinguish  between  the  croupous,  catarrhal,  gelatinous,  and  cellular  forms, 
with  the  differences  in  their  clinical  progress,  but  no  indications  could  be 
derived  from  them  nor  was  therapeutics  benefited  by  them.  The  latter  was 
still  controlled  either  by  a  theoretical  system  which  imprisoned  the  common 
sense  of  the  practitioner,  or  by  his  discriminating  intelligence  which  treated 
the  individual  patient  according  to  the  prevalence  of  either  mild  or  dangerous 
looking  symptoms. 

Another  era  began  for  nosology  and  for  therapeutic  hopes  when,  some 
decades  ago,  a  number  of  diseases  were  proven  or  supposed  to  be  of  microbic 
origin.  If  tuberculosis  was  the  result  of  a  bacillus,  that  bacillus  had  to  be 
killed.  Hot  air  blown  into  the  lungs  (Weigert)  sulphid  of  hydrogen  (Berget) 
into  the  rectum,  were  expected  to  do  that,  but  did  not.  If  pneumococcus 
caused  pneumonia,  the  easiest  way  to  cure  the  latter  was  to  go  for  the  coccus. 
That  has  been  done  without  success.  Evidently  our  views  concerning  its 
nature  have  changed,  are  improved  and  more  scientific,  but  our  art  is  not 
yet  abreast  of  our  knowledge  of  the  indications.  Bacilli  and  cocci  take  their 
own  time;  meanwhile,  we  have  to  turn  away  from  them  and  again  to  the 
individual,  who  wants  to  get  well,  individually  well,  no  matter  how  much  you 
know  of  the  essential  nature  or  symptoms  of  the  thousand  fellows  who  have 
their  own  pneumonia,  not  his.  Evidently  your  pneumonia  is  not  that  of  your 
neighbor,  for  you  are  not  he;  he  is  a  child,  an  adult,  a  senex,  previously 
healthy  or  not,  thin  or  fat,  in  good  health  or  run  down  by  care,  work  and 
starvation,  or  he  has  a  pneumonia  of  a  different  etiology  altogether. 

The  last  few  decades  of  nosology  may  be  called  an  etiologic  era.  Under 
the  influence  of  bacteriologic  research  the  causes  of  pulmonary  inflammations 
have  increased,  and  the  indications  may  be  expected  to  change  with  them. 
The  question  is  whether  they  can  be  fulfilled.  The  commonest  form  of 
pneumonia  is  that  which  depends  on,  or  is  complicated  with,  the  diplococcus 
lanceolatus.  This  ubiquitous  pneumococcus  inhabits  most  of  the  normal 
mucous  membranes.  In  the  healthy  it  is  found  in  the  nose,  mouth  and  pharynx. 
Its  presence  does  not  mean  the  existence  of  a  pneumonia  any  more  than  the 


THE  MEDICINAL  THERAPY  OF  PNEUMONIA.  389 

presence  of  a  diphtheria  or  a  tuberculosis  bacillus  on  the  intact  mucous  mem- 
brane signifies  diphtheria  or  tuberculosis.  To  start  a  pneumonia  the  pneumo- 
coccus  demands  a  proximate  cause,  low  barometer,  dust,  exposure  to  severe 
cold,  sudden  changes  of  temperature  from  warm  to  cold,  trauma  of  the  chest. 
The  lungs  are  not  the  only  organs  in  which,  during  the  disease,  the  pneurao- 
coccus  is  found.  It  is  met  in,  perhaps  causes,  pericarditis,  endocarditis, 
nephritis,  meningitis,  pleuritis,  conjunctivitis.  Death  may  be  caused  by 
universal  infection  under  symptoms  of  sepsis.  Then  it  is  found  in  the  blood. 
It  is  not  contagious.  The  etiologic  indication  is  the  finding  and  emplo}Tnent 
of  an  anti-pneumococcic  serum.  But  it  has  not  been  proven  that  a  soluble 
toxin  is  secreted  in  the  infected  animal  body.  A  serum  obtained  from 
pneumococci  which  has  been  used  to  immunize  horses,  cows  and  rabbits  is 
not  antitoxic  nor  bactericidal  but  Metchnikoff  believes  it  stimulates  the  increase 
of  leucocytes,  and  A.  E.  Wright  that  opsonin  is  formed — that  is  the  name 
given  to  a  protective  body — both  investigators  thinking  that  thereby  the  cocci 
are  made  subject  to  phagocytic  destruction. 

The  practical  constituents  of  any  hitherto  known  anti-pneumococcus 
serum  are  very  doubtful.  Anders  has  collected  data  with  very  imfavorable 
results.  In  Curschmann's  clinic  four  died  out  of  twenty-four  cases.  Eoemer 
has  made  what  is  called  a  polyvalent  "serum."  It  is  not  probable,  however, 
that  any  serum  which  is  credited  with  multiple  effects  will  have  any.  Nor 
have  we  any  proof  that  an  antitoxin  valuable  in  one  infection  will  prove  so  in 
another.  A  few  years  ago  diphtheria  antitoxin  was  recommended  against 
cerebrospinal  meningitis.  I  have  injected  from  five  to  forty  thousand  units 
into  the  spinal  canal  in  quite  a  number  of  cases.  So  have  others.  The  result 
was  a  temporary  notoriety  of  what  is  called  an  author,  a  discoverer. 

Let  me  again  urge,  though  I  am  aware  that  everybody  knows  it,  that  the 
ubiquity  of  the  pneumococcus  without  illness,  is  well  known  at  present.  One 
of  the  first  to  discuss  that  was  Durck  in  Deutsch.  Archiv.  f.  Klin.  Med.,  1897. 
Lungs  of  children  who  did  not  die  of  pneumonia  and  lungs  of  domestic 
animals  contained  the  diplococcus  and  other  bacteria.  Cultures  of  bacteria 
blown  into  the  lungs  of  healthy  animals  caused  no  pneumonia;  dust  did;  so 
did  a  mixture  of  cultures  and  dust.  It  is  not  the  presence  of  pneumococci, 
but  the  fixation  and  their  activity  in  generating  toxins,  which  cause  morbid 
tissue  changes. 

Acute  lobular  pneumonia  does  not  run  the  more  or  less  regular  course  of 
the  lobar  form.  Muscles,  including  the  heart,  are  not  so  easily  or  so  early 
affected.  Complications  with  pleuritis  are  not  so  common.  Thus  the  danger 
may  not  be  great  in  the  beginning,  but  it  lasts  long,  may  fatigue  and  often 
exhausts  the  heart,  or  may  terminate  in  suffocation  mostly  depending  on 
catarrhal  congestion  and  oedema. 

Interstitial  pneumonia,  synonymous  with  peribronchitis,  runs  a  protracted 
course,  with  temperatures  mostly  high  and  of  long  duration,  with  little  or  no 
cough,  and  incomplete  recovery  in  most  cases.  Induration  and  retraction  of 
the  pulmonary  tissue,  ending  in  bronchiectasia,  are  common.  They  are  the 
cases  which  after  many  years  are  frequently  mistaken  for  tubercular  infiltration 


390  THE  MEDICINAL  THEKAPY  OF  PNEUMONIA. 

of  the  apices  and  upper  lobes.  No  thickening  of  the  adventitia  of  the  smallest 
vessels  is  noticed,  like  that  in  the  white  hypatization  of  syphilis. 

Complications  with  bronchitis  are  frequent.  Then  there  is  cough;  also 
with  pleuritis,  also  with  lobular  and  lobar  pneumonia.  Then  the  consolidation 
or  cicatrization  of  the  tissues  is  a  verj^  early  result;  it  appears  very  probable 
that  the  interstitial  tissue  is  more  than  merely  a  mechanical  support  and  a 
rounding  off  tissue.  When  the  final  contraction  has  taken  place  no  treatment 
will  prove  effective.  That  is  why  iodides  should  be  given  quite  early  to  meet 
the  tendency  to  hardening.  With  the  action  of  fibrolysin  in  subcutaneous 
injection,  given  to  cause  absorption  of  the  organized  new  tissues,  I  have  no 
experience. 

Streptococcic  pneumonia  does  not  begin  so  suddenly,  nor  with  a  chill  like 
pneumococcic  pneumonia.  It  follows  angina,  diphtheria,  scarlatina,  or  typhoid 
fever.  The  localization  is  disseminated,  but  after  a  while  whole  lobes  may  be 
affected  by  confluence.  It  migrates  suddenly,  the  spleen  is  enlarged,  it  lasts 
days  or  weaks.  No  crisis.  The  cough  is  dry,  evaporation  scanty.  Like 
other  infectious  diseases,  it  shows  albuminuria.  Diarrhcea  is  frequent,  so  is 
the  combination  with  pericarditis,  erysipelas  and  empyema.  It  is  contagious, 
affects  whole  families,  and  is  epidemic.  The  diagnosis  from  pulmonary  con- 
sumption, when  abscesses  form  and  the  process  is  protracted,  is  made  by  the 
presence  of  cocci  to  the  exclusion  of  the  tubercle  baciUus.  This  form  of 
pneumonia  seems  to  have  been  known  to  Hippocrates,  who  gave  a  bad  prog- 
nosis when  a  severe  case  commenced  with  nasal  discharges;  and  for  whom, 
when  after  a  protracted  and  serious  course  the  disease  developed  parotiditis 
and  external  abscesses,  hope  revived.  Those  who  have  faith  in  the  efficiency 
of  Marmoreck's  or  other  anti-streptococcus  serums  in  malignant  affections, 
such  as  puerperal  fever  and  scarlatina  of  bad  type,  should  use  it  in  these  cases. 
I  am  sure  that  in  a  few  of  the  worst  cases  of  streptococcus  infections  the  serum 
has  served  me  well. 

Both  the  infectious  and  the  contagious  character  of  pneumonia  were 
observed  by  Sir  Hermann  Weber  in  1869.  In  the  Jacohi  Festschrift  of  1900  he 
describes  cases  of  a  "pneumonia  fever  as  an  infectious  fever,  the  prominent 
symptom  of  which  is  a  lobar  pneumonia."  After  an  incubation  of  from  eleven 
to  thirteen  days,  his  cases  would  run  an  acute  course  of  from  four  to  six  days, 
were  located  in  the  lower  lobe,  and  were  very  contagious.  One  developed  great 
weakness  of  the  heart,  one  neuritis,  and  one  a  peculiar  delirium,  such  as  he 
has  often  seen  in  the  rapid  decline  of  febrile  diseases. 

Influenza  pneumonia  starts  suddenly  and  develops  slowly,  is  disseminated, 
is  not  always  amenable  to  diagnosis  by  means  of  percussion  and  auscultation, 
and  lasts  long  unless  through  congestion  and  oedema  it  kills  by  suffocation. 
Influenza  pneumonia  participates  in  the  etiologic  treatment  of  influenza,  with 
all  its  failures. 

The  same  may  be  said  of  pneumonias  attending  or  caused  by  anthrax  or  by 
plague.  They  prove  fatal  in  almost  every  case  of  the  latter,  in  fifty  or 
seventy-five  per  cent,  of  the  former.  So  far,  we  have  no  etiologic  indication 
for  treatment. 


THE  MEDICINAL  THEEAPY  OF  PNEUMONIA.  391 

Typhoid  pneumonia  is  ot  two  different  types.  It  may  be  the  first  and 
sometimes  the  only  recognized  ilhiess  before  typhoid  fever  is  diagnosticated,  or 
it  is  secondary  to  the  changes  which  are  early  prominent  in  the  bronchial  mucous 
membrane.  Crisis  is  very  rare;  even  lysis  is  covered  by  the  other  typhoid 
symptoms.  Ko  etiologic  indication  for  treatment  of  the  bacillary  infection. 
Not  yet. 

Tuberculous  pneumonia,  sudden  or  after  a  haemorrhage,  with  or  without 
a  marked  chill;  may  last  one  or  more  months;  it  terminates  in  lysis,  con- 
solidation, or  cavities.  ISTo  treatment  to-day  for  this  pneumonia  based  upon 
its  etiology.  But  either  a  more  efficacious  tuberculin  treatment,  or  a  serum 
to  be  found,  may  attain  a  local  influence  on  the  diseased  lung.  The  tuber- 
cular pneumonia  resulting  from  hemorrhage  has  the  lobular  type.  Forty-five 
years  ago  I  removed  a  stone  from  a  baby  of  nine  months  by  laryngotomy.  The 
baby  died  five  days  after  of  lobular  pneumonia.  At  the  autopsy  it  became  quite 
clear  that  the  lobules  affected  had  collapsed  and  become  the  seats  of  inflamma- 
tion behind  small  or  large  blood  coagula  which  prevented  the  access  of  air  to 
the  air  cells. 

Malaria  pneumonia  requires  close  observation  and  examination  to  be 
diagnosticated.  Begins  with  or  without  a  severe  chill,  which  I  have  seen 
renewed  after  a  day  or  two.  It  may  intermit,  exhibits  often  a  severe  per- 
spiration toward  evening.  At  last  there  is  here  an  etiological  indication  for 
the  administration  of  quinine. 

There  is  also  a  pneumonia  which  is  lit  up  by  a  S}^hiloma  of  a  lung  or 
one  that  accompanies  constitutional  s^^'philis.  Mercury  and  iodides  are 
effective,  but  on  the  other  hand  Lewin  speaks  of  them  as  occasional  accessory 
causes  of  pneumonia. 

Bacterium  coli,  bacterium  proteus,  also  lepra,  are  connected  with  occasional 
pneumonias,  either  as  causes  or  as  combinations,  No  etiologic  indications 
thus  far. 

When  a  pneumonia  runs  an  unusually  abnormal  course  the  case  is  no  longer 
simple.  There  are  many  cases  of  mixed  infection.  A  mere  pneumococcus 
infection  never  causes  gangrene,  or  abscess,  or  protracted  absorption.  Com- 
plications with  influenza  or  tuberculosis  are  frequent.  Old  tubercular  deposits 
may  soften  and  become  absorbable  by  a  new  infection  with  pneumococcus,  with 
measles,  or  pertussis,  naturally  with  the  impairment  of  direct  therapeutic 
possibilities. 

Indications  for  Treaiment. — Extermination  of  tlie  living  or  other  causes. 
If  that  cannot  be  done,  prevent  the  living  or  other  causes  from  exterminating 
the  man.     The  principal  indication  is  to  treat  the  man,  not  the  disease. 

Some  rules  are  valid  for  all  sick  with  pneumonia — rest  of  body  and  mind, 
no  risitors,  no  noise,  no  excess  of  light,  no  high  temperature  of  the  room-air, 
not  higher  than  60  or  65,  not  necessarily  so  low. as  Northrup  recommends  it  in 
all  cases;  liquid  food,  milk  diluted  with  cereals,  milk  diluted  with  hydrochloric 
acid  according  to  the  plan  of  Dr.  J.  Eudisch  (dil.  hydr.  acid  1;  water  250; 
milk  500;  heat  to  boiling  point);  plenty  of  water  or  lemonade,  or  hydro- 
chloric acid  in  water.     Relieve  the  abdominal  circulation  and  the  diaphragm 


392  THE  MEDICINAL  THERAPY  OF  PNEUMONIA. 

by  a  purgative, calomel,  unless  hydrochloric  acid  be  taken;  no  heav}'  bedding; 
warm  the  feet;  mustard  paste  to  the  chest;  mustard  footbaths  in  bed.  In 
very  fulminant  cases  with  excessive  congestion  and  cyanosis:    a  venesection. 

In  the  cases  with  cyanosis,  dilatation  of  the  right  heart,  and  threatening 
oedema  on  the  second  or  third  day,  a  venesection  with  one  or  a  few  big  doses 
of  digitalis,  the  equivalent  each  of  ten  or  twelve  grains,  may  save  life.  Those 
are  the  cases  in  which  a  doctor  is  wanted,  while  a  mild  case  may  be  served 
well  by  a  nurse. 

High  Temperature.— li  is  understood  that  a  high  temperature  is  not  a 
uniform  danger.  In  persons  suffering  from  an  old  heart  disease,  in  the  pre- 
maturely bom,  in  the  anaemic  of  all  ages  it  is  so,  or  may  be.  Whether  a  warm 
bath,  or  a  warm  bath  gradually  cooled  down,  or  a  cold  bath,  or  cold  washing 
and  spongmg  and  friction,  or  a  warm  or  a  cold  pack  over  chest  and  abdomen 
are  indicated,  or  the  local  application  of  an  ice-bag,  depends  on  the  individual 
case  and  the  individual  doctor.  Forty  years  agoi  I  could  speak  of  a  fair  experi- 
ence with  cold  water  in  typhoid  fever,  pneumonia,  scarlatina,  variola,  ophthal- 
mia, diphtheria  of  the  conjunctiva,  heart  diseases,  local  inflammation,  phlegmon, 
sj-novitis  and  peritonitis.  It  has  served  me  well  since.  No  uniform  rules 
fitting  every  case  of  pneumonia  can  be  given.  It  takes  brains  to  treat  lungs. 
The  length  of  these  remarks  obliges  me  to  be  very  brief  in  the  description  of 
medicinal  agents ;  indeed,  I  may  be  permitted  to  be  axiomatic. 

The  most  frequent  form  of  pneumonia  is  the  lobar.  Even  in  children  one- 
third  of  the  cases  belong  to  that  class.  As  a  rule,  it  runs  its  course  in  a  cer- 
tain number  of  days;  it  is  self-limited.  But  from  day  to  day  the  patient  is 
under  its  debilitating  influence.  I  appeal  to  the  common  sense  and  to  the 
conscience  of  the  individual  practitioner  for  the  decision  of  the  question 
whether  there  should  be  in  the  individual  case  of  his  patient  more  or  less 
food,  more  or  less  bathing,  more  or  less  medicinal  stimulation.  A  fat  person, 
a  feeble  person,  a  tuberculous  person,  an  influenza  patient,  a  child  with  lobular 
pneumonia,  requires  early  stimulation.  I  have  seen  harm  from  neglecting  it, 
never  any  from  obeying  that  indication.  As  alcohol  is  in  part  eliminated 
through  the  lungs,  I  believe  it  is  better  not  to  give  it  during  the  first  few  days. 
Moderate  doses  of  digitalis,  strophanthus,  spartein,  caffein,  or  ammonium 
(liquor  anisatus  better  than  the  carbonate)  will  be  well  tolerated,  brace  the 
heart,  and  may  save  the  strength  required  for  a  speedy  convalescence.  Digi- 
talin  is  no  alkaloid.  The  preparations  of  most  manufacturers  are  almost  inert; 
they  are  unequal,  and  unreliable.  Strychnine  is  given  too  much ;  indeed,  it  is 
abused.  No  myocarditis  bears  it  well;  in  arteriosclerosis  it  may  be  tolerated 
in  small  doses;  but  you  do  not  give  medicines  for  an  indifferent  but  for  a 
full  effect.  The  doses  of  strychnine  must  be  large  in  the  septic  and  the 
thoroughly  anaemic. 

Of  the  possible  benefit  derived  from  big  doses  of  digitalis  and  of  blood- 
letting, I  have  spoken.  When  expectoration  is  defective,  permanent  inhala- 
tions of  crude  turpentine  have  a  good  effect.     Fill  the  room  with  the  vapor, 

1  Medical  Record,  1870. 


PROGRESS  IN  THE  TREATMENT  OF  TUBERCULOSIS.  393 

but  do  not  annoy  your  sick  friend  with  pots  and  kettles  and  towels  near  the 
bedside.  As  stimulants,  I  believe  in  camphor,  also  in  benzoic  acid,  about  a  gram 
or  more  daily.  When  the  stomach  refuses  to  aid  you,  give  your  medicines 
subcutaneously.  Camphor  in  four  parts  of  sweet  almond  oil,  sodio-caffein 
salicylate  or  benzoate,  one  part  in  two  parts  of  distilled  water,  a  dose  of  10 
or  15  minims  every  two  or  four  hours,  or,  in  pulmonary  oedema,  every  15  or  20 
minutes,  imtil  you  are  satisfied. 

Dry  pleurisy  with  its  excessive  pain,  demands  morphine,  never  internally, 
but  subcutaneously.  Internally  it  will  have  no  effect  such  as  you  want;  sub- 
cutaneously, that  means  locally  over  the  seat  of  the  pain,  it  will  never  fail  you. 
It  will  not  cure  it,  but  will  relieve,  and  aid  in  curing  your  patient  who  is 
anxiously  searching  your  eye  for  immediate  relief  and  final  cure.  Incessant 
cough  and  sleeplessness  caused  by  pain,  must  be  relieved  by  an  opiate.  You 
may  kiU  your  patient  by  not  relieving  him.  The  fanatic  interdiction  of  opium 
in  the  cases  of  infants  is  copied  from  one  text-book  into  the  next  by  those 
who  treat  people  at  their  desks,  and  not  at  the  bedside. 


PROGRESS  AND  CHANGES  IN  THE  TREATMENT  OF  TUBERCULOSIS 
DURING  THE  PAST  TWENTY  YEARS.* 

By  EDWARD  R.  BALDWIN,  M.D., 

SABA.NAC   LAKE,   N.   T. 

A  EEQUEST  from  our  president  is  the  immediate  occasion  for  this  review, 
which  he,  as  I  am  sure  is  true  of  all  of  the  members  present,  would  have 
preferred  from  Dr.  Trudeau's  own  pen,  since  it  was  Dr.  Quimb/s  hope  to 
have  an  expression  directly  from  him.  As  this  could  not  fairly  be  added  to 
the  necessary  burdens  placed  upon  Dr.  Trudeau,  I  shall  essay  to  represent 
faithfully  in  what  follows  the  views  which  he  holds  of  the  subject  announced, 
trusting  that  it  will  fulfil  in  a  degree  the  desire  to  hear  from  Dr.  Trudeau's 
experience.  As  a  matter  of  fact,  it  has  been  my  own  privilege  to  observe 
the  changes  during  nineteen  years  of  the  past  two  decades,  many  of  which 
have  been  full  of  unprecedented  and  dramatic  incidents  connected  with  the 
treatment  of  tuberculosis.  There  have  been  many  changes  and  some  progress 
in  those  years. 

During  the  later  years  among  the  80's  the  trend  of  treatment  was  toward 
germicides  aimed  against  the  bacillus.  Creosote  was  perhaps  the  most  widely 
used  agent  with  supposed  disinfectant  powers.  Sulphide  of  hydrogen  per 
rectum,  inhalations  of  hydrofluoric  acid,  oxygen  and  antiseptic  oils  were  in 
vogue.  Belief  in  specifics,  discovered  or  to  be  discovered,  was.  natural  con- 
sidering that  the  enemy  had  been  located  and  the  bacillus  could  be  studied 
with  reference  to  the  influence  of  antiseptics.  Dr.  Trudeau's  earliest  experi- 
ments were  concerned  with  this  idea,  but  he  and  others  very  soon  found  that 

•Read  before   the   meeting  of   tlie   American   Climatological   Association,   June   6, 
1909. 


394  PROGRESS  TM  THE  TREATMENT  OF  TUBERCULOSIS. 

the  bacillus  in  a  test  tube  could  not  be  safely  compared  with  those  imbedded 
in  cheesy  tubercles  or  masses  of  purulent  sputum. 

This  fatuous  belief  in  germicides  has  never  died  out,  and  who  knows 
but  that  some  clever  Japanese  may  even  yet  discover  a  specific  as  deadly  to 
tubercle  bacillus  as  quinine  to  the  plasmodium  nialarice,  and  equally  harmless 
to  man?  I  fain  would  believe  that  he  would  be  received  with  plaudits  on 
the  Pacific  Coast! 

As  we  all  know,  belief  in  the  specific  virtues  of  climate,  and  especially 
of  altitude  and  dryness,  was  well-nigh  a  universal  conviction.  The  treat- 
ment of  tuberculosis  at  home,  or  even  in  the  few  sanatoria  where  special 
climatic  advantages  were  wanting,  was  viewed  with  disfavor,  indifference,  and 
alwaj^s  required  an  apologetic  attitude  on  the  part  of  the  physician  as  well 
as  resignation  by  the  patient  to  his  incurability.  The  pessimism  of  that 
time  was  more  in  relation  to  the  possibility  of  a  cure  in  unfavorable  climates 
than  in  disbelief  in  the  virtue  of  medication,  although  the  secondary  impor- 
tance of  medicaments  was  generally  recognized  and  taught  by  the  lead- 
ing men. 

Meanwhile,  animal  experimentation  was  giving  encouragement  to  Koch 
for  his  reluctant  announcement  of  tuberculin  in  1890.  Nothing  seemed  more 
appropriate  than  that  such  a  wizard  should  produce  a  bona  fide  cure,  and 
only  those  of  us  who  experienced  the  thrill  of  injecting  the  precious  fluid 
can  appreciate  the  emotions  excited  at  that  time.  I  need  not  dwell  on  the 
depression,  unwarranted  resentment  and  carping  criticism  which  followed. 
Only  a  few  brave  and  confessedly  daring  men  persisted  in  experiments  with 
tuberculin.  Dr.  Trudeau  was  one  of  the  few,  but  he  was  inspired  by  the 
rather  surprising  results  on  animals  which  he  obtained  from  1891  to  1893 
vnth  various  modifications  of  tuberculin.  These  were  supposed  to  have 
removed  its  sting  while  retaining  its  curative  properties.  Ecactions  were 
feared  so  that  this  treatment  seemed  only  justified  so  long  as  no  harmful 
reactions  could  be  observed. 

Nevertheless,  the  disappointment  was  very  great  on  the  part  of  the  mass 
of  physicians,  and  less  medication  or  none  was  the  popular  impulse,  at  least 
so  far  as  trying  new  remedies  emanating  from  laboratory  investigations 
was  concerned.  Such  research  was  in  decided  disfavor  as  a  basis  for  human 
therapeutics  among  the  men  on  the  street,  and  naturally  so.  Dependence 
upon  the  time-honored  tonics,  strychnine,  arsenic,  iron  and  hypophosphites 
was  the  routine  to  fall  back  on,  or  at  most  a  trial  of  the  latest  derivative 
of  creosote.  Many  physicians  in  their  indifference  abandoned  patients  to 
the  quacks  with  their  perennially  new  inhalation  specifics  or  bacillus  killers 
of  every  description.  It  was  a  barren  year  that  has  not  produced  at  least 
two  sensational  "cures"  during  the  past  twenty  years,  and  the  public  is  not 
to  be  blamed  for  listening  to  the  blatant  voice  of  the  charlatan  with  equal 
readiness  to  the  quieter  tone  of  the  sincere  worker  in  the  field  of  science, 
who  has  been  exploited  by  newspapers  or  had  misled  them  by  over-enthu- 
siasm about  some  new  lead  he  w^as  following;  forgetful  perhaps  that  the 
cure  of  tuberculosis  involves  m.any  things  undreamed  of  in  his  laboratory. 


PROGRESS  IN  THE  TREATMENT  OF  TUBERCULOSIS.  395 

In  the  midst  of  this  mixture  of  skepticism  and  popular  credulity  in  1891 
to  1893,  there  came  along  some  undoubtedly  meritorious  agents,  such  as 
cinnamic  acid  and  nuclein,  whose  injection  exerted  a  semi-specific  action  by 
exciting  leucocytosis.  The  chloride  of  gold  Avith  sodium  and  the  iodide  of 
manganese  injections,  as  practiced  by  Drs.  Shurly,  Gibbes,  and  J.  Blake  White, 
were  given  serious  attention  as  rational  alteratives  for  a  time.  The  dis- 
covery of  antitoxins  was,  however,  the  signal  for  renewed  hope  along  the  line 
of  a  true  specific,  and  while  the  enthusiasm  was  quieter  we  were  exulting 
in  expectations.  Much  time  was  required  to  find  out  what  the  difficulties 
really  were  in  the  way  of  a  tuberculosis  antitoxin,  and  it  might  be  added, 
such  research  is  still  going  on  and  is  not  altogether  hopeless. 

Meanwhile  the  feeling  had  been  growing  that  sooner  or  later  all  infec- 
tious diseases  must  be  conquered.  Sanitation  has  been  advancing,  more 
interest  was  developing  in  the  hygienic  and  dietetic  treatment  of  tuberculosis 
in  and  outside  of  institutions  abroad,  together  with  the  feeling  that  possibly 
something  radical  could  be  accomplished  Avithout  climatic  factors  hitherto 
thought  necessary. 

The  modest  attempts  of  Drs.  Trudeau  and  Bowditch  in  their  pioneer 
sanatoria,  which  were  inaugurated  with  misgiving  and  against  heavy  odds, 
began  to  show  results.  State  and  private  sanatoria  have  since  successfully 
justified  their  location  in  situations  relatively  inferior  as  to  climate  and 
weather  conditions,  until  the  climatic  nihilist  has  joined  hands  with  the 
medication  nihilist  in  decrying  the  real  value  of  climatic  change. 

Having  discovered  the  elements  of  paramount  importance  in  fresh  air, 
food  and  rest,  certain  sanguine  but  not  over-wise  individuals  have  gone  to 
extremes  in  their  enthusiasm,  so  that  to-day  we  find  the  home  treatment 
vaunted  beyond  reason.  No  doubt  the  great  good  that  has  come  in  this 
movement  more  than  counter-balances  the  harm  from  the  exaggeration,  and 
great  improvement  has  followed  in  a  more  rational  treatment  of  symptoms. 
Medication  for  cough,  sweats  and  fever  has  rightly  been  replaced  by  external 
measures,  or  infrequent  use  of  cough  sedatives  and  antipyretics.  The  intro- 
duction of  heroin,  of  local  ansesthetics  useful  in  the  throat,  such  as  orthoform 
and  anaesthesin,  and  of  mentholic  preparations  in  sprays  and  inhalations  in 
place  of  nauseant  expectorants  is  certainly  a  sign  of  progress. 

Haemoptysis  has  passed  through  many  phases  of  expcrunentation  with 
vaso-constrictors  and  vaso-dilators,  and  with  very  questionable  advantage. 
The  use  of  opiates  in  bleeding  to  check  cough  and  calm  excitement  still  holds 
the  chief  place,  but  they  are  certainly  less  often  needed  than  was  formerly 
thought. 

A  decided  gain  has  been  achieved  in  the  general  management  of  patients 
in  the  matter  of  exercise,  and  by  a  greater  attention  to  rest  during  febrile 
conditions  and  avoidance  of  harmful  excitement. 

Artificial  collapse  of  the  lung  by  nitrogen  injections  to  secure  immobility 
had  a  rational  basis  along  this  line  under  the  name  of  the  Murphy  treat- 
ment. Its  use  was  short-lived  here,  but  it  still  receives  some  attention 
abroad.    Mechanotherapy  has  had  faithful  adherents  in  the  use  of  the  pneu- 


396        PROGRESS  IN  THE  TREATMENT  OF  TUBERCULOSIS. 

matie  cabinet  for  influencing  the  circulation  through  the  lungs  by  pressure 
differentiation,  a  most  rational  procedure  for  properly  selected  cases.  A 
tribute  is  due  to  our  president  for  his  persistent  advocacy  of  this  treatment, 
which  embodies  principles  amply  in  accord  with  the  best  proven  rationale 
to-day  for  successful  results;  namely,  intermittent  hyperaemia.  Probably  it 
would  have  received  more  attention  but  for  the  trouble  and  study  required 
to  apply  it  intelligently  and  long  enough  to  secure  results. 

The  simple  truth  is  that  styles  in  the  treatment  of  tuberculosis  have 
changed,  like  hats,  with  the  seasons,  and  for  fear  of  being  regarded  anti- 
quated, undoubtedly  useful  measures  are  dropped  by  the  majority  of  us, 
after  a  most  superficial  trial.  One  reason  for  this  has  been  the  necessity 
placed  upon  the  men  most  engaged  in  phthisiotherapy  to  test  every  claim 
made  by  some  one  who  had  seen  a  vision  of  a  cure  in  whatever  he  brought 
forth  from  years  of  mighty  struggle.  These  have  been  legion.  On  the  other 
hand,  the  gradual  return  of  interest  in  tuberculin  therapy  illustrates  the  fact 
that  a  few  demonstrated  truths  from  serious  studies  on  immunity  have  taken 
the  attention  of  our  profession  again.  There  is  at  least  a  more  thorough 
study  being  made  of  tuberculin  now  than  of  any  other  previous  treatment 
known  to  me,  unless  it  be  creosote.  Yet  there  is  now  danger  from  ignorant 
and  reckless  exploiters,  who  will  throw  discredit  upon  the  conservative  men 
who  are  proceeding  cautiously  with  the  hope  that  time  vdll  produce  still 
better  indications  to  govern  immunizing  methods  of  treatment. 

That  there  is  some  value  in  these  methods  is  now  recognized  pretty 
widely  by  those  who  have  carried  out  tuberculin  therapy  according  to  a 
system  of  which  Dr.  Trudeau  has  been  the  exponent  as  much  as  anyone  in 
this  country.  This  has  for  its  principle  a  heightened  resistance  or  tolerance 
for  tuberculin  itself.  Until  some  better  explanation  can  be  given  for  the 
good  results,  this  is  to  be  taken  for  the  rationale  in  specific  therapy  rather 
than  direct  immunity  against  the  bacillus. 

A  word  should  be  said  of  the  progress  made  in  the  treatment  of  surgical 
tuberculosis  by  the  Bier's  method,  and  the  gradual  decrease  of  operative 
interference  through  this  means,  as  well  as  by  early  aspiration  of  cold 
abscesses  and  effusions.  Admitting  that  exaggeration  is  having  its  usual 
sway  in  this  as  in  all  previous  treatments,  there  is  yet  much  to  be  grateful 
for  in  the  good  results  already  obtained.  The  application  of  this  principle 
to  pulmonary  tuberculosis  by  means  of  the  Kuhn  mask  is  not,  I  think,  des- 
tined to  become  popular  any  more  than  the  same  treatment  applied  by  pos- 
ture with  the  head  below  the  trunk.  The  theory  is  good,  but  the  application 
too  unpleasant. 

I  have  referred  to  some  of  the  things  which  seemed  to  make  for  progress 
in  our  art  as  applied  to  the  treatment  of  tuberculosis.  It  is  impossible  to 
mention  all  the  good  things  that  have  been  gained  and  also  lost  during 
twenty  years. 

The  gains  to  an  appreciable  degree  have  been  negative,  by  the  abandon- 
ment of  much  polypharmacy  and  the  education  of  the  laity  against  it,  not 
forgetting  the  discomforture  of  many  quacks  by  our  friend  Samuel  Hopkins 


THE  STANDARDIZATION  OF  MATERIA  MEDICA  PRODUCTS.  397 

Adams,  and  the  journals  which  have  espoused  decent  advertising,  notably, 
Collier's  and  the  Ladies'  Home  Journal. 

Much  yet  remains  to  be  done  along  this  line  inside  the  profession,  and 
I  believe  is  being  done  by  the  Council  of  Pharmacy  of  the  American  Medical 
Association. 

In  the  history  of  all  progress  some  good  things  are  lost,  yet  compara- 
tively little  of  value  can  be  pointed  out  in  the  list  of  abandoned  medicaments 
for  tuberculosis. 

Creosote  in  some  form  appears  to  me  to  be  one  which  has  lost  some 
prestige  unjustly,  and  it  still  has  many  supporters  in  the  guaiacol  derivatives. 
Probably  iodine,  arsenic  and  phosphorus  are  still  held  in  repute,  but  in  the 
present  neglect  of  any  but  specific  medication  along  the  lines  of  vaccines, 
one  hears  but  little  of  their  use.  Most  noticeable  in  some  quarters  is  the 
preachment  against  the  usefulness  of  climatic  treatment  per  se.  I  think  this 
is  a  loss,  but  destined  only  to  be  a  temporary  one.  Disappointment  and 
reaction  must  follow,  and  those  of  us  who  realize  what  deep-seated  constitu- 
tional weaknesses  must  be  combatted  in  many  cases  of  tuberculosis,  know 
that  only  by  radical  and  permanent  change  of  climate  and  environment  can 
results  be  accomplished. 

The  truth  of  these  matters  becomes  redistilled  and  purified  by  experience 
and  opposition,  leaving  behind,  clearly  established,  what  is  most  valuable  for 
retention.  i 


THE  STANDARDIZATION  OF  MATERIA  MEDICA  PRODUCTS. 

By  F,  E.  STEWART,  Ph.G.,  M.D. 

(Concluded  from  June  number.) 

At  a  meeting  of  physicians  and  phannacists  held  at  the  office  of  Dr.  Henry 
Gibbons,  Jr.,  to  organize  a  San  Francisco  branch  of  the  bureau.  Dr.  Philip  Mills 
Jones  proposed  that  we  make  the  bureau  more  effective  by  reorganizing  under 
the  joint  auspices  of  the  A.  M.  A.  and  A.  Ph.  A.  This  plan  was  approved,  and 
a  joint  committee  appointed,  which  further  elaborated  the  plan,  and  reported 
favorably.  Conflicting  commercial  interests  defeated  this  commendable 
attempt.  Then  the  House  of  Delegates  took  part  of  the  plan  as  a  basis  for  its 
Council  on   Pharmacy  and  Chemistry. 

The  plan  of  the  Council  is  intended  to  act  as  a  clearing  house  for  the  adver- 
tising department  of  the  Journal  of  the  American  Medical  Association.  It 
leaves  the  proprietary  claims  of  the  manufacturing  houses  precisely  as  it  found 
them.  The  plan  of  the  Bureau  is  opposed  to  materia  medica  monopoly  no  mat- 
ter how  obtained,  with  the  exception  of  the  limited  monopoly  acquired  by  process 
patents  which  publish  exact  knowledge  of  the  patented  processes  in  such  clear 
and  comprehensive  language  as  to  permit  the  duplication  of  the  products  by 
those  skilled  in  the  art.  The  plan  also  admits  the  use  of  brand  names  to  dis- 
tinguish b'fetween  the  various  brands  of  products  on  the  market,  each  product  to 


398  THE  STANDARDIZATION  Or  MATERIA  MEDICA  PHODDCTS. 

be  known  under  a  technical  name  by  which  it  may  be  freely  discussed  in  medical 
societies  and  Journals,  and  find  a  place  in  scientific  literature. 

The  plan  of  the  Council  includes  a  therapeutic  committee,  having  as  its 
function  the  determining  of  whether  claims  made  in  the  advertisements  of  so- 
called  proprietary  medicines  are  sufficiently  worthy  of  credence  to  have  the 
product  admitted  to  the  "New  and  Non-Official  Eemedics."'  The  plan  of  the 
Bureau  recognizes  that  therapeutic  verdicts  can  only  be  obtained  by  the  co- 
operative investigation  of  many  competent  observers,  working  for  long  periods 
of  time  under  varying  conditions  of  environment,  and  upon  patients  of  different 
nationalities.  For  this  purpose  a  Working  Bulletin  System  is  included  for  col- 
lecting the  results  of  original  research  and  furnishing  the  same  to  the  profession 
in  the  fonn  of  abstracts  giving  credit  to  the  original  reports  from  which  the 
information  is  derived. 

No  intention  exists  on  my  part  to  disparage  the  excellent  work  of  the  Coun- 
cil. It  is  accomplishing  its  purpose  admirably.  The  object  of  the  Council  is  not 
to  place  the  practice  of  the  pharmacologic  arts  on  a  professional  basis.  It  recog- 
nizes the  practice  of  pharmacy  merely  as  a  commercial  business.  The  plan  of 
the  Bureau,  on  the  contrary,  is  intended  to  reform  pharmaceutical  practice  and 
place  it  on  a  professional  basis  as  part  of  the  practice  of  medicine,  and  to  aid 
in  conducting  the  practice  in  harmony  with  scientific  and  professional  require- 
ments. 

The  advocacy  of  the  bureau  plan  has  not  only  resulted  in  the  founding  of 
tbe  Council  which  has  proved  of  so  much  value  to  all  concerned  except  dishonest 
advertisers,  but  has  done  much  to  aid  the  cause  of  materia  medica  standardiza- 
tion in  other  ways. 

The  scientific  department  idea  has  been  adopted  by  several  of  the  large 
manufacturing  houses.  As  a  result  of  their  work,  galenical  standardization  has 
been  added  to  the  United  States  Pharmacopoeia.  This  was  accomplished  at  the 
National  Convention  for  Revising  the  United  States  Pharmacopeia  of  1890. 
The  plan  worked  so  well  that  it  was  extended  by  the  convention  of  1900.  Phys- 
iological standardization  may  be  advocated  for  the  next  revision.  There  is  much 
to  recommend  it  provided  care  is  exercised  by  the  committee  of  revision  to  keep 
on  the  conservative  side.  As  the  next  convention  meets  in  1910,  the  time  is 
appropriate  for  discussing  this  question. 

But  there  still  remains  much  work  to  be  done  in  the  way  of  establishing 
materia  medica  standards  and  enforcing  the  same  by  various  agencies  having 
this  function  in  charge. 

The  ergots  on  the  market  are  in  a  very  unsatisfactory  condition,  many  of 
them  being  inert.  Yet  ergot  is  purchased  and  sold  by  wholesale  and  retail  drug- 
gists, manufactured  into  fluidextract  by  manufacturing  houses  and  retail  drag-  ^ 
gists,  and  placed  on  the  market  for  physicians  prescribing  without  testing  the 
products  to  ascertain  whether  they  possess  any  activity  or  not.  One  example 
will  illustrate  the  condition  of  affairs.  A  certain  manufacturing  house  making 
a  specialty  of  testing  ergot  preparations  by  physiological  methods  and  chemical 
as?ay,  purchased  their  supply  of  this  drug  and  stored  it  under  what  were  sup- 
posed to  be  proper  precautions.     Within  two  months  it  was  mnde  into  fluid- 


THE  STANDARDIZATION  OF  MATERIA  MEDICA  PRODUCTS.  399 

extract,  and  then  tested  cliemically  and  physiologically,  when  it  was  ascertained 
to  be  virtually  inert.  Sixteen  hundred  pounds  of  fluidextract  were  thus  ren- 
dered useless. 

Manufacturers  and  retailers  preparing  fluidextract  of  ergot  without  testing 
the  actiyity  of  the  finished  product  on  animals,  are  not  in  position  to  guarantee 
their  products,  or  even  to  know  whether  they  are  of  any  activity  whatever.  The 
methods  of  testing  ergot  physiologically  by  injecting  into  roosters  and  observing 
the  effect  upon  the  comb  and  wattles  is  qualitative,  not  quantitative.  Checked 
by  the  chemical  assay  for  total  alkaloids,  the  combined  method  is  of  more  value. 

That  the  presence  of  alkaloids  is  considered  to  be  indicative  of  therapeutic 
activity  is  shown  by  the  fact  that  the  Swiss  Pharmacopoeia  has  adopted  a  test 
for  fluidextract  of  ergot  in  which  the  presence  of  a  minimum  quantity  of  the 
alkaloids  in  the  fluidextract  is  used  as  a  method  of  standardization. 

As  pointed  out  by  Edmunds  and  Hale,  in  their  valuable  paper  on  "The 
Physiological  Standardization  of  Digitalis,"  "at  the  present  time  it  is  impossible 
to  secure  a  standardized  preparation  of  the  drug  by  any  known  chemical  means 
on  account  of  the  fact  that  the  activity  of  the  drug  depends  upon  no  single 
active  principle,  but  upon  several  whose  chemistry  is  not  completely  known  and 
for  the  isolation  of  which  there  does  not,  at  the  present  time,  exist  any  satis- 
factory chemical  method." 

Several  workers  have  tried  to  find  a  relationship  between  the  digitoxin 
content  and  the  activity  of  the  preparations  as  determined  by  biological  meth- 
ods. This  combined  method  of  standardization,  while  the  best  now  in  vogue,  is 
not  entirely  satisfactory. 

As  stated  by  the  authorities  just  quoted,  "Reedi  and  Vanderkleed,  using 
guinea  pigs,  claimed  to  have  found  a  certain  parallelism,  but  a  study  of  their 
results  shows  that  the  parallelism  is  by  no  means  without  exceptions."  Their 
figures,  tabulated  in  the  paper  by  Edmunds  and  Hale  referred  to,  show  a  closer 
relationship  than  has  been  obtained  by  previous  workers. 

Eeed  and  Vanderkleed's  method  is  used  by  one  of  the  manufacturing 
houses,  and  has  proved  comparatively  satisfactory. 

That  there  is  necessity  for  standardizing  digitalis  preparations,  is  apparent 
when  it  is  considered  that  the  investigators  who  have  reported  on  this  subject, 
show  such  a  wide  variation  in  the  preparations  of  digitalis  on  the  market.  Reed 
and  Vanderkleed  demonstrated  that  the  various  brands  of  tincture  of  digitalis 
marketed  by  the  large  manufacturing  houses  vary  about  300  per  cent. 

*TBenncfeld,  in  1881,  showed  thnt  for  rabbits  the  lethal  doses  of  eight  dig- 
italis tinctures  varied  about  fourfold. 

'^uhrer  (1900)  demonstrated  on  frogs  that  some  of  the  fluidextracts  of 
digitalis  were  four  times  as  strong  as  others. 

"In  1902  Frankel  showed  that  six  infusions  of  digitalis  varied  from  100 
to  275  per  cent.,  and  six  tinctures  from  100  to  400  per  cent. 

'Edmunds,  in  1907,  showed  that  seventeen  tinctures  of  ditn'talis.  purchased 
in  the  open  markot,  varied  in  strength  as  1  to  4. 


IRppd  nnd  Vanrlfrklperl.     Am.  .1.  Pliann.,  PJiila..  IflOS,  \xsx.  110. 


400  THE  STANDARDIZATION  OF  MATERIA  MEDICA  PRODUCTS. 

"Frankel,2  j^  1903,  showed  that  seven  strophanthus  tinctures  varied  as 
high  as  6600  per  cent. 

"It  has  been  suggested  that  on  account  of  the  variation  in  the  strengths 
of  the  digitalis  series,  the  active  principles  should  be  substituted  for  them  in 
general  practice,  but  Haynes,^  in  1906,  showed  that  in  their  isolation  much  of 
their  potency  is  lost  and  that  they  require  standardization  even  more  than  the 
galenical  preparations." 

An  important  factor  in  materia  medica  standardization  is  the  determina- 
tion of  the  botanic  identity  of  the  species  of  medicinal  plants  employed  in  the 
manufacture  of  pharmaceutical  preparations.  Dr.  H.  H.  Eusby,  of  New  York, 
President  of  the  American  Pharmaceutical  Association,  and  Dean  of  the  New 
York  College  of  Pharmacy,  Columbia  University,  in  his  lecture  delivered  before 
the  Philadelphia  Branch  of  the  American  Pharmaceutical  Association,  April  20, 
1909,  stated  that  a  large  part  of  the  work  represented  by  the  United  States 
Pharmacopoeia  is  valueless,  owing  to  the  failure  on  the  part  of  investigators  to 
identify  the  species  of  plants  used  in  their  researches. 

For  example,  it  has  been  ascertained  that  in  a  certain  species  of  apocynum 
there  resides  a  glucoside  equal,  if  not  superior,  to  digitalin  as  a  remedy  in  the 
treatment  of  heart  affections.  Yet,  because  the  discoverer  of  this  principle  did 
not  describe  the  species  of  apocynum  in  which  this  glucoside  resides,  no  one 
knows  to-day  just  where  to  look  for  it.  After  citing  a  number  of  other  instances 
to  prove  the  enormous  value  of  botanic  standardization,  he  stated  it  probable 
that  the  next  revision  of  the  Pharmacopoeia  would  include  methods  for  the 
botanical  standardization  of  a  number  of  the  medicinal  plants. 

Owing  to  the  development  of  microscopic  methods,  botanic  standardization 
can  be  readily  applied  to  powders,  and  adulteration  may  often  be  detected  more 
readily  in  powders  than  in  the  drugs  themselves.  By  microscopic  means  species 
can  often  be  determined  on  account  of  peculiarities  of  cell  structure  and  the 
presence  or  absence  of  crystals.  At  one  time  the  presence  of  acicular  crystals 
of  calcium  oxalate  in  certain  amounts,  was  regarded  as  evidence  of  purity  in 
belladonna  root.  Now  it  is  known  that  the  crystals  came  from  poke  root  used 
as  an  adulterant,  and  the  amount  of  crystals  present  is  a  measure  of  adultera- 
tion, not  of  purity. 

What  do  you  suppose  would  be  the  therapeutic  effects  from  a  mixture  like 
the  following?  Dr.  Eusby  related  an  instance  where  a  lot  of  stramonium  was 
submitted  to  him,  which  chemical  assay  demonstrated  to  contain  0.25  per  cent, 
mydriatic  alkaloids  as  required  by  the  Pharmacopoeia,  but  ocular  inspection 
showed  the  presence  of  other  than  stramonium  leaves.  Botanic  standardization 
of  the  powdered  leaves  then  demonstrated  that  the  stramonium  had  been  forti- 
fied by  using  belladonna  leaves;  that  the  addition  had  raised  the  alkaloidal 
content  of  the  mixture  too  high ;  then,  to  correct  this,  a  poor  lot  of  hyoscyamus 
leaves  was  added,  which  brought  the  alkaloidal  strength  to  the  standard  of  the 
Pharmacopoeia.  It  is  not  necessary  to  say  that  the  port  of  New  York  rejected 
the  consignment. 

2  FrSnkel.     Therap.  d.  Gegenw.,  Berlin  u.  Wien.,  1902,  xlii,  106. 
8  HajTies.     Bio-Chem.  Jour.,  1906,  i,  63. 


THE  STANDARDIZATION  OF  MATERIA  MEDICA  PRODUCTS.  401 

I  think  that  I  have  fui'nished  you  with  sufficient  evidence  to  prove  that  the 
subject  of  materia  medica  standardization  includes  a  much  wider  field  than  is 
usually  supposed  to  belong  to  it;  that  it  embraces  the  fixing  of  standards  for 
determining  the  identity,  source  or  genesis,  physical  and  chemical  properties, 
physiological  and  therapeutic  action,  and  the  methods  of  preparing,  dispensing, 
and  applying  materia  medica  products  in  the  practice  of  medicine  and  phar- 
macy ;  that  it  includes  the  application  of  these  standards  in  the  practice  of  the 
pharmacologic  arts,  namely,  the  arts  of  pharmacognosy,  pharmacy,  pharmaco- 
d}Tiamics,  and  therapydynamics ;  that  it  includes  the  study  of  methods  of  intro- 
ducing new  materia  medica  products  to  science  and  brands  of  the  same  to  com- 
merce; that  it  includes  the  protection  of  capital  invested  in  materia  medica 
commerce  by  patents  either  on  products  or  processes,  or  both ;  that  it  includes 
the  protection  of  the  public  from  fraudulent  substitution  by  the  use  of  trade- 
marks and  brand  names  whereby  the  brands  of  manufacturers  can  be  distin- 
guished from  each  other  and  specified  by  physicians  and  pharmacists  wishing  to 
obtain  the  advantages  of  special  skill  in  the  pharmacologic  arts;  that  it  also 
includes  a  study  of  the  advertising  question  in  its  relations  with  medical  and 
pharmaceutical  journals.  For  all  of  these  subjects  relate  to  the  materia  medica 
and  have  standards  of  their  own,  ethically,  professionally,  and  commercially, 
and  each  subject  dovetails  into  the  other  to  such  an  extent  that  it  is  impossible 
to  carry  out  any  systematic  plan  of  materia  medica  standardization  without  con- 
sidering the  subject  from  the  broadest  possible  point  of  view. 

The  final  question  which  we  are  to  consider  briefly  is  embraced  by  the  ques- 
tion. Who  is  to  do  the  work  of  standardization? 

Theoretically  we  have  a  profession  of  pharmacy  consisting  of  retail  drug- 
gists, graduates  of  colleges  of  pharmacy,  having  as  its  function  the  selection, 
preparation,  preservation,  compounding  and  dispensing  of  medicines  to  meet 
the  demands  of  the  medical  profession  for  materia  medica  products,  and  also 
the  legitimate  demands  of  the  public  for  domestic  medicines.  Theoretically 
the  practice  of  pharmacy  includes  the  selecting  of  all  the  crude  material  and 
manufacturing  all  the  preparations  of  the  same  used  in  treating  the  sick,  includ- 
ing what  are  known  as  chemicals,  galenicals,  and  extemporaneous  pharmaceu- 
tical preparations.  Practically  no  such  profession  exists.  For  a  long  time  retail 
druggists  have  not  manufactured  their  chemicals,  either  inorganic  or  organic. 
Little  by  little  the  manufacture  of  galenicals  has  drifted  out  of  their  hands  and 
into  the  laboratories  of  the  large  manufacturing  houses.  Extemporaneous  phar- 
macy has  dwindled  down  to  small  proportions.  Eeady-made  preparations,  such 
as  pills,  tablets,  capsules,  etc.,  have  taken  the  place  of  the  extemporaneous  pre- 
scriptions. The  retail  druggist  has  thus  become,  to  a  great  extent,  a  mere 
hander  down  of  ready-made  goods.  This  is  due  in  part  to  a  want  of  proper 
education  of  the  medical  profession  in  materia  medica,  therapeutics,  and  pre- 
scription writing.  In  part  it  is  due  to  the  development  of  standardization  as 
applied  to  medicinal  drugs,  chemicals,  and  preparations  of  the  same.  While 
the  future  will  doubtless  show  a  decline  in  the  use  of  ready-made  prescriptions 
on  account  of  the  tendency  of  the  profession  to  proscribe  with  greater  accuracy, 
the  time  will  never  come  when  the  idonl  of  n  pharmnoentical  profession  of  retail 


402  THE  STANDARDIZATION  OE  MATERIA  MEDICA  PRODUCTS. 

druggists  will  be  realized.  The  subject  of  standardization  will  continue  to 
develop,  and  as  it  does  so  the  demand  for  skilled  botanists,  chemists,  and  physi- 
ologists will  increase.  To  become  really  skilled  in  any  one  of  these  departments 
as  a  branch  of  pharmacology  requires  a  preliminary  university  training  and  a 
post-graduate  course  in  medicine,  botany,  and  pharmaceutical  chemistry,  wntb 
special  training  in  the  particular  branch  specialized. 

Colleges  of  pharmacy  are  not  turning  out  his  class  of  men. 

The  National  Syllabus  Committee,  representing  the  colleges  and  boards  of 
pharmacy,  has  issued  a  pamphlet  containing  their  proposed  course  of  study 
designed  to  fit  retail  dniggists  to  practice  the  pharmacologic  arts  in  a  profes- 
sional manner.  The  plan  is  ideal,  but  it  is  doubtful  whether  it  can  ever  be 
realized  to  any  great  extent  so  far  as  the  retail  druggists  are  concerned,  for 
reasons  just  stated,  and  because  the  manufacturing  and  standardization  of  ma- 
teria medica  products  on  a  large  scale  can  be  effected  with  much  greater  econ- 
omy than  it  is  possible  to  secure  when  the  practice  is  conducted  on  a  small  scale. 

The  large  manufacturing  houses  have  come  to  stay,  and  it  therefore  be- 
comes important  for  the  profession  to  investigate  their  methods  of  doing  busi- 
ness. Is  the  practice  of  the  pharmacologic  arts  to  be  carried  on  as  a  side  line 
by  great  commercial  houses  engaged  in  the  manufacture  and  sale  of  nostrums, 
under  their  own  labels,  under  the  labels  of  retail  druggists,  or  under  the  labels 
of  the  large  patent  medicine  concerns  for  which  the  said  commercial  houses  are 
doing  the  work?  Or  is  the  practice  to  be  conducted  by  graduates  of  medicine 
and  pharmacy  co-operatively  associated  with  capitalists  and  conforming  with 
scientific  and  professional  requirements?  These  are  important  questions  for 
the  medical  profession  to  decide.  The  Supreme  Court,  in  its  decision  in  the 
Syrup  of  Figs  case,  already  quoted,  has  pointed  out  the  way. 

Who  is  to  do  the  work  of  fixing  the  standards  ?  Theoretically  the  medical 
and  pharmaceutical  profession  assemble  in  Congress  every  ten  years  to  appoint 
a  committee  for  revising  the  United  States  Pharmacopoeia,  consisting  of  a  list 
of  medicinal  drugs,  chemicals,  and  pharmaceutical  preparations  used  by  the 
medical  profession  for  treating  the  sick,  with  formulae  for  their  preparation, 
and  standards  for  determining  their  identity,  character,  purity,  and  strength. 
Invitation  to  this  Congress,  known  as  a  Pharmacopceial  Convention,  has  recently 
been  issued  by  Dr.  Murray  Gait  Hotter,  Secretary  of  the  Convention,  which  will 
assemble  May  10th  next  year,  at  Washington,  D.  C.  The  following  extracts 
from  the  constitution  shoxv  the  qualifications  for  membership: — 

"The  mcnibeis,  in  addition  to  tiie  incorporators  and  their  associates,  shall 
be  delegates  elected  by  the  following  organizations:  Incorporated  Medical  Col- 
leges, and  Medical  Schools  connected  with  Incorporated  Colleges  and  Univer- 
sities; Incorporated  Colleges  of  Pharmacy,  and  Pharmaceutical  Schools  con- 
nected with  Incorporated  Universities;  Incorporated  State  Medical  Associations; 
Incorporated  State  Pharmaceutical  Associations;  the  American  Medical  Associa- 
tion, the  American  Pliarmaceutical  Association,  and  the  American  Chemical 
Society;  provided  that  no  siich  organization  shall  be  entitled  to  representation 
unless  it  shall  have  been  incorporated  within  and  shall  have  been  in  continuous 
operation  in  the  United  States  for  at  least  five  years  before  tlie  time  fixed  for 
the  decennial  meeting  of  this  corporation. 


PNEUMONIA:    ITS  DANGER  POINT  AND  HOW  TO  AVOID  IT.  403 

"Delegates  appointed  by  the  Surgeon-General  of  the  United  States  Army, 
the  Surgeon-General  of  the  United  States  Navy,  and  the  Surgoon-Genoral  of  the 
United  States  Marine  Hospital  Service,  and  by  the  orgauizationa  not  hereinbe- 
fore named,  which  were  admitted  to  representation  in  the  Convention  of  1900, 
shall  also  be  members  of  the  corporation.  Each  body  and  each  branch  of  the 
United  States  Government  above  mentioned  ehall  be  entitled  to  send  three  dele- 
gates to  the  meetings  of  this  corporation." 

For  the  first  thirty  years  of  its  history  the  National  Convention  for  revising 
the  Pharmacopoeia  was  a  medical  body.  In  1850  colleges  of  pharmacy  were  first 
permitted  representation.  Decade  by  decade  the  pharmaceutical  representation 
has  increased,  until  in  the  Convention  of  1900  it  was  slightly  in  the  ascendancy 
over  medical  representation.  The  Committee  on  Eevision,  appointed  by  the  last 
Convention,  consisted  of  tAventy-six  members,  nineteen  of  whom  represented 
pharmaceutical  colleges,  and  only  two  of  whom  were  practicing  physicians.  The 
pharmacopoeia  resulting  from  the  labors  of  this  committee  is  acknowledged  to 
be  superior  to  almost  any  other  pharmacopoeia  in  the  world.  Therefore  no  seri- 
ous fault  is  to  be  fotmd  with  the  work  of  the  committee.  But  the  conditions 
existing  demonstrate  a  great  lack  of  interest  in  the  pharmacopoeia  on  the  part  of 
the  medical  profession.  The  question  is.  How  can  the  interest  of  the  medical 
profession  in  the  National  Standard  be  stimulated?  It  is  my  belief  that  the 
way  to  stimulate  the  interest  of  physicians  in  the  pharmacopoeia  is  through  the 
medium  of  standardization  of  materia  medica  products,  and  the  sending  out 
of  literature  on  this  subject  by  the  Committee  for  Revising  the  United  States 
Pharmacopoeia,  also  by  the  various  departments  at  Washington  interested  in  the 
identification  and  standardization  of  drugs,  by  the  Council  on  Pharmacy  and 
Chemistry,  and  by  the  manufacturing  houses  engaged  in  the  pharmacal  and 
chemical  industries. 

I  believe  that  the  medical  and  pharmaceutical  journals  should  take  up  this 
subject  for  discussion.  It  is  evident  that  it  would  be  unsafe  to  throw  open  the 
educational  channels  of  the  medical  and  pharmaceutical  professions  to  a  discus- 
sion of  advertised  materia  medica  products  without  the  establislimont  of  a 
strong  Central  Committee,  Board  of  Control,  Bureau  of  Materia  Medica,  or 
Pharmacologic  Society — call  it  what  you  please — representative  in  character, 
having  as  its  function  the  co-operative  classification  and  standardization  of  the 
newer  materia  medica,  the  censorship  of  advertising,  the  promotion  of  profes- 
sional and  commercial  interest,  and  the  protection  of  the  public  from  dishonest 
commercial  exploitation. 


PNEUMONIA:  ITS  DANGER  POINT  AND  HOW  TO  AVOID  IT 
ACCORDING  TO  DR.  SAJOUS.* 

By  J.  Mi\DISON  TAYLOR,  A.B.,  M.D., 

Pneumonia  is  described  by  many  text-books  and  rnnny  authoritios  as  a 
self-limited  disease.  Some  of  the  most  positive  teachers  declare  that  an 
expectant  treatment,  fortified  by  hygienic  precautions,  is  not  only  sufficient 

•Summary  of  nn  article  read  before  the  American  C^liinatological  Assopiatioii,  June 
4,  1909. 


404  PNEUMONIA:    ITS  DANGER  POINT  AND  HOW  TO  AVOID  IT. 

but  safest;  that  medication  is  dubious  at  best.  The  evidence  from  all  forms 
of  treatment  in  the  past  forty  years  offers  little  encouragement  because  the 
mortality  is  to-day  about  three  and  one-half  times  greater  than  it  was  then; 
standing  on  a  par  with  tuberculosis.  It  is  steadily  on  tlie  ascendant,  whereas 
the  latter  is  growing  less.  It  is  plain  that  neither  the  empirical  drugging  of 
half  a  century  ago  nor  the  drug  nihilism  of  later  years,  nor  again  the  open- 
air  housetop  treatments  of  the  present  has  served  to  check  the  steady  holo- 
caust from  one  infectious  disease. 

To  gain  the  mastery  over  this  appalling  slaughter  it  would  seem  plain 
that  we  must  approach  the  problem  by  subjecting  the  enormous  mass  of 
valuable  evidence  to  a  thorough  analysis,  because  it  is  reasonable  to  assume 
that  we  have  learned  something  from  which,  upon  revision  and  selection, 
the  truth  shall  appear.  Moreover  it  is  necessary  to  add  to  what  has  been 
learned,  some  essential  facts  concerning  the  resources  of  the  organism  and 
how  these  can  be  so  enhanced  as  to  lift  the  infected  individual  over  the 
danger  points.  The  object  of  this  brief  contribution  is  to  give  a  succinct 
summary  of  the  interpretations  of  Sajous,  which  have  shed  much  light  on 
many  obscure  places,  and  have  been  instrumental  in  reducing  the  mortality 
of  the  disease  by  those  physicians  who  have  carefully  studied  his  views  and 
the  remedial  procedures  he  pointed  out  in  the  second  volume  of  his  work 
on  the  "Internal  Secretions." 

Sajous  teaches  that  the  main  period  of  danger  coincides  with  the  stage 
of  engorgement.  The  affected  area  becomes,  he  states  in  his  work  on  the 
"Internal  Secretions,"  intensely  congested  and  the  capillaries  between  and 
towards  the  air-cells,  are  greatly  distended.  They  evidently  pour  their  con- 
tents into  these  air-cells,  for  they  and  the  terminal  bronchioles  are  more  or 
less  filled  with  red  and  white  corpuscles,  epithelial  cells,  etc.,  and  blood- 
plasma.  During  this  period,  we  know,  there  is  greatly  increased  frequency 
of  the  respirations,  which  may  vary  from  40  to  60  per  minute  in  adults,  and 
GO  to  100  or  more  in  children.  There  is  marked  oppression,  a  "grunt" 
being  more  or  less  audible  at  each  expiration.  In  plethoric  individuals, 
the  dyspnoea  is  especially  intense.  Now,  how  explain  this  phenomenon? 
This  is  where  text-books  fail,  and  where  Sajous's  researches  supply  life- 
saving  information. 

He  has  pointed  out,  and  this  is  made  particularly  clear  in  his  recently 
published  paper  on  the  "Auto-protective  Mechanism"^  that  the  adrenal, 
thyroid  and  pancreatic  secretions  jointly  supply  to  the  blood  all  its  immu- 
nizing constituents.  Of  all  these,  however,  that  produced  in  greatest  amount 
is  the  adrenal  secretion  (the  amboceptor  in  the  immunizing  triad),  which,  as 
every  one  knows  is  the  most  powerful  blood-pressure  raising  agent  known. 
The  toxin  having  induced  a  violent  auto-protective  reaction,  the  adrenal 
product  not  only  causes  a  general  rise  of  blood-pressure,  but  this  is  especially 
marked  in  the  diseased  portion  of  the  lung,  where  the  immunizing  process 
is  carried  on  with  the  greatest  vigor.  Hence  the  intense  respiratory  sym.p- 
toms,  the  dangerous  interference  with  the  heart's  action  which  involves 
1  New  York  Medical  Journal,  Eobniary  20-27,   1900. 


PNEUMONIA:    ITS  DANGER  POINT  AND  HOW  TO  AVOID  IT.  405 

the  familiar  tendency  to  cardiac  failure — a  most  dangerous  phase  of  the 
disease.     The  patient's  circulation  is  practically  blocked  in  the  lungs. 

It  is  to  the  mastery  of  this  stage  that  Sajous  attaches  the  greatest 
importance.  Proper  measures,  at  this  time  he  urges,  and  his  opinion  is 
now  justified  by  the  experience  of  many  practitioners,  prevent  a  fatal  issue. 
The  measures  he  advocates  do  not  involve  the  need  of  special  technical 
knowledge;  they  are  of  the  simplest  possible  kind  and  within  the  reach  of 
any  physician.  They  are  (1)  the  free  use  of  saline  solution  and  (2)  the  use 
of  creosote  carbonate,  ioih  begun  at  once,  i.e.,  when  the  case  is  first  seen. 

As  to  the  saline  solution;  his  purpose  is  to  replace  the  sodium  chloride 
consumed  with  abnormal  rapidity  in  pneumonia,  and  to  compensate  for  the 
one-half  ounce  of  this  salt  eliminated  daily  with  the  excretions  (urine,  sweat, 
tears,  etc.)  which  is  replaced  only  in  part  through  the  reduced  diet.  An 
adult  patient  who  drinks  not  less  than  one  quart  of  saline  solution  (approxi- 
mately two  teaspoonfuls  of  common  salt  to  the  quart  of  water,  or  milk,  or 
water  and  milk),  not  only  meets  these  drawbacks  but  it  does  more:  By  pre- 
serving the  normal  osmotic  properties  of  the  blood  and  preventing  undue 
viscidity,  it  facilitates  greatly  its  circulation  in  the  tissues,  including  the 
diseased  lungs.  Their  engorgement  is  not  only  kept  thereby  within  safe 
bounds,  but  the  detritus  (fibrin,  broken  down  red  corpuscles,  leucocytes,  etc.) 
is  promptly  transferred  to  the  general  blood-stream  and  converted  therein 
into  end-products  which  are  readily  and  rapidly  eliminated  by  the  kidneys. 

The  creosote  carbonate  fills  another  all-important  purpose:  it  enhances 
the  bacteriolytic  and  antitoxic  power  of  the  blood  and  enables  this  blood 
to  reach  the  nidus  of  infection  with  increased  freedom — thus  aiding  the 
saline  solution.  It  does  this  by  depressing  the  sympathetic  (which  Sajous 
traced  to  the  pituitary  body),  and  thus  causes  dilation  of  all  arterioles  includ- 
ing those  of  the  diseased  area.  Moreover,  the  dilation  of  these  small  arteries 
being  general,  the  blood-pressure  is  lowered,  thus  antagonizing  the  general 
rise  of  blood-pressure  which  is  in  part  responsible  for  the  pulmonary  engorge- 
ment which  it  is  our  purpose  to  antagonize.  Full  doses  10  to  15  grains  (0.6 
to  1.0  Gm.)  of  creosote  carbonate  (best  administered,  though  an  oil,  in  cap- 
sules) at  short  intervals,  i.e.,  every  two  or  three  hours  from  the  start,  give 
the  best  results. 

In  strong  plethoric  individuals,  the  arterial  tension  and  therefore  the 
pulmonary  congestion  are  such  that  additional  measures  are  necessary  to 
relieve  the  lungs  and  the  heart.  Sajous  recommends  veratrum  viride  or  the 
bromides  in  full  doses.  Both  of  these  drugs  depress  the  vasomotor  center 
and  by  thus  causing  the  great  splanchnic  area  to  contain  more  blood  it 
depletes  the  peripheral  organs  including  the  lungs. 

This  treatment  has  saved  many  valuable  lives,  and  its  benefits  will  be 
enormously  extended  when  the  senseless  and  murderous  "expectant"  plan 
will  have  been  dropped  by  the  wayside,  and  logical  reasoning  on  the  use  of 
remedies  will  have  replaced  empiricism. 


406 


ADIPOSIS  DOLOROSA. 


AMYL  NITRITE.  ACTION  OF. 


C^clopezdla  o!  Current  I^iterature 


ADIPOSIS   DOLOEOSA. 

Two  cases  that  came  to  autopsy  are 
reported  by  the  writer.  The  disease 
develops  gradually  in  most  cases;  occa- 
sionally rapidly  but  never  abruptly.  The 
cardinal  symptoms  are  (1)  fatty  deposit; 
(2)  pain  and  tenderness  on  manipulation 
of  the  adipose  deposits;  (3)  general 
asthenia;  (4)  psychic  phenomena.  The 
writer  differs  with  those  who  disregard 
alcoholism  and  syphilis  as  possible  eti- 
ologic  factors.  The  thyroid  has  been 
found  to  be  affected  in  7  of  the  8  recorded 
cases.  The  hypophysis  also  was  dis- 
tinctly aff'ected  in  5  cases,  and  had  been 
unexamined  microscopically  in  at  least  2 
of  the  remaining  3  cases.  It  has  been 
found  that  in  animals  when  the  thyroid 
is  extirpated  the  pituitary  body  enlarges. 
The  writer  thinks  that  sufficient  atten- 
tion has  not  been  given  to  the  hypophysis, 
and  suggests  that  etiologically  it  is 
almost  as  important  as  the  thyroid.  He 
suggests  that  the  symptom  group  may 
result  from  a  primary  disease  of  either 
of  those  structures,  the  other  being 
involved  secondarily,  though  their  close 
interrelations  have  been  noted  in  other 
structures,  particularly  the  genital  or- 
gans. Recovery  from  adiposis  dolorosa  is 
rare,  but  the  disease  itself  does  not 
directly  cause  death.  Complete  inter- 
missions are  but  remissions  and  are 
common. 

The  treatment  leaves  much  to  be 
desired.  The  salicylates  advantageously 
combined  with  bromid  salts  are  useful  to 
relieve  pain.  Aspirin  is  of  value.  Ex- 
tract of  the  thyroid  gland  is  the  most 
valuable  remedy  at  our  command.     The 


pituitary  body  at  present  has  little  value 
as  the  results  of  its  use  are  not  known. 
Potassium  iodid  is  called  for  with  a 
syphilitic  history.  The  heart  may 
require  attention.  G.  E.  Price  (Ameri- 
can Journal  Medical  Sciences,  May, 
1909). 

AMYL    NITEITE,    ACTION    OF,     ON     THE 
ARTERIES. 

In  health  amyl  nitrite  relaxes  the 
arteries  with  a  very  slight  drop  in  the 
diastolic  blood-pressure.  The  blood-pres- 
sure returns  at  once  to  normal  on  removal 
of  the  amyl  nitrite,  thanks  to  the  elas- 
ticity of  the  arteries.  In  arteriosclerosis 
the  diastolic  blood-pressure  drops  con- 
siderably although  the  heart  action  may 
be  stronger.  On  removal  of  the  amyl 
nitrite  conditions  return  only  very  slowly 
to  normal,  the  blood-pressure  not  return- 
ing to  its  former  height  until  after  half 
an  hour.  The  phenomena  observed  indi- 
cate that  the  higher  tension  in  arterio- 
sclerosis is  the  consequence  of  the  per- 
manent organic  contraction  and  immov- 
ability of  the  intestinal  arterial  system. 
The  true  essence,  therefore,  of  arterio- 
sclerosis is  the  lack  of  elasticity  in  the 
walls  of  the  intestinal  arteries.  The 
writer  has  the  patients  inhale  ten  drops 
of  amyl  nitrite  at  once,  and  has  never 
witnessed  any  threatening  symptoms 
from  it  in  several  hundred  experiments 
on  healthy  subjects.  He  has  also  found 
it  effectual  in  treatment  of  tuberculous 
haBmoptysis.  C.  v.  Ezentkowski  (Ziet- 
schrift  fiir  klinische  Medizin  Bd.  Ixviii, 
Nu,  1-2;  Journal  American  Medical 
Association,  Juno  12,  1909). 


ANJSMIA,  PERNICIOUS. 


ANGINA  PECTORIS. 


407 


ANiEMIA,   PERNICIOUS. 

Slight  evening  pyrexia  is  seldom 
absent  in  pernicious  ansemia  cases  that 
are  decidedly  ill.  Pigmentation  within 
the  mouth,  of  precisely  similar  charac- 
ter to  that  seen  in  Addison's  disease,may 
occur  in  pernicious  ansemia  cases  treated 
with  arsenic.  The  spleen  is  to  be  felt  in 
about  one-third  of  the  eases,  and  is  really 
enlarged.  The  nerve  symptoms  are  not 
at  all  uncommon  in  pernicious  anaemia. 
The  color  index  of  the  blood,  though 
typically  higher  than  when  an  advanced 
stage  of  the  disease  has  been  reached,  is 
not  always  or  continually  high  especially 
during  a  period  of  improvement  in  the 
patient's  condition,  when  it  may  be 
actually  low.  Pernicious  amemia  is  rery 
possibly  only  a  late  and  almost  incurable 
stage  of  a  disease  that  it  is  to  be  hoped 
will  some  day  be  recognizable  early 
enough  to  be  cured.  H.  French  ( Clinical 
Journal,  May  12,  1909). 

ANGINA    PECTORIS,    PAINLESS    AND 
PAINFUL. 

Painless  angina  is  much  more  com- 
mon than  one  would  suppose  it  to  be 
from  the  infrequency  vsdth  which  it  is 
mentioned;  but,  in  all  probability,  the 
disease  is  not  always  recognized,  and  the 
patient's  sufferings  are  attributed  to 
hysteria  or  some  reflex  disturbance. 
When  the  symptoms  are  accompanied 
by  a  dilated  right  heart  or  distinctly 
atheromatous  changes  the  diagnosis  is 
easy,  but  when  physical  signs  are  absent 
it  is  difficult  to  arrive  at  an  absolute 
opinion.  If,  when  free  from  the  parox- 
ysms, the  patient  continually  suffers 
from  a  feeling  of  weight  or  distress  over 
the  prgecordia,  and  has  a  tendency  to 
take  occasional  deep  inspirations,  there 
is  a  strong  probability  that  the  right 
ventricle  is  affected;  and  this  amounts 
to  certainty  if  the   symptoms   are  in- 


variably produced  or  aggravated  by  ex- 
ertion. This  form  of  angina  is  entirely 
different  from  the  painful  variety,  and 
in  many  instances  demands  a  diametric- 
ally opposite  treatment. 

The  cause  of  angina  pectoris  is  still 
a  matter  for  discussion,  but  in  all  proba- 
bility it  is  due  to  some  local  obstruc- 
tion in  the  coronar)''  circulation  which 
may  be  organic,  spasmodic,  or  a  com- 
bination of  both.  The  fact  that  the 
radial  pulse  varies  in  different  cases,  the 
pressure  being  sometimes  high  and  at 
other  times  low,  indicates  that  the  at- 
tacks cannot  invariably  be  attributed  to 
increased  resistance  in  the  peripheral 
circulation.  It  has  been  suggested  that 
angina  pectoris  is  due  to  strain  on  the 
heart  by  obstruction  in  the  arterial  sys- 
tem, and  that,  while  in  certain  cases 
the  vascular  pressure  may  be  actually 
low,  nevertheless  it  may  be  too  high  for 
the  capabilities  of  the  myocardium. 

The  treatment  of  those  two  forms  of 
angina  will  be  entirely  different  during 
the  seiziTres,  but  as  a  rule  it  is  identical 
between  the  parox}^sms.  Since  cardiac 
asthma  is  due  to  failure  of  the  right 
ventricle,  rapidly  acting  stimulants,  such 
as  caffeine,  camphor,  or  strophanthus, 
will  be  indicated  for  the  relief  of  the 
parox^'sra ;  while  angina  pectoris,  on  ac- 
count of  the  coronary  spasm,  will  call 
for  vasodilators  such  as  amyl  nitrite, 
nitroglycerin,  or  morphine.  It  not  in- 
frequently happens  that  the  subject  of 
coronary  spasm  is  also  suffering  from 
a  weak  heart,  and  under  such  circum- 
stances a  combination  of  heart  stimu- 
lant and  antispasmodic  is  demanded. 
Between  the  attacks  the  treatment  is 
that  which  has  been  recommended  in 
cases  of  chronic  myocarditis  and  ar- 
teriosclerosis. The  regulation  of  diet, 
in  regard  to  both  variety  and  quantity, 
so  that  the  circulation  never  will  he 


408 


BISMUTH  POISONING. 


CEREBROSPINAL  MENINGITIS. 


overloaded  with  food  or  waste  material, 
is  of  the  greatest  importance.  Avoid- 
ance of  mental  and  physical  strain  and 
the  regulation  of  exercise  in  accordance 
with  the  capabilities  of  each  individual 
case  must  be  carefully  observed. 

The  administration  of  arsenic  and 
the  prolonged  use  of  iodides,  in  small 
doses,  for  a  period  of  several  months 
will  be  found  in  many  instances  to  have 
a  very  beneficial  effect  on  both  the  car- 
diac muscle  and  the  blood-vessels.  And 
last,  the  judicious  use  should  never  be 
neglected  of  remedies  which  will  aid  in 
eliminating  by  their  natural  channels 
all  toxic  substances  resulting  from 
physiological  activity  or  food  metabol- 
ism. W.  W.  Kerr  (Journal  American 
Medical  Association,  May  29,  1909). 

BISMUTH  POISOinNG. 

The  following  symptoms  are  pro- 
duced by  bismuth:  Blackish  discolora- 
tion of  the  mucous  membranes  of  the 
digestive  tract,  inflammation  of  the 
tissues  in  the  mouth,  with  swelling, 
excoriation  or  croupous  changes,  saliva- 
tion and  loosening  of  the  teeth,  nausea, 
pains  along  the  oesophagus,  dysphagia, 
vomiting,  distention  of  the  abdomen, 
diarrhoea,  diminution  of  the  quantity  of 
urine,  albuminuria,  cylindruria,  desquam- 
ative nephritis  and  parenchymatous 
degeneration  of  the  kidney,  disturb- 
ances of  the  pulse,  singyltus,  coldness 
of  the  body,  dyspnoea,  cyanosis,  collapse, 
headache,  fever  and  delirium.  The 
writer  suggests  magnetic  iron  oxide  as 
a  substitute  for  X-ray  absorption, 
Lewin  (Miinchener  medizinische  Woch- 
enschrift,  March  30,  1909). 

BRONCHIAL  ASTHMA,  ATROPINE  IN  THE 
TREATMENT  OF. 
The  writer  speaks  for  the  wider  use  of 
atropine  in  the  treatment  of  bronchial 


asthma.     He    believes    it    exceedingly 
valuable    for    certain    cases,    especially 
those  with  a  marked  neurotic  element. 
The  histories  of  seven  severe  cases  of 
bronchial   asthma   treated  by   atropine 
with  very  encouraging  results  are  cited. 
In  one  of  these  cases  the  author  not 
only  succeeded  in  arresting  the  acute 
attacks,  but  the  patient  was  so  much 
improved  that  there  was  no  recurrence 
of  attacks  for  ten  months.     Previously 
this   patient   had   been   constantly  af- 
fected for  twenty  years.    He  prescribes 
atropine  in  pills,  each  pill  containing 
0.0005  gram  (K20  grain).  One  pill  a  day 
is  first  given,  then,  after  two  or  three 
days,  the  dose  is  gradually  increased  to 
a  total  of  from  four  to  six  pills  a  day. 
When  this  amount  has  been  reached, 
the  amount  is  gradually  reduced  to  one 
pill  a  day.     The  writer  believes  that 
atropine  not  only  will  arrest  an  attack, 
but  it  also  will  prevent  a  recurrence. 
One  great  advantage  is  that  atropine 
can  be  advantageously  used  as  a  sub- 
stitute for  morphine,  or  may  be  alter- 
nated with  morphine.     Terray  (Medi- 
zinische Klinik,  Bd.   iii,  S.  79,   1909; 
American    Journal    Medical    Sciences, 
Jime,  1909). 

CEREBROSPINAL  MENINGITIS,  EPIDEMIC. 

Seeing  that  tuberculous  meningitis  is 
the  one  with  which  the  diagnosis  of 
epidemic  cerebrospinal  meningitis  is 
liable  to  be  confounded,  the  writer  notes 
the  following  differentiation:  In  the 
epidemic  form  the  onset  is  sudden, 
while  in  the  tuberculous  type  it  is  slow. 
Temperature,  eyes,  and  pulse  are  about 
the  same  in  each  disease.  The  tempera- 
ture in  the  tuberculous  variety  may 
correspond  more  nearly  to  the  tubercu- 
lous type  of  fever.  Neck  symptoms, 
Kernig's  sign;  spasm  of  the  extremities 
and  paralysis,  are  more  marked  in  the 


EXOPHTHALMIC  GOITER. 


FEVER  IN  INFECTION",  ACTION  OF. 


409 


epidemic  form.  Cerebral  pressure,  as 
shown  by  the  fontanelles,  is  more 
marked  in  the  epidemic  type.  There  is 
a  high  leucocyte  count  in  the  epidemic 
type,  while  there  is  a  low  count  in  the 
tuberculous  variety.  We  have  the  his- 
tory of  an  epidemic  variety,  and  a  his- 
tory of  tuberculosis  in  the  tuberculous 
form.  In  the  epidemic  variety  the  cere- 
brospinal fluid  is  turbid  and  contains 
polymorphonuclear  leucocytes  in  excess, 
and  the  meningococcus.  In  the  tuber- 
culous type  the  fluid  is  clear  and  con- 
tains lymphocytes  in  excess  and  the 
tubercle  bacilli.  W.  M.  McCabe  (South- 
em  Medical  Journal,  April,  1909), 

EXOPHTHALMIC    GOITER    AND    PREG- 
NANCY. 

Basedow^s  disease  is  a  rare  complica- 
tion of  pregnancy,  and  it  exerts  a 
pernicious  influence  upon  that  condi- 
tion. Cases  which  have  been  reported 
show  important  kidney  symptoms,  in- 
cluding albuminuria,  glycosuria,  and 
renal  casts.  Vomiting  and  diarrhoea 
are  also  of  common  occurrence.  Skin 
lesions  are  profuse  perspiration,  eryth- 
ema, urticaria,  CEdema,  and  falling  of 
the  hair.  The  condition  of  the  heart 
and  arteries  predispose  to  spontaneous 
abortion,  premature  separation  of  the 
placenta,  and  postpartum  haemorrhage. 
The  heart  may  be  dilated,  its  valves  in- 
sufficient, its  muscle  the  seat  of  fatty 
degeneration.  A  pregnant  patient  with 
goiter  may  grow  rapidly  worse  as  preg- 
nancy progresses,  and  die  in  the  early 
months  under  conditions  similar  to 
those  with  the  pernicious  vomiting  of 
pregnancy.  Or  the  bad  symptoms  may 
be  in  abeyance  during  pregnancy  and 
recur  after  delivery.  Recurring  preg- 
nancy is  unfavorable  in  those  who  have 
goiter.  The  foetal  mortality  is  higher 
than  the  maternal.     If  the  bad  symp- 


toms are  not  promptly  relievable,  preg- 
nancy should  be  terminated.  The 
thyroid  gland  should  not  be  extirpated 
during  pregnancy.  H.  M.  Stowe  (Ameri- 
can Journal  of  Obstetrics,  May,  1909). 

FEVER  IN  INFECTION,  ACTION  OF. 

The  generally  accepted  opinion  in  re- 
gard to  febrile  temperatures  is  that 
they  are  part  of  the  defenses  of  the 
organism,  but  certain  injury  is  con- 
nected with  them,  which  compels  us, 
under  some  circumstances,  to  strive  to 
reduce  the  febrile  temperature.  In  in- 
fectious diseases  there  is  increased  de- 
struction of  albumin,  both  as  a  result  of 
the  high  temperature  and  as  a  result  of 
the  causes  inducing  the  fever.  With  a 
temperature  under  104  F.  the  share  of 
the  fever  in  this  increased  destruction 
of  albumin  is  comparatively  so  small  as 
to  be  negligible.  The  changes  in  the 
corpuscles  and  in  the  proportion  of 
haemoglobin  are  the  work  of  the  infec- 
tious cause,  and  are  not  the  results  of 
the  increased  temperature.  The  au- 
thor's experiments  show  that  the  agglu- 
tinins are  increased  in  the  heated 
rabbits;  the  higher  temperature  favors 
the  production  of  agglutinins,  as  also 
of  antitoxins  and  bacteriolysins.  On 
the  whole,  he  concludes,  the  febrile 
temperature,  if  not  excessive,  must  be 
regarded  as  a  process  which  does  much 
more  good  than  harm.  It  is  a  manifes- 
tation of  the  efforts  of  the  organism  to 
neutralize  or  get  rid  of  the  invading 
bacteria  or  toxins.  Fever  under  104° 
F.  should  not  be  combated  unless  in 
case  of  severe  disturbances  of  the  cen- 
tral nervous  system,  such  as  headaches, 
stupor  or  excitement.  Antipyretic 
measures  in  these  cases  are  not  directed 
against  the  high  temperature  so  much 
as  against  the  other  symptoms.  If  anti- 
pyretic measures  become  necessary  they 


410        FUEUNCULOSIS  AND  PEMPHIGUS. 


INTESTINAL  OBSTRUCTION. 


should  not  be  too  severe,  merely  tepid 
baths  with  mild  spongings,  and,  pos- 
sibly, a  moderate  use  of  antipyretic 
drugs,  never  cold  baths,  according  to 
Brand  or  Liebermeister.  F.  Eolly 
(Miinchener  medizinische  Wochen- 
schrift,  April  13,  1909;  Journal  of  the 
American  Medical  Association,  May  29, 
1909). 

rURTTNCTJLOSIS    AND    PEMPHIGUS    IN 
CHILBREN,    SWEATING    AND    MER- 
CTJUIAL  BATHS  FOB,. 
The  author  has  applied,  on  a  large 
scale,    licwandowsky's   method    of    dis- 
lodging  the    staphylococci   from    their 
nests  in  the   horny  layer  of  the   skin 
where  they  start  the  abscesses.    This  is 
accomplished  by  vigorous  sweating;  the 
staphylococci  thus  drawn  forth  are  then 
killed  by  immersing  the  child  in  a  bath 
of    1    to    10,000   solution   of   mercuric 
chlorid.     The  child  is  first  given  a  hot 
bath,   and  then  the  pack,  with  warm 
drinks,  and,  possibly,  from  0.2  to  0.3 
Gm.  (3  to  5  grains)  aspirin.     The  fur- 
uncles are  opened  and  sponged  out  in 
the  bath,  and  the  body  lightly  rubbed. 
The  child  is  then  rinsed  off,  wiped  dry, 
and  dusted  with  talcmn  powder.     This 
procedure  is  repeated  every  day  for  two 
or  three  days,  the  loss  of  fluids  being 
compensated  by  plenty  of  warm  drinks. 
The  children  tolerate  the  sweating  and 
baths  well,  and  in  a  number  of  cases  in 
which  all  other  measures  had  proved  in- 
effectual, the  furunculosis  was  cured  by 
the  end  of  one  or  two  weeks,  and  the 
general   health  much   improved  under 
the  cautious  diet.     This  treatment  has 
proved  successful  even  with  very  frail 
infants   suffering  from   general  furun- 
culosis.   The  same  method  has  been  ap- 
plied with  excellent  results  in  the  acute 
pemphigus    of    the    new-born,    supple- 
mented by  application  of  a  mixture  of 


5  parts  iciiihyol  and  5  parts  glycerin  in 
100  parts  water.  A.  Eeiche  (Thcrapeu- 
tisclie  Monatschefte,  May,  1909;  Jour- 
nal of  the  American  Medical  Associa- 
tion, June  12,  1909). 

INTESTINAL  OBSTHTJCTION. 

The  writer  considers  that  intestinal 
obstruction  is  due  to  prevention  of  the 
normal  interrelations  and  coordination 
of  secretions  of  different  parts  of  the 
intestinal    tract.      He    shows    evidence 
that  the  cause  of  shock  in  these  cases 
cannot  be  attributed  to  traumatic  ef- 
fects upon  the  nervous  system  or  to 
bacterial  action,  except  in  some  cases 
where  the  obstruction  is  low.    Intestinal 
obstruction  is  known  to  be  productive 
of  more  severe  symptoms  the  higher  up 
in  the  intestinal  tract  it  occurs.     In  a 
large    number    of   animal    experiments 
the  writer  showed  that  the  symptoms 
are  most  severe  if  the  obstruction  is  less 
than    35    centimeters    from    the    duo- 
denal papilla,  and  much  less  severe  if 
the  obstruction  is  more  than  35  centi- 
meters   from    tliis    point.      When    the 
obstruction  is  close  to  the  duodenum 
the  animal  dies  with  s5'mptoms  similar 
to  those  of  tetany.     The  writer,  there- 
fore, suspects  that  in  high  obstructions 
gome  toxic  substance  is  present  which 
fails  to  be  neutralized  by  a  hypothetical 
normal  antibody.     "With  the  bile  con- 
ducted by  tube  into  the  lower  portion 
of   the  gut,   no  change  in  results   oc- 
curred.   But  when  the  pancreatic  secre- 
tion   was    conducted    into    the    lower 
segment  the  fatal  symptoms  failed  to 
appear.     Thus,  while  the  evidence  is  as 
yet  not  conclusive,  it  is  suggested  that 
death  in  high  intestinal  obstruction  is 
due  to  the  toxic  action  of  a  pancreatic 
product,  possibly  trypsin,  which  is  de- 
prived of  its  normal  antibody.    In  treat- 
ment, irrigation   into  a  stoma  of  the 


LEUCORRHCEA. 


MYOCAHDIAL  INCOMI^ETENCE. 


411 


duodenum  upward  and  out  of  an 
oesophageal  tube  is  suggested.  J.  W.  D. 
Maury  (American  Journal  Medical  Sci- 
ences, May,  1909). 

IETJCOaB,H(EA,  TREATMENT  OF. 

The  writer  deplores  the  present  cus- 
tom of  treating  leucorrhoea  with  dou- 
ches, etc.,  stating  that  the  same 
principle  should  be  applied  here  as  to 
other  secreting  lesions,  that  is,  to  ab- 
sorb the  secretion  and  keep  the  surface 
dry,  thus  giving  the  parts  a  chance  to 
heal.  This  is  accomplished  by  dusting 
with  a  dry  powder,  and  for  which  the 
writer  has  found  bolus  alba  the  most 
convenient,  inerpensive  and  effectual. 
The  powder  is  applied  at  the  same  time 
the  walls  of  the  vagina  are  distended 
with  air,  thus  smoothing  out  all  the 
folds  and  recesses.  This  is  accom- 
plished with  a  pear-shaped  glass  bulb 
with  a  reservoir  opening  into  a  tube 
which  passes  through  the  glass  pear  con- 
nected with  a  rubber  bulb.  The  glass 
bulb  closes  the  entrance  to  the  vagina 
air-tight,  and  pressure  on  the  rubber 
bulb  fills  the  vagina  with  air,  and  at  the 
same  time  sprays  it  with  the  dry  pow- 
der. The  author  calls  this  little  ap- 
paratus a  "siccator,"  and  has  obtained 
good  results  with  it  in  100  cases.  About 
once  a  week  a  cleansing  douche  is  or- 
dered, followed  by  the  dry  powder. 
Good  results  were  also  obtained  in  acute 
gonorrhoeal  affections,  senile  colpitus, 
inoperable  cancer,  etc.  M.  Nassauer 
(Miinchener  niedizinische  Wochen- 
schrift,  April  13,  1909;  Journal  of  the 
American  Medical  Association,  May  29, 
1909). 

MATERNAL    MILK    AS    AN    IMrMTJNIZING 
AGENT  TO  THE  NURSLING. 
The  prevailing  custom  of  considering 
only  the  nutritional  values  of  milk  and 


other  forms  of  food  used  in  the  artificial 
feeding  of  infants  is  partly  responsible 
for  the  great  mortality  that  prevails 
among  them,  especially  during  the  first 
year.  The  protection  of  the  infant 
against  infection  depending  in  no  small 
degree  upon  bactericidal  and  antitoxic 
substances  physiologically  supplied  to  it 
in  the  maternal  milk,  the  protective 
properties  of  any  artificial  food  should 
receive  attention  as  well  as  its  nutri- 
tional values.  All  phases  of  the 
problem  indicate  that,  of  the  various 
modes  of  feeding,  direct  maternal  nurs- 
ing affords  the  greatest  protection  to  the 
infant;  it  follows,  therefore,  that  all 
should  be  done  in  our  power  to  promote 
the  abandonment  of  artificial  feeding, 
and  thus  reduce  greatly  the  mortality 
among  infants.  L.  T.  de  M.  Sajous 
(University  of  Pennsylvania  Medical 
Bulletin,  June,  1909). 

MYOCARDIAL   INCOMPETENCE,    CHRONIC 
CHOLECYSTITIS  AS  A  CAUSE  OF. 

The  writer  reports  eleven  cases  di- 
vided into  four  groups.  A  healthy 
heart  muscle  may  endure  such  a  dis- 
turbing influence  or  may  recover  quicldy 
from  its  derangement  of  function.  A 
myocardium,  already  the  seat  of  struc- 
tural disease,  on  the  contrary,  is  seri- 
ously affected  by  conditions  of  strain  or 
by  illness,  which  otherv/ise  would  prove 
harmless.  Therefore,  since  chronic  in- 
fection of  the  gall-bladder  manifests 
itself  chiefly  in  persons  at  or  past  mid- 
dle age,  when  presumably  the  heart 
muscle  is  no  longer  so  able  to  resist  at- 
tacks, there  are  furnished  the  condi- 
tions capable  of  producing  the  symptom 
complex  reported  in  these  cases.  The 
explanation  of  the  baneful  effects  on 
the  heart  of  some  cases  of  gall-bladder 
disease  and  not  of  others  is  hypotheti- 
cal,   and    accordingly    several    theories 


412 


MYOPATHY  AND  SYEINGOMYELIA. 


NITRITES. 


may  be  advanced:  (1)  The  circulation 
in  the  blood  of  bacteria  or  their  toxines ; 
(2)  the  depressing  influence  of  bile  con- 
stituents on  the  myocardium;  (3)  dis- 
turbance of  the  splanchnic  circulation 
and  secondarily  of  the  systemic  circula- 
tion and  heart;  (4)  a  reflex  inhibition 
through  irritation  of  the  vagus.  It  is 
quite  possible  that  a  different  explana- 
tion is  applicable  to  different  cases,  and, 
moreover,  that  there  must  be  a  predis- 
posing cause  residing  in  the  heart  mus- 
cle, that  is,  chronic  myocarditis,  in 
consequence  of  which  the  heart  is  un- 
favorably affected  by  influences  which  a 
healthy  myocardium  would  be  able  to 
resist.  R.  H.  Babcock  (Journal  of  the 
American  Medical  Association,  June  12, 
1909). 

MYOPATHY  AND  SYEINGOMYELIA. 

These  two  maladies  ought  not  to  be 
confounded,  although  they  are  both  dis- 
eases of  development.  The  one  is  de- 
fective structural  formation  in  the 
spinal  cord,  whereby  cavities  are  left  in 
the  process  of  its  development  or  por- 
tions of  embryonic  neuroglial  tissue  fail 
to  achieve  their  change  into  nerve  ele- 
ments, but  remain  as  tracts  of  low  con- 
sistence, which  break  down  into  cavities. 
These  enlarge  by  distention,  and  thus 
cause  symptoms,  or  the  residual  tissue 
may  increase  by  a  slow  process  of 
growth.  Myopathy,  or  muscular  dys- 
trophy, is  a  defect  of  muscular  growth, 
not  dependent  on  the  nervous  system, 
but  inherent  in  the  muscles,  by  which 
the  fibers  fail,  sometimes  early  in  life, 
sometimes  later.  The  interstitial  tis- 
sue grasps  the  nutritional  influence  and 
increases,  but  not  enough  to  compensate 
for  the  defect  in  the  fibers,  unless  fat 
forms  among  them,  when  the  bulk  of 
the  feeble  muscles  may  be  much  in- 
creased.    This  is  the  case  in  the  early 


variety,  the  pseudohypertrophic  form, 
which  is  known  best;  in  tliis  the  mus- 
cles vary  in  size,  the  calves  being  usually 
largest,  the  extensors  of  the  knees  often 
increase  in  size  in  the  lower  part,  the 
infraspinati  are  large,  the  lower  parts 
of  the  pectoralis  and  the  latissimus 
dorsi  are  small,  and  often  they  seem 
almost  absent.  The  face  is  free.  This 
form  affects  chiefly  males,  females  sel- 
dom; sometimes  all  the  males  of  a 
family  suffer,  and  all  the  females  escape, 
but  transmit  the  disease  to  their  sons. 
The  malady  increases  in  degree  and  ex- 
tent as  its  subjects  grow  up;  it  impairs 
the  power  of  breathing  until  some  pul- 
monary disease  develops;  or  it  may  be 
some  slight  catarrh,  which  would  be  a 
trifle  to  a  normal  individual,  that  ends 
the  feeble  life  soon  after  adult  age  has 
been  attained.  But  there  are  other 
forms  of  myopathy  which  do  not  pre- 
sent the  increased  size  of  muscles.  On 
the  contrary,  all  or  most  lessen  in  size, 
though  often  not  to  the  same  degree  as 
in  spinal  atrophy.  A  more  abundant 
growth  of  the  interstitial  tissue  takes 
place,  but  it  does  not  become  the  seat 
of  fat  formation,  partly,  perhaps,  be- 
cause the  change  usually  takes  place 
after  the  period  of  growth  is  over.  The 
author  reports  two  cases  in  which  he 
demonstrates  the  distinctive  points  of 
myopathy  and  syringomyelia.  W.  R. 
Gowers  (British  Medical  Journal,  May 
8,  1909). 

NITEITES,  LOWERING  OF  BLOOD-PRES- 
SURE BY. 
Experiments  by  the  authors  with 
amyl  nitrite,  nitroglycerin,  sodium  ni- 
trite, and  erythrol  tctranitrite  show 
that  these  substances  all  cause  a  uni- 
form percentage  fall  of  blood-pressure; 
the  higher  the  blood-pressure  the 
greater  the  fall.    The  effect  is,  within 


PANCREATIC  GLYCOSURIA. 


RACHITIS  FROM  LIME  STARVATION.       413 


certain  limits,  directly  proportionate  to 
the  size  of  the  dose.  While  the  effect 
of  amyl  nitrite  inhalations  is  almost  in- 
stantaneous, the  action  of  nitroglycerin, 
given  by  mouth,  begins  in  about  two 
minutes,  and,  therefore,  nothing  is 
gained  by  resorting  to  the  hypodermic 
use  of  this  drug.  Headache  following 
the  administration  of  the  nitrite  seldom 
occurs  when  the  blood-pressure  is 
originally  high.  Even  very  sclerotic 
arteries  respond  readily  to  nitrites,  and 
in  patients  with  arterial  hypertension 
the  effect  lasts  much  longer  than  is  the 
case  with  normal  individuals.  Thus  the 
duration  of  the  action  of  erythrol  tetra- 
nitrite  in  this  series  with  hypertension 
averaged  three  hours,  the  minimum  be- 
ing reached  in  one  hour,  while  in  nor- 
mal individuals  the  action  lasted  for  an 
hour  only.  The  action  of  sodium 
nitrite  lasts  one  hour  in  the  normal  man 
and  two  in  men  with  high  blood-pres- 
sure. Nitroglycerin  seems  to  last  about 
one-half  hour  in  either  case. 

The  writers  have  found  the  most  ef- 
fective method  of  exhibiting  these  drugs 
to  be  as  follows:  Amyl  nitrite  by  in- 
halation, nitroglycerin  in  the  official  1- 
per-cent.  solution,  sodium  nitrite  in 
freshly-made  solution,  and  erythrol  in 
chocolate  tablets.  G.  B.  Wallace  and  A. 
S.  Einger  (New  York  Medical  Journal, 
June  12,  1909). 

PANCEEATIC  GLYCOSURIA,  RELATION  OF 
THE  THYROID  AND  ADRENALS  TO. 
The  parathyroids  play  so  important  a 
part  in  the  carbohydrate  metabolism 
that  the  simultaneous  removal  of  the 
pancreas  and  thyroids,  when  the  para- 
thyroids are  not  considered,  can  give  no 
conclusive  results.  Nothing  definite 
can  be  proved  concerning  the  inter- 
relation of  the  pancreas  and  adrenals  by 
their  simultaneous  removal.     Removal 


of  the  adrenals  greatly  increased  the 
activity  of  the  pancreas,  at  least  with 
regard  to  its  "external"  secretion.  The 
injection  of  secretin  after  removal  of 
the  adrenals  gives  more  marked  results 
than  while  the  adrenals  are  in  place. 
The  pancreas  is  completely  under  the 
control  of  hormones.  The  hormone 
called  secretin  actively  stimulates,  and 
apparently  the  hormone  of  the  adrenals 
inhibits,  its  activity.  C.  H.  Stone  (Uni- 
versity of  Pennsylvania  Medical  Bulle- 
tin, June,  1909). 

RACHITIS  FROM  LIME  STARVATION. 

The  deficit  in  lime  may  result  from 
inadequate  intake  or  from  defective  ab- 
sopption  with  normal  intake.  Breast- 
milk  may  be  deficient  in  lime,  and  it  is 
important  to  note  the  lime  contents  of 
breast-milk,  as  well  as  its  proportion  of 
fat,  albumin  and  carbohydrates.  It  is 
possible  that  a  preparation  of  lime, 
phosphorus  and  codliver  oil  might  in- 
crease the  retention  of  lime,  although 
in  the  writer's  experience  no  benefit  was 
derived  from  them  except  in  rachitis. 
It  is  important  to  change  the  wet-nurse 
in  case  the  lime  content  of  the  breast- 
milk  cannot  be  kept  normal.  If  coVs 
milk  is  given,  it  should  not  be  diluted 
too  much,  giving  at  least  one-third  milk. 
The  slightest  deviation  from  normal  in 
digestion  or  the  digestive  tract  should 
be  promptly  treated  to  ward  off  disturb- 
ances in  the  intestinal  functions  which 
might  affect  the  lime  metabolism  un- 
favorably. Eachitis  due  to  lime  star- 
vation is  liable  to  induce  clinical 
phenomena  more  readily  than  true 
rachitis,  but  severe  rachitic  disturb- 
ances in  a  child  exclude  the  pseudo- 
rachitis  from  lime  starvation.  During 
the  onset  of  rachitis  there  is  increased 
elimination  of  lime  and  phosphorus,  the 
latter   predominating,   but   in   pseudo- 


414 


SCARLET  FEVER  CARRIERS. 


TUBERCULOSIS,  INCIPIENT. 


rachitis  from  lime  starvation  the  elirai- 
Eation  of  lime  predominates.  J.  A. 
Schabad  (Berliner  klinische  Wochen- 
sehrift,  May  3,  1909;  Journal  of  the 
American  Medical  Association,  June  5, 
1909). 

SCARLET  FEVER  CARRIERS. 

The  writer  believes  that  desquama- 
tion is  an  unimportant  factor  in  the 
spread  of  scarlet  fever.  He  has  often 
seen  desquamating  children  play  with 
other  children,  who  did  not  contract  the 
disease.  Infected  rooms  are  much  more 
commonly  at  the  bottom  of  furthering 
the  disease.  Another  factor  is  the 
throat  of  an  individual  not  really  ill 
with  the  disease,  but  acting  as  host  to 
the  microorganisms.  The  most  impor- 
tant cause,  however,  lies  with  the  pa- 
tients themselves,  who  may  retain  the 
causal  agent  for  a  long  time  (even 
months)  in  the  secretions  and  dis- 
charges of  the  nose,  mouth,  ear,  etc. 
From  30  to  50  per  cent,  of  convalescing 
scarlet  fever  patients  have  discharging 
noses  and  ears.  Mild  scarlet  fever  cases 
are  often  not  diagnosticated,  but  may 
still  act  as  scarlet  fever  carriers  through 
the  discharges  mentioned.  Isolation 
should  be  strictly  enforced  during  an 
epidemic,  and  the  children  of  a  family 
having  a  scarlet  fever  patient  should 
not  be  permitted  to  attend  school. 
Nasal  and  oral  hygiene  should  be  en- 
forced; adenoids,  tonsils,  and  carious 
teeth  removed  or  treated.  Disinfection 
of  the  premises  after  scarlet  fever 
should  never  be  neglected.  C.  Herr- 
man  (Archives  of  Pediatrics,  vol.  xxvi, 
p.  112,  1909). 

TUBERCLE    BACILLI,    HUMAIT    AND 
BOVINE. 
Human  and  bovine  tubercle  bacilli  are 
distinctlv    different   in    most   of   their 


characteristics.  The  human  subject 
may  become  the  host  for  either  form  of 
tuberculous  infection,  human  or  bovine. 
Likewise,  the  bovine  may  be  inoculated 
in  the  same  way  and  under  like  condi- 
tions. Tuberculous  infection  of  the  re- 
spiratory tract  will  usually  be  found  to 
be  due  to  bacilli  of  the  human  type, 
while  those  of  the  bones,  joints,  and 
lymphatics  are  likely  to  be  due  to  bacilli 
of  the  bovine  type. 

From  clinical  study  of  cases  treated 
during  the  past  five  years,  the  writer 
concludes  that  an  antitoxic  vaccine  or 
lymph  may  be  derived  from  the  bovine 
which  has  been  previously  immunized 
through  the  administration  of  attenu- 
ated doses  of  tubercle  bacilli.  Also  that 
this  immunity  may  be  accomplished 
through  the  use  of  either  human  or 
bovine  tubercle  bacilli  in  the  emulsion 
which  is  used  for  immunizing  purposes. 
G.  B.  Sweeny  (New  York  Medical  Jour- 
nal, June  19,  1909). 

TUBERCULOSIS,  INCIPIENT. 

The  writer  considers  that  too  many 
wait  imtil  bacilli  are  present  in  the 
sputum  before  making  up  their  minds 
as  to  the  diagnosis  of  tuberculosis.  One 
has  to  be  constantly  on  guard  for  the 
incipient  signs,  loss  of  weight,  failing 
appetite,  general  debility,  and  increased 
pulse  rate,  and  a  daily  slight  elevation 
of  temperature,  or  many  cases  of  in- 
cipient disease  will  escape  notice.  Re- 
peated examinations  of  the  chest  may 
have  to  be  made  before  distinct  signs 
are  detected.  Of  these,  one  of  the 
earliest  is  a  change  from  the  continu- 
ous, breezy,  inspiratory  rhythm  to  an 
interrupted,  cog-wheel  rhythm.  Next 
in  importance  is  the  finding  of  fine, 
crepitant  rales  on  inspiration.  Cough 
may,  or  may  not,  be  present.  Hsemop- 
tysis,  when  present,  is  most  important. 


BOOK  REVIEWS.  415 

Ninety  per  cent,  of  cases  of  haemoptysis  be  much  more  prevalent  among  infants 
are  said  to  be  followed  sooner  or  later  and  children  than  it  was  formerly  snp- 
by  evidences  of  pulmonary  tuberculosis,  posed  to  be.  He  particularly  empha- 
Percussion  of  the  chest  is  frequently  sizes  the  fact  that  fine  crackling  rales 
negative  in  the  incipient  stage.  One  of  often  constitute  the  only  physical  signs 
the  most  reliable  signs  of  consolidation  to  be  found  in  incipient  cases  of  pul- 
ls the  whispering  voice  sign.  monary  tuberculosis,  and  if  they  are 
The  writers  experience  has  led  him  persistently  localized  in  one  long,  they 
to  believe  that  the  ophthalmic  test  is  may  be  considered  almost  pathogno- 
much  less  reliable  than  the  hypodermic  monie  of  this  disease.  C.  H.  Johnston 
test  in  incipient  disease.  Eecent  in-  (Journal  Michigan  State  Medical  So- 
vestigations  have  shown  tuberculosis  to  ciety.  May,  1909). 


5ool<  Reviews 


Book  ox  The  Physician  Himself  and  Tilings  That  Concern  His  Reputation  and  Success.  By 
D.  W.  Cathell,  M.D.,  the  Tw^entieth  Century  Edition.  Revised  and  Enlarged  by  the 
Author  and  His  Son,  William  T.  Cathell,  A.M.,  M.D.,  Baltimore,  Maryland.  Philadel- 
phia:   F.  A.  Davis  Company,  Publishers,  1908.     Price,  $2.50, 

This  valuable  book  has  been  so  long  before  the  public,  and  has  received,  through  a  num- 
ber of  editions,  such  commendatory  consideration  from  leading  men  of  the  medical  profession 
that  the  new,  or  twentieth  century  edition,  hardly  needs  a  formal  introduction,  other  than 
that  it  has  been  carefully  revised,  new  material  added,  and  many  new  and  valuable  suggestions 
introduced.  As  in  previous  editions,  the  various  phases  of  the  doctor's  life  is  considered  in 
detail,  and  many  points  which  often  open  up  avenues  for  bitter  disputes,  and  not  infrequently 
cause  a  breach  in  the  closest  of  friendships,  are  treated  in  the  most  skilful  manner.  Nothing 
is  more  iriiportant  to  the  young  physician  than  a  right  beginning,  for  it  is  at  this  time  that 
ho  is  laying  the  foundation  which  is  to  determine  a  career  of  success  or  failure, 

"For  thus  the  world  goes  round  and  round, 
Some  go  up  and  some  go  down." 

It  seems  impossible  for  any  man,  whether  he  be  young  or  old  in  the  practice  of  medicine, 
to  read  this  book  and  not  finish  it  with  loftier  motives,  a  purer  heart,  and  a  higher  regard 
for  the  responsibilities  in  the  noble  profession  which  he  represents. — R.  B.  S. 

Diseases  of  the  Skin  and  the  Ebuptive  Fevers.  By  Jay  Frank  Schamberg,  M.D.,  Professor 
of  Dermatology  and  Infectious  Eruptive  Diseases  in  the  Philadelphia  Polyclinic  and  Col- 
lege for  Graduates  in  Medicine.  Octavo  of  534  Pages,  Illustrated.  Philadelphia  and 
London:    W.  B.  Saunders  Company,  1908.     Cloth,  $3.00  net. 

If  there  ever  was  a  book  written  to  supply  the  general  practitioner  precisely  what  he 
needs  in  the  field  of  dermatology,  Sohamberg's  certainly  was.  Not  an  unnecessary  word  has 
been  used,  and  yet  each  subject  is  replete  with  information  calculated  to  give  a  clear  insight 
into  the  nature  of  the  disease — besides,  of  course,  its  synvptoms,  diagnosis,  etiology  and 
prognosis — and  its  treatment.  The  latter  includes  those  measures  which  have  been  found  of 
exceptional  value  by  the  author.  The  diagnosis  is  greatly  fa-cilitated  by  the  numerous  and 
excellent  illustrations  that  the  book  contains.  Syphilodermata  are  very  properly  given  con- 
siderable space,  both  the  acquired  and  congenital  forms  being  treated  at  length.  The  acute 
eruptive  fevers,  especially  small-pox,  are  treated  at  considerable  length,  and  constitute  a  most 
valuable  addition  to  the  work,  owing  to  its  author's  vast  experience. 


416 


BOOK  REVIEWS. 


Refraction  and  How  to  Refract,  Including  Sections  on  Optics,  Retinoscopy,  Tlie  Fitting  of 
Spectacles  and  Eye-glasses,  etc.  By  James  Thorington,  A.M.,  M.D.,  Professor  of  Diseases 
of  the  Eye  in  the  Philadelphia  Polyclinic  and  College  for  Graduates  in  Medicine;  Mem- 
ber of  the  American  Ophthalmological  Society;  Fellow  of  the  College  of  Physicians  of 
Philadelphia,  etc.  Fourth  Edition.  Two  Hundred  and  Twenty  Illustrations,  Thirteen 
of  which  are  Colored.     Philadelphia:    P.  Blakiston's  Son  &  Co.,  1909.     Price,  $1.50  net. 

In  this  attractive  book  of  324  pages  are  set  forth  clearly  the  essential  facts  bearing  on  the 
diagnosis  and  correction  of  the  mechanical  ocular  defects.  The  author  has  sought  to  make 
the  text  readable  and  easily  understood  by  omitting  all  complex  mathematical  considerations, 
and  to  present  the  subject  in  the  most  practical  and  useful  manner  for  both  practitioners  and 
students.  The  first  chapter  very  properly  deals  with  optics,  forming  a  basis  for  the  under- 
standing of  the  methods  of  diagnosis  and  treatment  which  follow.  Chapter  II  considers  the 
mechanism  of  vision  in  the  normal  eye,  and  the  means  of  determining  visual  acuity  and  the 
powers  of  accommodation  and  convergence.  Several  forms  of  test-type  are  illustrated.  The 
ophthalmoscope  and  its  methods  of  use — direct  and  indirect — are  next  described.  The  various 
forms  of  ametropia — hyperopia,  myopia,  and  astigmatism — are  then  given,  the  causes,  varie- 
ties, symptoms  and  diagnosis  of  each  form  being  considered.  No  less  than  sixteen  methods 
available  in  the  diagnosis  of  astigmatism  are  mentioned,  including  a  large  variety  of  astig- 
matic charts.  Chapter  VI  discusses  retinoscopy  and  its  application  in  the  several  forms 
of  ocular  defect.  Chapter  VII  considers  the  disorders  of  the  extrinsic  eye-muscles.  Succeed- 
ing chapters  include  the  uses  of  mydriatics,  asthenia,  systematic  examination  of  the  eyes,  and 
a  very  practical  section  on  "How  to  Refract,"  with  a  series  of  eleven  cases  illustrating  the 
commoner  ocular  defects  with  which  the  practitioner  has  to  deal.  The  final  pages  are  devoted 
to  presbyopia,  aphakia,  anisometropia,  the  construction  of  lenses,  and  directions  for  the  proper 
adjustment  of  spectacles  and  eye-glass  frames.  There  are  numerous  diagrams  and  figures 
illustrating  very  clearly  the  principles  and  instruments  discussed.  On  the  whole,  the  work 
has  been  carefully  planned  and  neatly  executed.  It  should  prove  of  great  use  to  the  busy 
practitioner,  and  will  undoubtedly  become  a  favorite  with  any  student  into  whose  hands  it 
may  fall. 

A  Text-book  of  Botany  and  Pharmacognosy.  Intended  for  the  Use  of  Students  of  Phar- 
macy, as  a  Reference  Book  for  Pharmacists,  and  as  a  Hand-book  for  Food  and  Drug 
Analysts.  By  Henry  Kraemer,  Ph.B.,  Ph.D.,  Professor  of  Botany  and  Pharmacognosy, 
and  Director  of  the  Microscopical  Laboratory,  in  the  Philadelphia  College  of  Pharmacy; 
Member  of  tlie  Committee  of  Revision  of  the  Pharmacopoeia  of  the  United  States  of 
America;  Corresponding  Member  of  the  Soci6t6  de  Pharmacia  de  Paris,  etc.  Illustrated 
with  over  300  Plates,  comprising  about  2,000  Figures.  Third  Revised  and  Enlarged  Edi- 
tion.    Philadelphia  and  London:    J.  B.  Lippincott  Company. 

The  third  edition  of  Dr.  Kraemer's  excellent  text-book  contains  changes  in  the  illustra- 
tions calculated  to  enhance  the  usefulness  of  the  work  as  well  as  its  appearance;  a  review  of 
the  results  of  research  published  during  the  preceding  year.  In  addition  the  sections  on 
reagents  have  been  considerably  extended  with  a  view  to  afTording  greater  assistance  to  the 
student  and  practical  worker.  The  subjects  covered  are:  A  description  of  the  principle 
groups  of  plants;  the  outer  morphology  of  angiosperms,  the  inner  morphology  of  the  higher 
plants;  a  classification  of  angiosperms  yielding  vegetable  drugs;  the  cultivation  of  medicinal 
plants;  pharmacognosy,  i.e.,  the  external  characters,  gross  structure,  histology  and  chemical 
constituents;    and  reagents  and  microscopical  technique. 

Although  the  work  is  intended  for  students  of  pharmacy,  as  a  reference  book  for  phar- 
macists, and  as  a  hand-book  for  food  and  drug  analysts,  it  is  also  a  valuable  work  for  those 
members  of  the  medical  profession  who  teach  pharmacology  or  who  do  analytical  work  along 
any  of  its  lines.  It  is  also  a  valuable  reference  book  for  writers  on  therapeutics  who  wish 
to  consider  with  due  care  the  morphology  of  each  drug  studied.  In  fact.  Professor  Kraemer's 
work,  owing  to  its  completeness  and  excellence,  would  constitute  a  valuable  addition  to  the 
libraiy  of  any  physician  who  desires  to  acquire  a  closer  insight  into  plants  he  is  constantly 
using  in  the  treatment  of  disease,  than  he  acquires  from  the  average  text-book  on  materia 
medica  and  therapeutics  available  to  physicians. 


Monthly    Cyclopedia 

AND 

Medical   Bulletin 


Published  the  Last  of  Each  Month 


Medical  Bulletin  Section 


Vol.  11.  PHILADELPHIA,  JULY,  1909.  No.  7. 


Address 


ADDRESS  AT  THE  COMMENCEMENT  EXERCISES  OF  THE  MEDICO- 

CHIRURGICAL  COLLEGE  AND  HOSPITAL,  PHILADELPHIA,  PA., 

ON  JUNE  5,  1909. 

By  HON.  CHAUNCEY  M.  DEPEW. 

My  Friends  :  There  is  no  day  in  life  more  interesting  or  important  than 
the  one  which  marks  the  close  of  scholastic  studies  and  the  entrance  upon  the 
world.  It  is  a  period  which  captures  the  attention  of  all  ages.  To  the  eager 
youth  it  is  full  of  hope  and  ambition,  to  the  man  in  middle  life  still  struggling 
it  is  a  delight  to  revisit  the  scenes  he  loves  to  recall,  and  to  the  old  alumnus 
whose  lifcwork  is  practically  completed  commencement  day  has  unequalled 
charm  in  participation,  if  he  can  get  to  his  Alma  Mater  and  in  reminiscences 
if  he  cannot. 

The  month  of  June  in  our  country  is  the  one  set  apart  for  graduation  day 
in  our  academies,  colleges,  universities  and  professional  schools.  The  leaves 
upon  the  trees,  the  flowers  upon  the  bushes,  the  gi'owing  harvests  in  the  fields 
are  not  more  abundant  than  the  advice  which  is  poured  out  on  these  occasions 
to  the  youth  of  our  Innd  in  this  blcs?cd  month.  I  am  far  from  decrying  this 
advice  or  its  value.  Some  of  it  may  convey  lessons  impossible  to  learn  or  to 
live  up  to,  but  on  a  whole  it  has  great  value. 

One  of  tiie  most  gratifying  of  the  many  pleasant  things  which  occur  to 
me  is  to  meet  a  man  who  says,  "Twenty,  twenty-five,  thirty  or  forty  years  ago 
you  made  a  speech  at  my  college  which  determined  my  career,"  But,  gentle- 
men, your  career  is  fixed  by  the  profession  which  you  have  selected.  There  is 
none  more  ancient,  more  honorable  or  possessing  greater  opportunities  for 
distinction  and  usefulness  tlian  medicine. 

5  (417) 


418  ADDRESS  TO  THE  MEDICO-CHIRUEGICAL  COLLEGE. 

The  pessimist  of  to-day  tells  the  young  man  that  owing  to  modern  con- 
ditions there  are  no  chances  left  for  him  in  life,  while  the  optimist  cries, 
"They  are  as  good  as  ever."  1  owe  my  vigorous  age  to  the  fact  that  I  am  an 
optimist  and  always  have  been.  The  wider  my  observation  and  the  larger  my 
experience  the  more  I  am  convinced  that  the  opportunities  under  our  govern- 
ment are  greater  than  ever  for  ambitious  and  equipped  youth. 

The  first  duties  which  come  to  you  will  be  those  of  citizenship.  Under 
our  institutions  that  means  large  responsibilities.  For  unnumbered  centuries 
the  world  has  been  governed  from  the  top ;  first,  the  king,  who  rules  by  divine 
right.  According  to  that  conception  the  people  live  and  labor  and  fight  and 
die  only  for  him.  Next  comes  the  devolution  of  power  from  the  throne  to 
a  privileged  class  who  were  educated  and  trained  for  government  and  who 
firmly  believe  that  the  distribution  of  this  power  among  the  masses  meant 
the  distribution  of  property  and  the  overthrow  of  the  buttresses  which  law 
has  built  about  civilization.  But  with  the  settlement  in  the  wilderness  of 
North  America  by  a  virile  race  who  already  had  some  education  in  self-govern- 
ment and  much  experience  in  religious  liberty  a  new  era  dawned  upon  the 
world.  After  three  hundred  years  this  wonderful  experiment  reversing  the 
rule  of  the  ages  is  a  demonstrated  and  triumphant  success.  Government  of  the 
people  and  by  the  people  is  the  best  in  the  world.  Liberty  and  law  go  hand  in 
hand  together,  and  universal  education  at  the  expense  of  the  State  destroys 
all  class  distinction  and  brings  every  youth  up  not  only  to  an  appreciation  and 
understanding  of  but  to  a  capacity  for  government.  Every  American  is  a 
sovereign  because  he  is  taught  to  be.  "I  live  up  to  and  maintain  the  traditions 
of  my  house,"  says  the  Bourbon  kmg,  but  "I  live  up  to  and  maintain  the 
liberty  taught  in  the  Declaration  of  Independence,  and  the  practice  in 
American  life  of  the  equality  of  all  men  before  the  law  and  the  equal  oppor- 
tunity of  all  for  the  honors  and  rewards  of  life  according  to  their  character, 
industry,  capacity  and  equipment,"  says  the  American  citizen  sovereign. 
Citizen  sovereignty  has  its  duties  and  the  better  educated  the  sovereign  the 
larger  his  influence.  The  doctor,  the  minister  and  the  lawyer  are  powers  in 
their  several  conmmnities.  Every  mechanical  trade  requires  a  training  of  the 
muscles  until  they  are  so  perfected  tbat  the  artisan  can  accomplish  more  and 
more  profitably  and  do  more  and  more  usefully  than  the  untrained  laborer. 
The  brain  increases  its  power  by  training  the  same  as  do  the  muscles.  The 
ability  to  grasp,  to  absorb  and  to  teach  comes  with  education,  and  especially 
with  technical  education,  along  professional  lines.  Questions  are  constantly 
arising  in  every  community  which  profoundly  affect  its  welfare.  Reform  must 
always  be  active  or  there  will  be  municipal,  State  and  universal  stagnation. 
Eeform  is  the  refuge  of  demagogues,  charlatans  and  half-baked  philanthropists. 
The  word  is  so  abused  that  one  can  say  of  it  almost  what  Madame  Eoland  said 
at  the  foot  of  the  scaffold  as  she  was  ascending  to  be  guillotined,  "Oh!  liberty, 
what  crimes  are  committed  in  thy  name."  But  in  a  large  sense  every  movement 
for  more  school  accommodations  and  better  ones,  for  better  roads  and  high- 
ways, for  more  efficient  government  in  villages  and  cities  and  in  the  State, 
for  more  intelligent  treatment  of  the  insane,  helpless,  injured  and  diseased,  for 


ADDRESS  TO  THE  MEDICO-CHIRURGICAL  COLLEGE.  419 

the  improvement  of  sanitation  and  the  promotion  of  health,  is  practical  reform. 

Every  citizen  should  have  his  party  and  his  church.  I  have  no  patience 
with  the  man  who,  worse  than  the  Pharisee,  not  only  says,  "I  am  holier  than 
thou,"  but  declines  to  take  any  part  in  that  work  of  organization  which  makes 
good  or  bad  laws,  which  benefits  or  rums  peoples.  It  is  not  necessary  for  the 
doctor  to  be  so  aggressive  in  his  politics  that  his  practice  will  be  confined  to 
Eepublicans,  Democrats  or  Independents.  He  need  not  take  the  position 
which  would  make  him  offensive  to  those  who  disagree  with  him,  but  he  can 
perform  excellent  service  in  helping  to  purify  or  to  keep  pure  the  party  to 
which  he  belongs.  The  doctor  has  a  larger  public  duty  because  of  his  larger 
intelligence  than  most  citizens.  He  recognizes  that  health  and  wholesome 
thinking  and  action  come  from  men  and  women  who  lead  healthy  and  whole- 
some lives  and  possess  vigor  and  health.  Sanitation  in  new  communities  is 
expensive  to  the  taxpayer  and  inconvenient  to  the  citizen  and  is  always  fought, 
but  here  the  doctor  should  be  a  leader.  The  people  who  supply  milk  full  of 
tuberculosis  germs  will  resist  the  remedies  which  are  necessary  for  the  disin- 
fection of  their  stables  and  the  riparian  owners  who  are  polluting  the  water 
supply  with  typhoid  genns  and  other  poisonous  bacteria  will  always  fight  the 
measures  which  will  compel  them  to  remove  and  remedy  the  fault.  Here 
again  the  doctor  should  put  his  finger  upon  the  source  of  the  disease. 

A  young  man  should  belong  to  some  church.  Any  faith  is  better  than 
none.  It  is  the  peculiarity  of  church  work,  and  especially  in  the  manifold 
duties  imposed  by  modem  conditions,  that  it  is  a  liberal  education  for  mind, 
heart  and  muscles.  Life  is  full  of  compromises  and  they  are  absolutely  essen- 
tial. No  man  can  live  unto  himself  and  for  himself  alone.  The  party  or  the 
church  must  be  made  up  by  many  minds,  and  the  individual  must  recognize 
early  the  lesson  that  the  success  of  any  organization  is  upon  the  principle;  in 
essentials,  unity;  in  non-essentials,  liberty.  Each  individual  by  surrendering 
much  to  the  judgment  of  the  majority  secures  the  success  of  the  cohesive  whole 
represented  by  a  militant  organization  which  wins  for  him  in  the  main  that 
kind  of  government  which  he  believes  best  for  the  country.  Our  fathers,  in 
the  formation  of  our  goYemment,  determined  that  the  wisest  method  for  its 
perpetuity  was  to  provide  as  far  as  possible;  the  first,  for  intelligent  citizen- 
ship, and  next  for  such  essentials  as  would  prevent  the  wild  passions  of  an 
hour  crystallizing  into  legislation  which  might  be  injurious  or  fatal  to  the 
public  welfare.  So  to  effectuate  this  they  created  a  representative  government. 
They  believed  that  as  the  country  became  more  populous,  communities  more 
crowded,  the  struggle  of  competition  for  earning  a  living  more  severe,  govern- 
ment should  be  delegated  by  the  people  in  frequent  elections  to  those  whom 
they  could  trust  and  who  would  devote  themselves  to  carrying  out  the  measures 
which  would  be  for  the  best  interests  of  all.  They  pinned  their  faith  on 
representative  government.  To  make  this  representative  government  safe, 
sound  and  conservative  they  had  two  houses  of  the  legislative  branch,  and  an 
executive  with  large  powers  of  recommendation  and  of  veto,  a  written  con- 
stitution upon  broad  lines  within  which  only  could  action  be  had,  and  a 
Supreme  Court  limited  in  number  and  with  a  life  tenure,  removed  from  the 


420  ADDRESS  TO  THE  MEDICO-CHIRURGICAL  COLLEGE. 

passions  and  prejudices  of  tlie  hour,  wlio  should  decide  whether  the  act  as 
finally  perfected  by  the  legislative  and  executive  authority  came  within  the 
powers  granted  by  the  written  constitution. 

Medicine  has  been  practiced  since  Eve  gave  the  apple  to  Adam.  As  then 
and  since  then  until  with  the  present  memory  it  has  been  largely  experimental. 
The  Greek  physician  who  cured  Macajnas,  the  Prime  Minister  to  the  Emperor 
Augustus,  of  insomnia  by  arranging  a  waterfall  until  its  trickling  noise 
induced  sleep,  knew  no  other  method.  To-day  medical  science  traces  insomnia 
to  its  cause  and  has  found  its  almost  infallible  cure.  You  have  heard  of  the 
young  doctor  who  diagnosed  a  case  of  typhoid  fever,  and  coming  around  the 
next  day  found  the  farmer  in  the  field  and  was  informed  by  his  wife  that  he 
had  been  cured  by  a  good,  old-fashioned  dish  of  com  beef  and  cabbage.  He 
wrote  in  his  diary,  "For  typhoid  fever,  corn  beef  and  cabbage,"  and  when  he 
next  prescribed  it  the  patient  died  in  an  hour  and  he  wrote  in  his  diary,  "Com 
beef  and  cabbage  for  typhoid  fever.     Does  not  work  every  time." 

Happily  for  mankind  as  well  as  for  the  profession  legislation  is  becoming 
more  and  more  rigid  in  regard  to  admission  to  practice  and  the  powers  of  a 
medical  college  to  give  a  diploma.  Neither  Galen  nor  Hippocrates,  the  fathers 
of  medicine,  could  graduate  from  any  well  administered  college  to-day. 
Within  the  last  thirty  years  medicine  has  advanced  with  greater  strides  and  to 
more  beneficent  results  than  during  all  the  ages  which  are  behind.  Surgery  can 
almost  take  apart  and  reconstruct  a  living  organism.  The  X-ray  reveals  what 
could  foi-merly  only  be  discovered  by  the  knife  and  often  with  fatal  results. 
Antitoxin  has  minimized  to  almost  nothing  the  dangers  of  diphtheria  and  other 
diagnoses  which  were  regarded  as  fatal.  Medical  men  are  not  satisfied  with 
the  present  but  they  are  exploring  the  past.  The  mummy  of  the  Pharaoh  of 
the  Exodus  perfectly  preserved  is  in  the  museum  at  Cairo.  Not  long  since  a 
company  of  doctors  undertook  by  an  examination  of  the  mummy  to  find  the 
source  of  his  phenomenal  cruelty  against  a  whole  people.  They  discovered 
that  he  was  a  sufi'erer  from  chronic  toothache  which  there  was  no  dentistry  at 
that  period  to  alleviate.  We  know  nothing  of  Horace  except  what  is  found 
in  his  writings,  and  yet  another  company  of  doctors  have  demonstrated  that 
the  reason  he  died  in  his  early  prime  was  because  the  life  in  his  poems  demon- 
strates that  his  trouble  was  sclerosis  of  the  liver. 

One  of  the  great  heroes  of  the  Eevoiutionary  War  and  the  Vice  President 
of  the  United  States,  whose  remains,  with  magnificent  ceremonial,  were  removed 
from  the  Congressional  Cemetery  at  Washington,  where  they  had  rested  for  a 
hundred  years,  to  his  home  in  Kingston,  was  Governor  George  Clinton.  The 
cofiin  in  which  he  was  buried  was  opened  and  the  doctors  instantly  decided, 
upon  an  examination,  that  his  death  was  due  to  pneumonia,  a  disease  fatal 
and  little  understood  in  that  early  period.  Washington  was  killed  at  sixty- 
seven  by  excessive  bleeding  for  a  quinsy  sore  throat. 

Time  is  practically  unlimited  for  young  practitioners.  It  becomes  more 
valuable  as  they  grow  more  successful.  Except  on  the  score  of  income  it  is  not 
wholly  a  misfortune  but  rather  an  opportunity.  Most  young  men  waste 
opportunity,  with  the  result  that  when  they  are  called  they  are  found  wanting. 


ADDRESS  TO  THE  MEDICO- CHIRURGICAL  COLLEGE.  421 

It  is  in  this  period  of  halting  business  that  the  industrious,  energetic  and  far- 
sighted  man  perfects  the  learning  of  the  schools  and  vastly  enlarges  it.  He 
has  learned  more  or  less  thoroughly  the  text-books  and  the  lectures,  but  in  the 
review  for  which  he  has  ample  leisure  he  will  confirm  the  teachings  of  the 
college,  and  more  than  that  can  absorb  the  literature  of  his  profession.  The 
curriculum  made  him  a  drudge;  the  literature  will  make  him  an  enthusiast. 
Few  appreciate  the  value  of  odd  minutes.  Scraps  of  time  instead  of  being 
thrown  into  the  wastebasket  can  be  utilized  for  a  liberal  education.  The  odd 
half  hours  when  you  are  ready,  but  the  lunch  or  the  dinner  is  not,  will  soon 
enable  you  to  finish  a  volume.  When  you  are  married  you  will  discover  that^ 
punctuality  is  not  a  gift  of  nature  but  a  habit.  You  will  find  that  is  a  pardon- 
able peculiarity  of  the  female  mind  to  remember  something  at  the  last  minute 
which  requires  a  halt  in  the  procession  to  the  church  on  Sunday  or  to  the 
theatre  or  concert  or  lecture  on  week  days.  It  may  be  that  in  taking  the  last 
and  inevitable  look  into  the  glass  there  is  a  touch  missing  which  a  mere  man 
would  not  notice  but  she  knows  that  other  women  would,  or  it  may  be  that  the 
voice  of  the  child,  while  making  the  father  impatient,  simply  arouses  solicitude 
in  the  mother.  Now,  do  not  quarrel  or  show  temper  or  stamp  around  in  a 
heat  under  these  circumstances.  If  you  do,  you  will  not  listen  to  the  sermon 
or  enjoy  the  play.  But  have  your  book  ready  and  read.  Your  wife  will  think 
you  are  an  angel,  your  temper  and  temperament  will  be  improved  and  3'our 
knowledge  grow  apace. 

Every  professional  man,  in  fact  any  man  in  any  occupation  should  have  a 
hobby  or  a  fad.  A  man  who  uses  one  set  of  muscles  grows  abnormally  on  one 
side  to  the  decrease  in  vigor  or  paralysis  of  the  other.  So  with  the  brain.  A 
man  who  is  simply  a  lawyer,  a  doctor,  a  dentist,  a  scientist  and  nothing  else 
grows  narrow  in  his  general  conception  of  the  world  about  him  and  his 
place  and  duties  in  it  if  his  whole  mind  and  time  are  concentrated  on  his 
pursuit.  A  brilliant  example  of  what  I  mean  was  Doctor  Oliver  Wendell 
Holmes.  He  was  great  in  his  profession,  and  greater  because  he  cultivated 
general  literature.  His  "Autocrat  of  the  Breakfast  Table,"  is  one  of  the  most 
delightful  as  well  as  the  wisest  of  books.  In  it  is  concentrated  the  philosophy 
of  life  taught  by  contact  with  human  nature  in  a  large  general  practice.  In  the 
faculty  of  this  city  of  Philadelphia  is  a  brilliant  illustration  in  Doctor  Weir 
Mitchell.  Our  greatest  lawyers,  like  Webster  in  his  day,  and  Evarts  in  his 
day,  and  Choate  and  Eoot  now,  and  your  John  G.  Johnson  are  greater  in  their 
profession  because  of  the  all-round  constant  exercise  of  every  faculty  of  the 
brain  in  statecraft,  diplomacy,  on  the  platform  and  in  the  study  and  apprecia- 
tion of  the  highest  art  of  all  times.  Every  profession  is  a  jealous  mistress 
and  requires  the  best  thought  and  time  of  her  votary,  but  she  is  a  wise  mistress 
and  knows  that  the  attentions  to  her  are  fresher  and  brighter  if  her  lover  takes 
recreations  and  vacations. 

The  professional  man,  because  of  his  wider  culture  and  more  accurate 
training,  is  a  leader  in  every  community.  He  founds  or  he  energizes  the 
Young  Men's  Christian  Association.  He  is  active  in  movements  for  the  organ- 
ization of  the  savings  bank,  or  committees  which  have  for  their  object  the 


422  ADDRESS  TO  THE  MEDICO- CHIRUEGICAL  COLLEGE. 

promotion  of  the  many  things  which  are  necessary  for  the  public  welfare.  It 
is  his  mission  to  expose  frauds  and  fools.  Your  profession  more  than  any 
other  is  the  victim  of  these  parasites  of  society.  The  itinerant  dentist  will 
advertise  in  the  village  newspapers  that  he  does  every  kind  of  work  required  by 
his  profession  without  pain  and  leaves  the  village  with  crowns  that  have  to  be 
removed  and  teeth  with  their  enamel  destroyed  by  the  acids  which  he  used. 
So  with  the  itinerant  doctor  who  empties  for  a  time  the  consulting  offices  of 
the  local  physician  while  he  professes  to  accomplish  miracles  and  does  great 
and  sometimes  lasting  injury  to  vital  organs. 

As  soon  as  you  can  afford  it  get  married  but  not  before.  It  is  a  fearful 
handicap  to  a  young  professional  man  to  have  upon  his  hands  a  family  without 
the  means  to  care  for  them.  The  question  of  how  much  income  is  dependent 
upon  the  man,  the  girl  and  the  locality  in  which  they  live,  but  if  both  husband 
and  wife  are  wisely  economical  and  good  business  managers  and  housekeepers  it 
is  astonishing,  in  these  days  when  large  incomes  so  fill  the  press  and  fire  the 
imagination,  upon  how  little  a  family  can  be  very  comfortable.  "Stick,  dig 
and  save"  is  a  good  motto  to  have  on  the  front  page  of  your  memorandum  book. 
The  practice  of  those  three  maxims  will  secure  for  you  permanence,  independ- 
ence and  a  home. 

The  progress  of  the  world  in  the  last  half  century  has  been  beyond 
precedent  in  all  preceding  ages — greater  in  your  profession  than  in  any  other. 
The  triumphs  of  the  laboratory  and  the  beneficent  processes  of  invention  have 
prolonged  human  life  and  increased  human  happiness.  The  chemist  from 
coal  tar  alone  has  evolved  some  four  hundred  new  articles  of  therapeutical 
value,  while  a  piece  of  radium  a  little  larger  than  a  pinhead  and  worth  five 
thousand  dollars  inserted  beneath  the  skin  is  said  to  accomplish  in  fighting 
cancer  more  than  all  the  hospitals  of  the  world  have  been  able  to  do.  I  know 
not  whether  it  is  true,  but  I  saw  an  article  the  other  day  that  they  had  dis- 
covered in  one  of  the  great  research  laboratories  in  New  York  that  all  the 
organs  could  be  kept  in  cold  storage  indefinitely  and  used  to  replace  those 
which  had  become  impaired.  According  to  a  recent  German  authority  genius 
is  as  much  dependent  upon  the  relation  of  heart,  liver,  kidneys,  lungs  and 
spleen  to  the  human  body  as  the  divine  fire  to  the  brain.  If  this  be  so  what 
marvels  may  come  in  the  future  by  transfers  from  these  cold  storage  establish- 
ments into  the  anatomy  of  plain,  ordinary  people?  A  Shakespeare  or  a 
Milton,  a  Homer  or  a  Demosthenes  may  bo  among  the  possibilities  of  the 
doctor's  skill. 

Sidney  Smith  once  remarked  that  a  friendship  broken  may  be  renewed, 
a  fortune  lost  may  be  regained,  but  a  dinner  gone  is  gone  forever.  We  meant 
that  you  could  never  have  the  same  dinner  nor  the  same  number  of  them  in 
your  life.  There  are  assets  for  the  right-minded  man  and  woman  which  are 
never  lost.  Among  them  are  the  culture  which  comes  from  the  college,  the 
associations  of  undergraduate  days,  the  faculty  whose  foibles  of  the  student 
hour  are  virtues  in  the  best  recollections  of  after  years,  and  the  friendships 
formed  from  commimity  of  occupation  and  certain  qualities  of  companion- 
ship which  last  through  life. 


SCIATICA.  423 


Clinical  Lecture 


SCIATICA. 


By  JOHN  V.  SHOEM^iltER,  M.D.,  LL.D., 

Professor  of  Materia  Medica,  Therapeutics,  Clinical  Medicine  and  Diseases  of  the  Skin 
in  the  Medico-Chirurgical  College  and  Hospital  of  Philadelphia. 

PHILADELPHIA. 

Gentlemen:  Tliis  patient  presents  an  affection  which  is  comparatively 
rare  before  the  age  of  twenty-one  years. 

M.  H.  aged  52  years,  nativity,  U.  S.  A. 

Family  History. — The  patient  states  that  his  mother  is  living  and  well; 
his  father  died  from  old  age.  He  had  six  brothers  and  two  sisters.  One 
brother  died  in  infancy  and  the  other  died  at  the  age  of  18  years  from  the 
kick  of  a  horse.  As  to  his  sisters  one  died  from  apoplexy  at  the  age  of  43 
years,  while  the  other  died  at  the  age  of  6  years  from  scarlet  fever.  His  grand- 
parents are  all  dead.  Paternal  and  maternal  grandfathers  died  of  apoplexy 
while  his  paternal  and  maternal  grandmother  both  died  of  old  age.  He  does 
not  possess  any  knowledge  of  the  history  of  his  imcles  or  aunts. 

Previous  Personal  History. — As  a  child  he  had  diphtheria,  measles,  and 
whooping-cough.  Otherwise  he  had  always  been  well  and  had  enjoyed  good 
health. 

Social  History. — He  is  married  and  is  the  father  of  two  children — a  son 
and  a  daughter  all  living  and  well. 

Habits. — He  drinks  beer  occasionally  but  never  takes  whiskey.  As  far 
back  as  he  can  remember  he  has  only  been  intoxicated  twice.  He  drinks 
three  cups  of  coffee  daily  and  does  not  chew  or  smoke  tobacco,  having  aban- 
doned this  habit  14  years  ago ;  denies  any  venereal  diseases. 

Present  Illness. — About  six  years  ago  a  heavy  piece  of  iron  fell  upon  his 
patella  and  injured  it  so  badly  that  he  was  unable  to  walk  for  twenty-one  days. 
Since  tben,  he  did  not  have  any  more  trouble  until  the  middle  of  last  January 
when  he  experienced  severe  pain  in  the  region  of  the  coccyx  and  then  it  became 
more  intense  below  the  gluteal  fold  and  in  the  upper  part  of  the  thigh.  Then 
the  region  which  corresponds  to  the  anatomical  distribution  of  the  sciatic 
nerve  became  very  tender  and  painful.  The  pain  would  start  gradually  above 
the  hip  joint  and  radiate  down  behind  the  knee  to  about  the  middle  of  the 
leg.  Tbis  p^in  was  very  much  aggravated  when  he  would  move  the  leg  as 
in  walking,  due  to  the  compression  of  the  nerve.  He  also  has  a  loss  of  the 
tendo  Achilles  reflex. 

Diagnosis. — The  diagnosis  of  this  patient's  trouble  is  quite  easy  and  could 
not  possibly  be  mistaken  for  any  other  disease  than  sciatica.  The  case  is  a 
typical  one  in  that  the  pain  follows  the  course  of  the  sciatic  nerve.     The  sharp 


424  SCIATICA. 

lancinating  pain,  tenderness  over  the  sciatic  nerve  and  the  peculiar  gait  so 
characteristic  suffice  to  prevent  error  in  the  diagnosis. 

Differential  Diagnosis. 
Sciatica.  Tales  Dorsalis. 

1.  Absence  of  Ar^ll  Robertson  pupil.  1.  Presence  of  Argyll  Robertson  pupil. 

2.  Develops  rapidly.  2.  Slower  in  development. 

Sciatica.  Disease  of  Hip  Joint. 

1.  Pain  along  the  course  of  the  nerve.  1.  Joint  tenderness  and  fixation. 

2.  Pain  corresponds  to  th.e  sciatic  nen^e.  2.  Pain  corresponds  to  the  obturator  nerve. 

Sciatica.  Neuralgia. 

1.  Persistent  pain.  1.  Fleeting  pain. 

2.  Tenderness  along  course  of  nerve.  2.  No  tenderness  or  very  slight  tenderness. 

PatJioIogy.— The  autopsical  findings  show  the  condition  of  the  nerve  to 
be  a  perineuritis  affecting  also  the  adventitia.  The  nerve  is  swollen,  soft  and 
red  in  color  due  to  the  hyperemia  of  the  vasa  nervorum  and  there  may  also  be 
foimd  minute  extravasations  of  blood  in  the  nerve.  Under  the  microscope  we 
observe  round  cell  infiltration  and  the  nerve  is  cedematous  and  tumefied.  The 
inflammatory  changes  are  observed  in  the  perineurium  and  endoneurmm. 
The  primary  changes  are  seen  in  the  connective  tissue  and  are  most  marked 
at  the  sciatic  notch  and  in  the  middle  of  the  thigh  due  to  the  fact  that  it  is 
exposed  to  more  irritation  at  these  points.  Then  the  myelin  sheathes  become 
involved,  and  finally  the  whole  nerve. 

Etiology.— This  affection  is  caused  by  the  same  factors  that  cause  neuritis 
elsewhere.  It  is  by  far  the  more  common  in  men  than  in  women  and  records 
show  that  it  stands  next  to  facial  neuralgia  in  order  of  frequency.  Those  who 
are  more  especially  liable  to  suffer  from  this  disease  are  the  gouty,  rheumatic 
and  neurotic  individuals.  It  is  unknown  in  children  and  occurs  after  twenty- 
one  years  of  age.  The  most  frequent  exciting  cause  is  exposure  to  cold  and  we 
therefore  find  it  in  those  whose  occupation  exposes  them  to  cold  and  wet 
weather  or  extreme  changes  of  temperature.  Other  factors  in  the  causation 
of  this  affection  are  compression  which  may  be  due  to  pelvic  diseases  such  as 
constipation,  tumors  and  other  formations  which  may  cause  pressure,  trauma- 
tism as  contusions  from  blows  below  the  sacrosciatic  notch.  Sciatica  may  also 
be  attributed  to  syphilis  but  this  is  not  a  common  cause.  It  may  also  be  due 
to  systematic  poisons  as  in  diabetes,  typhoid  fever,  etc.  Excessive  muscular 
fatigue  is  a  frequent  cause  and  spinal  diseases  may  also  cause  sciatica  by  giving 
rise  to  a  neuritis  by  affecting  the  cauda  equina. 

Treatment. — The  treatment  depends  largely  upon  the  cause,  which  of 
course,  must  be  removed  if  known.  I  believe  the  cause  of  this  man's  sciatica 
is  due  to  exposure  and  heavy  labor,  consequently  rest  in  bed  with  a  splint 
applied  to  the  leg  will  add  materially  in  the  cure  of  his  neuritis, 

I  have  found  that  an  ointment  containing  adrenalin  chloride  1-1000  solu- 
tion to  an  ounce  of  petrolatum,  well  rubbed  into  the  skin  over  the  course  of 
the  nerve,  very  valuable.  Three  applications  have  thus  far  been  made  with 
appreciably  good  results. 

High  frequency  electricity  applied  along  the  course  of  the  nerve  daily  will 


A  QUESTION  IN  THERAPEUTICS.  425 

also  be  valuable.     In  our  electrical  room  we  have  a  splendid  outfit  of  which 
he  will  receive  the  benefit. 

Internally  he  should  be  given  a  remedy  possessing  alterative  and  tonic 
properties,  and  the  drugs  indicated  can  be  given  in  a  capsule  as  follows: — 

IJ  Arseni  trioxidi    gr.  ss. 

Ferri  pyrophosphatis  solubilis 3j. 

Quininae  salicylatis 3ss. 

Aloini    gr.  iss. 

Sulplmris  praecipitati    3j. 

Misce.     Fiant  capsulae  no.  xx. 

Signa:    One  capsule  after  each  meal  and  at  bedtime. 

Prognosis. — It  will  require  from  one  to  two  months  to  cure  this  patient, 
but  I  believe  he  will  get  perfectly  well.  The  rest  in  bed  and  the  high  frequency 
current  as  employed  under  our  direction  will  do  more  for  him  than  the  drugs. 


Original  Articles 


A  QUESTION  IN  THERAPEUTICS. 

By  BROSE  HORNE,  M.D., 

Late  Physician  Indiana  State  Prison. 

GAS   CITT,  IND. 

Observation  teaches  us  that  life  is  an  unfoldment.  By  reason  and 
experience  we  learn  that  the  further  we  travel  the  more  truth  we  can  com- 
prehend. 

"To  understand  the  things  that  are  at  our  door  is  the  best  preparation 
for  imderstanding  those  that  lie  beyond.^'  Therapeutics  is  the  foundation  of 
our  art:  the  criterion  of  the  science.  If  the  germ  of  decay  attacks  thera- 
peutics it  assails  the  most  vital  part  of  scientific  medicine,  for  without  it 
medicine  has  no  excuse  for  existence. 

We  have  a  great  question  before  us  in  therapeutics  to-day  for  considera- 
tion, and  that  is — how  to  keep  the  influences  of  commercialism  from  destroy- 
ing the  art?  I  firmly  believe  that  it  is  our  duty  to  God  and  humanity,  let 
consequences  be  what  they  may,  to  preseut  the  truth,  as  we  see  it.  "All  may 
not  accept  our  conclusions,  but  our  business  should  be  to  declare  the  truth. 
Society  may  deal  with  the  truth  as  she  pleases." 

This  may  be  the  last  time  that  1  shall  ever  have  the  opportunity  to  write 
a  medical  paper,  life  is  so  uncertain.  But  if  I  knew  this  to  be  true  I  would 
prefer  to  stand  alone,  appreciating  that  I  offend  the  combined  interests  of 
medical  conmiercialism,  and  know  I  am  right  than  be  wrong  and  receive  the 
applause  of  the  rabble,  that  cheers  you  on  to-day  and  burns  you  at  the  stake 
to-morrow.  Commercialism  has  invaded  all  the  arts  and  sciences.  It  has 
even  influenced  the  most  sacred  things  we  have  in  life.  No  one  appreciates 
this  more  than  the  physician.     Medicine  has  become  tinctured  with  the  spirit 


426  A  QUESTION  IN  THERAPEUTICS. 

of  commercialism  to  such  an  extent  that  it  is  at  times  with  the  greatest  diffi- 
culty that  we  are  enabled  to  define  a  certain  therapeutic  procedure,  that  rests 
on  pure  scientific  research  from  one  that  has  the  influences  of  commercialism 
behind  it. 

Our  only  hopes  rest  in  a  return  to  the  first  principles — make  an  individual 
study  of  drug  therapy — originate  our  own  formulas,  join  hands  with  the  honest 
apothecary  and  chemist.  We  should  divorce  the  science  and  art  of  medicine, 
no  matter  at  what  cost,  from  all  commercial  influence.  True  medicine  can 
never  decline — the  truth  shall  live — but  unless  we  become  liberal  and  do  away 
with  machine  politics  in  our  difllerent  medical  organizations — cease  first,  last 
and  always  to  sanction  this  medical  trust  that  has  been  formed,  we  will  see 
a  decline  in  organized  medicine  as  it  exists  to-day  and  possibly  a  total  destruc- 
tion and  a  replacement  by  the  many  medico-religious  cults.  Too  many  laws 
are  an  injury  and  when  a  class  of  men  attempt  to  have  laws  passed  for  their 
own  selfish  interests  in  the  course  of  time  the  laity  will  raise  up  in  their 
indignation  and  destroy  them. 

The  science  of  medicine  is  a  broad  and  liberal  science.  We  have  handed 
down  to  us,  through  the  ages,  many  truths.  Medicine  is  a  true  religion  in 
itself.  Xo  class  of  men  see  the  inner  lives  of  the  people  more  than  the  physi- 
cian— no  class  of  men  have  a  greater  opportunity  for  doing  good.  It  is  a 
burning  shame  that  mammon  has  invaded  this  science  and  to-day  has  it  by  the 
throat.  The  physician  in  all  his  poverty,  misery  and  distress  should  raise  up 
in  all  the  dignity  of  his  manhood  and  proclaim  to  the  world  that,  "On  this  rock 
I  build  my  Church."  He  should  inform  the  investigators,  who  are  uninformed, 
that  Galen,  a  most  eminent  Eoman  physician,  taught  and  practiced  a  form  of 
"Mental  Science,"  years  before  the  birth  of  Jesus:  that  in  many  respects 
is  equal  if  not  superior  to  the  many  creeds  that  are  being  promulgated  to-day. 
If  you  surround  the  truth  with  a  creed  it  will  perish.  Organized  religion 
(churchanity)  and  organized  medicine,  although  doing  much  good,  have  also 
done  much  harm.  They  originate  prejudice  which  causes  one  to  resort  at 
times  to  violence.  They  are  weak  in  that  a  spirit  of  commercialism  has 
developed  in  this  age  which  has  produced  dire  distress  to  true  science.  It  is 
only  by  being  liberal  that  we  can  hope  to  live.  The  spirit  that  burned 
Savanarola  at  the  stake — that  dragged  Hypatia  through  the  streets  of  Alex- 
andria— forced  Socrates  to  drink  the  hemlock  and  crucified  Jesus  to  the  cross 
still  exists  in  a  modified  form  and  it  emanates  from  creeds,  frequently  backed 
up  by  commercialism. 

A  serious  matter  confronts  the  physician  of  the  age  and  day:  a  question 
of  such  importance  that  it  will  take  the  united  efl'orts  of  all  who  hold  true 
therapeutic  progress  above  the  shrewd  tricks  of  medical  commercialism,  to 
combat  it.  The  custom,  handed  down  to  us  from  the  Dark  Ages,  of  placing 
a  collection  of  symptoms  under  a  name  and  then  giving  a  set  formula  for  the 
named  condition — instead  of  treating  pathological  lesions,  and  making  an 
individual  drug  study — has  evolved  a  nostrum  practice  that  threatens  the  life 
of  the  science. 

The  almost  universal   use  of  dry,  hard,   'Tiand-me-down,"   ready  made 


A  QUESTION  IN  THERAPEUTICS.  427 

tablets,  pills  and  nostrums,  with  the  name  of  the  disease  on  the  bottle,  is  one 

of  the  predominating  evils.  A  physician  who  thinks  for  himself  and  has 
given  the  true  principles  of  medicine  any  study,  will  appreciate  at  once  that 
this  tablet  form  of  medication  and  nostrum  practice,  where  the  disease  is 
named  on  the  bottle,  is  a  remainder  of  that  old  medical  superstitution,  which 
has  been  the  stumbling  block  in  the  way  of  true  scientific  therapeutics  from 
time  immemorial. 

The  stomach  and  intestines  cannot  absorb  any  substances  until  it  is 
reduced  to  a  fluid  form.  The  digestive  organs  are  weak  when  disease  exists 
in  the  body,  and  consequently,  when  a  dry,  hard  tablet,  that  often  can  be  driven 
into  a  board,  is  administered,  no  results,  or  at  the  best,  no  proper  results,  can 
be  obtained.  ^lany  drugs,  when  reduced  to  a  dry  state,  lose  their  therapeutic 
value.  One  prominent  chemist,  and  the  only  one  in  the  world  to  do  so,  when 
the  tablet  craze  was  at  its  height,  prepared  thousands  of  tablets  from  choice  and 
carefully  selected  drugs:  with  care  he  selected  each  drug,  to  be  sure  of  its 
purity,  etc.  He  then  carefully  and  by  the  most  scientific  means  prepared 
tablets  from  these  different  drugs.  He  then  distributed  these  tablets  to 
different  eminent  physicians  and  had  them  use  them  in  their  practice.  And 
what  was  the  result?  Every  physician  reported  that  he  could  not  obtain  the 
action  from  these  tablets  that  he  could  from  the  fluid  drugs.  And,  as  a 
result,  this  eminent  and  honest  chemist  in  his  quiet  way  refused,  at  a  great 
financial  loss,  to  manufacture  tablets.     Not  a  tablet  in  the  world  bears  his  name. 

It  is  with  the  minority  school  of  medicine  that  the  welfare  of  the  true 
science  of  medicine  rests.  It  will  be  the  minority,  by  great  self-sacrifice,  that 
the  decline  of  medicine  will  be  prevented.  Ecmember  what  Kaufman  said, 
"Just  one  man  in  a  hundred  can  see  beyond  his  nose.  The  short-sighted  people 
are  in  the  majority — and  the  majority  rules.  Only  imagination  can  visualize 
what  is  to  be;  most  people  have  no  imagination,  therefore,  they  doubt  and 
ridicule  what  they  do  not  comprehend.  To  them  the  oak  is  never  apparent 
in  the  acorn." 

Tablets  are  dangerous  because  we  are  unable  to  determine  the  exact  time 
in  which  they  will  act.  Many  of  them  may  be  taken  and  their  absorption  be 
delayed.  Thus  several  tablets  may  accumulate  and  all  of  them  be  dissolved 
and  appropriated  by  the  body  at  the  same  time,  by  means  of  which  we  obtain 
a  toxic  dose.  Tablets  are  difficult  to  assimulate.  If  this  be  true,  why  prescribe 
such  a  fonn  of  medication  ?  It  is  an  undisputed  fact  that  the  liquid  form  of 
medication  is  superior  to  all  others.  The  action  obtained  is  quicker,  and  the 
results  much  better.  Inferior  drugs  can  be  concealed  within  a  tablet  or  pill. 
What  becomes  of  all  the  dry,  worm-eaten  drugs?  The  tablets  may  be  unclean 
from  frequent  handling  in  the  manipulation  of  manufacture,  while  the  alcohol 
in  the  liquid  drugs,  even  if  certain  unclean  agents  should  get  in  them,  will 
destroy  it. 

A  girl,  in  a  certain  manufacturing  establishment,  where  tablets  and  pills 
are  made,  was  noticed  to  have  coryza ;  she  was  packing  these  tablets— she  was 
observed  to  wipe  her  nose  with  her  fingers  and  then,  without  washing,  reach 
and  get  a  few  more  tablets  and  pack  them.    These  tablets  and  pills  are 


428  A  QUESTION  IN  THERAPEUTICS. 

manufactured  by  steam  power,  thousands  of  them  a  minute.  They  are  fre- 
quently packed  and  labeled  by  boys  and  girls.  These  boys  and  girls  have 
made  mistakes  in  labeling  and  packing  these  tablets,  as  happened  in  an  Eastern 
factory  where  the  morphine  tablets  were  packed  in  the  purgative  package,  and 
vice  versa.  These  were  sent  out  to  certain  physicians,  and  serious  results 
followed.  You  cannot  swear  from  your  personal  Icnowledge,  just  what  are 
in  those  pills  and  tablets,  nor  as  to  their  purity,  etc. 

Puckner  and  Clark  report  (from  American  Medical  Association),  the 
results  of  examination  of  various  brands  of  tablets,  said  to  contain  definite 
amounts  of  bismuth,  opium  and  phenol.  The  tablets  were  purchased  both 
direct  from  the  manufacturers  and  in  the  open  market.  They  were  subjected 
to  tests  to  determine  the  amount  of  phenol  each  contained.  The  methods  of 
examination  were  the  results  of  a  long  series  of  experiments  and  are  described 
briefly:  the  results  of  the  assays  are  given  in  tabulated  form,  and  show  that, 
assuming  the  amount  of  phenol  claimed  to  be  100  per  cent.,  the  amount  of 
phenol  actually  found  in  the  tablets  varied  all  the  way  from  12.66  per  cent.,  to 
72.65  per  cent.,  the  latter  number  being  the  highest.  Incidental  to  obtaining 
the  phenol  contents  of  the  tablets,  the  weights  of  the  tablets  were  compared 
and  found  to  vary  as  much  as  34.35  per  centum  in  one  instance,  and  over  10 
per  centum  in  some  othere.  The  examination  demonstrates  the  absurdity  of 
sacrificing  to  mere  convenience.  "These  tablets  are  a  typical  illustration  of  the 
attempts  to  produce,  in  elegant  and  palatable  form,  the  impossible — impossible 
at  least  without  care  and  expense.  From  the  nature  of  the  processes  involved 
in  the  manufacture  of  a  tablet,  it  is  very  difficult  to  produce  one  containing  a 
definite  amount  of  a  volatile  substance  like  carbolic  acid.  Accuracy  in  dosage 
is  indispensable  to  the  scientific  administration  of  drugs.  In  medicinal 
preparations  of  the  type  just  described,  the  essential — accuracy — is  sacrificed 
for  the  merely  desirable,  convenience  and  palatability.  To  the  extent  to  which 
physicians  prescribe,  as  tablets,  combinations  of  drugs  that  cannot  be  success- 
fully put  up  in  that  form,  to  that  extent  does  scientific  medicine  suffer." i 

All  kinds  of  microbes  have  been  found  upon  and  in  these  tablets  and  pills, 
notably  those  of  diphtheria.  The  substance  forming  the  basis  of  pills  and 
tablets  are  rarely  of  a  nature  to  destroy  this  dangerous  element,  which  is  intro- 
duced either  in  the  constituents,  or  more  often  by  manipulation  in  manufacture. 
In  fact,  the  skin  and  the  nasal  cavities,  even  of  a  healthy  man,  abound  in 
microbes,  and  they  are  still  more  abundant  in  laboratory  attendants,  too 
often  in  people  who  are  not  very  careful  of  their  persons.  Thus,  tablets  and 
pills  which  require  much  handling  may  not  only  contribute  to  the  cure  of  one 
disease,  but  at  the  same  time  introduce  the  germs  of  several  others;  this  use 
of  tablets  and  nostrums  forms  a  serious  question  which  the  profession  must 
deal  with  sooner  or  later. 

As  a  system  it  is  nothing  more  or  less  than  a  form  of  "Patent  Medicine," 
practice,  where  the  physician  simply  acts  the  part  of  a  distributing  agent  for 
some  tablet  house.     In  order  to  keep  up  with  true  progress  it  becomes  essential 


1  Druggists'  Circular,  September,  1908. 


A  QUESTION  IN  THERAPEUTICS.  429 

that  we  prepare  our  ovm  formulas  at  the  bedside,  meeting  the  indications  of, 
each  individual  case.  The  art  of  pharmacy  would  become  a  thing  of  the  past 
if  tliis  "Tablet  System"  should  be  universally  adopted  in  medical  practice.  Let 
the  apothecary  understand  the  ethics  of  his  profession  and  refuse  to  refill. 
Let  the  apothecary  and  physician  work  hand  in  hand  and  in  this  way  we  will 
not  lose  our  individuality.  The  reason  we  have  so  many  therapeutic  nihilists 
in  this  country  is  that  the  physician  becomes  a  slave  to  the  tablet  and  nostrum 
habit. 

The  lack  of  knowledge  of  drug-therapy  and  the  use  of  dry,  hard  tablets, 
and  ready  prepared  nostrums  on  the  part  of  physicians  is  the  cause  of  the 
rapid  growth  of  these  medico-religious  cults.  If  a  patient  is  disappointed  in 
the  results  of  the  physician's  drugs — too  often  a  dry,  hard,  ready-made  tablet 
— they  resort  to  other  forms  of  healing,  and  scientific  therapeutics  must  suffer 
from  the  ignorance  of  the  physician  in  prescribing.  This  tablet  and  nostrum 
evil  is  not  a  school  question  but  one  of  therapeutical  science.  The  physician 
and  the  laity  have  been  imposed  upon.  A  man  in  a  certain  state  combined 
two  very  common  drugs — gave  the  combination  a  new  name — advertised  the 
new  ''cure  all"  broad  cast:  the  physicians  paid  in  their  money — made  this 
fellow  rich,  and  in  a  shrewd  way  he  used  his  money  to  control  the  medical 
press.  Many  medical  journals  are  either  owned,  influenced  or  controlled  by 
these  tablet  and  patent  medicine  firms. 

Kot  very  long  ago  the  Pure  Food  Commission  gave  notice  that  they  would 
investigate  a  certain  patent  medicine.  In  one  building  in  New  York  State 
there  are  several  offices  that  represent  these  patent  medicine  interests.  As  soon 
as  the  word  was  sent  out  that  this  patent  medicine  was  to  be  investigated — we 
find  that  one  very  prominent  and  pious  congressman  from  New  York  State  and 
also  another  very  leading  politician,  who  holds  a  very  high  office  in  our  country 
— went  to  Washington  and  used  their  influence  to  stop  this  investigation. 2 
It  has  been  rumored,  with  much  evidence  to  substantiate  the  truth  of  the  rumor, 
that  one  very  prominent  senator,  who  was  elected,  was  furnished  the  money  for 
his  campaign  by  a  combination  of  patent  medicine  houses. 

It  is  true  that  organized  medicine  fails  to  represent  every  physician:  out 
of  230,000  physicians  only  about  38,000  belong  to  the  national  organizations. 
It  has  been  the  history  of  the  world  that  all  of  the  great  and  lasting  work  has 
been  done  by  the  non-conformist — men  who  would  sacrifice  all  personal  desires 
for  the  truth. 

There  is  a  crying  need  in  this  country  for  a  national  therapeutical 
organization  in  which  men  of  all  schools  of  medicine  can  join  for  investigation 
and  enlightenment.  Where  isms  and  creeds  will  be  cast  aside;  and  where  we 
can  look  the  truth  in  the  face.  An  organization  that  will  refuse  to  endorse 
the  efforts  of  any  class  who  are  prompted  by  the  spirit  of  commercialism. 
Therapeutic  research,  if  we  desire  truth,  cannot  afford  to  have,  "A  tin-can  tied 
to  its  tail."  I  am  not  interested  in  the  least  in  political  manipulations:  no 
selfish  motives  whatever  prompt  mo  in  making  these  few  remarks.     Only  a 

2  From  Collier's  Weekly,  Jauuary  30,  1909. 


430  REPORTS  ON  INTESTINAL  OBSTRUCTION  IN  PREGNANCY. 

love  for  a  profession  that  I  wish  to  serve,  and  the  respect  I  have  for  the  work, 
self-sacrifice,  and  deaths  that  my  ancestors  willingly  gave  drives  me  on  to 
duty.  If  I  must  sacrifice  all;  if  the  ones  I  love,  desert  me  because  I  go 
where  duty  calls;  I  trust  that  some  invisible  force  will  comfort  me  in  my 
distress.  I  know  that  "The  work  of  a  man  is  to  fight  against  the  difficulties 
which  his  own  proper  activities  have  stirred  up,  and  to  conquer  them." 
Because  my  own  native  State,  through  one  organization  refused  to  endorse 
in  a  frank  manner,  an  effort  to  stamp  out  an  evil  in  medicine,  is  no  discourage- 
ment whatever:  when  we  understand  the  influences  behind  the  act.  I  know, 
and  all  men  know,  who  do  unselfish  work  that,  "He  gains  the  prize  who  can 
most  endure,  who  faces  issues,  he  who  never  shrinks,  who  waits,  and  watches 
and  who  always  works.'' 

This  is  an  Age  of  Eeason,  and  the  future  of  true  medicine  rests  in  the 
hands  of  the  unselfish  minority.  The  true  physician  will,  no  matter  from  what 
school  he  graduated,  divorce  himself  from  the  narrow  prejudice  of  creeds  and 
isms.  He  will  stand  up  boldly  for  the  true  principles  of  medicine,  and  if  in 
the  end  he  must  even  give  up  his  life  for  the  truth  his  only  regret  will  be  that 
he  did  not  have  a  thousand  lives  to  give  up  for  the  same  cause. 

The  future  of  this  race  rests  in  the  education  and  enlightenment  that  will 
be  imparted  by  the  self-sacrificing  physician.  The  future  work  rests  in  their 
hand  by  the  nature  of  their  work.  This  is  an  age  of  commercialism.  The 
people  have  gone  money-mad  and  sex-mad.  In  the  unfoldment  the  true 
science  of  medicine,  and  its  allied  branches,  will  save  the  race,  if  saved  at  all. 
A  true  physician  is  not  a  man  who  goes  about  giving  excuses  for  being  here — 
his  life  is  not  an  apology.  He  takes  up  his  life  task  in  honesty  and  sincerity; 
and  takes  a  promise,  "That  he  will  go  out  in  the  world,  not  mailed  in  scorn, 
but  in  the  armor  of  pure  intent — great  duties  are  before  him ;  and  great  songs, 
and  whether  crowned  or  crownless  when  he  falls  it  matters  not,  so  God's  work 
is  done."  Gladstone  said,  "Physicians  will  become  the  future  leaders  of 
nations." 


REPORT  OF  TWO  CASES  OF  INTESTINAL  OBSTRUCTION  COMPLICATING 
ADVANCED  PREGNANCY:  OPERATION:  RECOVERY.* 

By  JOHN  A.  McGLINN,  A.B.,  M.D., 

Assistant  Professor  of  Gynecology  in  the  Medico-Chinirgical   College;    Gynecologist   to 
St.  Agnes'  Hospital,  Philadelphia. 

PHILADELPniA. 

Mrs.  L.  'N.,  white,  nullipara,  age  26,  admitted  to  the  medical  ward  of 
St.  Agnes'  Hospital  February  29,  1908.  She  gave  the  following  history. 
Two  weeks  ago  she  developed  tonsillitis  and  was  compelled  to  go  to  bed.  She 
then  complained  of  pain  in  the  frontal  region,  back  and  abdomen.  Pain 
radiates   from   the    epigastric    region    to   tlie    back    particularly    between    the 


Read  before  the  Philadelphia  Obstetrical  Society,  February,  1909. 


REPORTS  ON  INTESTINAL  OBSTRUCTION  IN  PREGNANCY.  431 

shoulders.  She  has  been  constipated  for  the  past  ten  days  and  vomits  every 
time  she  eats.  At  no  time  has  the  vomit  been  faecal  in  character.  For  two 
months  previous  to  her  present  illness  she  had  a  cough  but  this  has  entirely 
disappeared. 

She  has  had  tj^hoid  fever,  rheumatism  and  the  usual  infectious  diseases 
of  childhood.  Five  years  ago  she  broke  her  leg.  This  is  the  only  surgical 
condition  she  ever  had. 

She  was  married  five  months  ago.  Since  marriage  she  has  not  menstru- 
ated.    Before  marriage  menstruation  was  alwaj's  regular. 

Physical  Examination. — Lungs  negative.  Heart  negative  except  for  a 
slight  thrill  over  the  precordial  region.  Abdomen  is  greatly  distended  and 
t}Tnpanitic.  She  complains  of  pain  and  tenderness  over  the  entire  abdomen. 
The  pain  and  tenderness  is  most  marked  in  the  epigastric  region.  The 
spleen  cannot  be  palpated  on  account  of  the  distention  of  the  abdomen.  The 
lower  border  of  the  liver  is  not  palpable.  Temperature  on  admission,  101 
degrees  F. ;  pulse  100,  respirations  24. 

Examination  March  5th  (five  days  after  admission).  Patient  complains 
of  very  little  pain.  Tongue  coated  dark  brown.  Abdomen  tympanitic  except 
in  right  lower  quadrant  where  there  is  dullness.  On  palpation  a  doughy  mass 
seems  to  be  present  in  this  region. 

From  date  of  admission  to  March  6th,  bowels  have  been  constipated. 
After  the  use  of  high  enemas  small  amounts  of  fascal-stained  mucus  have  been 
discharged.  She  does  not  pass  flatus.  She  has  been  placed  on  eserine  salicylate 
without  results.  Purgatives  by  the  mouth  have  caused  vomiting  and  no  move- 
ment of  the  bowels  has  resulted. 

An  examination  of  tlie  matter  discharged  after  the  enemas  showed  the 
following.  Fa?ces  dark  brown  in  color  about  the  consistency  of  cream.  Alka- 
line in  reaction.  Many  bacteria.  Triple  phosphates  present  in  large  amoimts. 
Calcium  phosphates  present.  Few  vegetable  cells  present.  Muscle  fibres  and 
fat  cells  not  present. 

Widal  reaction  not  present. 

Blood  Examination. — March  6,  1908.  Leucocytes,  7,800;  polymorpho- 
nuclear, 64  per  cent.;  small  lymphocytes,  26  per  cent.;  large  IjTnphocytes, 
6  per  cent. ;  eosinophiles,  1  per  cent. ;  myelocytes,  3  per  cent. 

The  case  was  referred  to  me  on  March  6,  1908.  An  examination  was 
made  and  the  following  points  noted.  No  subjective  signs  of  pregnancy  except 
the  absence  of  menses.  No  breast  or  abdominal  signs  of  pregnancy  found. 
Vulva  slightly  discolored  and  bathed  in  a  discharge.  Pulsation  of  the  vagiual 
arteries  present.  Cervix  enlarged  and  softened.  Uterus  could  not  be  outlined 
on  account  of  the  abdominal  distention  and  rigidity  of  the  abdominal  muscles. 
No  mass  could  be  palpated  to  the  sides  of  the  cervix.  Free  fluid  could  not  be 
demonstrated  in  the  abdominal  cavity.  No  mass  found  in  the  abdominal 
cavity.  The  patient  was  etherized  and  examined  but  no  additional  informa- 
tion could  be  gained.  The  temperature  at  this  time  was  99%,  pulse  118, 
respirations  26,  general  condition  poor.  A  diagnosis  of  intestinal  obstruction 
probably  in  the  colon  was  made  and  abdominal  section  advised. 


432  REPORTS  ON  INTESTINAL  OBSTRUCTION  IN  PREGNANCY. 

Operation.— March  7,  1908.  Median  abdominal  incision.  Ascending  and 
transverse  colon  tremendously  distended.  Small  intestines  also  distended. 
Gravid  uterus  reaching  midway  between  the  umbilicus  and  ensiform.  No 
signs  of  inflammation  anywhere  in  the  lower  abdomen.  Appendix  normal  was 
not  removed.  At  the  splenic  flexure  of  the  colon  a  band  of  adhesions  were 
found  constricting  the  bowel.  These  were  cut  and  the  colon  milked  from  the 
ca3cum  past  the  point  of  obstruction.  Abdomen  closed  in  layers.  No  difficulty 
was  experienced  in  this  case  in  bringing  together  the  edges  of  the  abdominal 
incision.  Temperature  dropped  to  normal  the  second  day  after  operation  and 
remained  so  until  her  discharge  from  the  hospital.  Bowels  moved  on  the 
second  day  after  the  administration  of  calomel.  No  further  difficulty  in 
obtaining  bowel  evacuation.  She  was  discharged  from  the  hospital  x\pril 
2,  1908. 

Patient  went  to  term  and  was  delivered  of  a  dead  baby  after  a  difficult 
labor.  Uterus  contracted  normally  and  no  complications  arose  during  the 
puerperium. 

Case  II.  Sara  McG.,  white,  multipara,  age  43.  Admitted  to  St.  Agnes' 
Hospital  December  28,  1908.  She  was  sent  in  with  a  diagnosis  of  pregnancy 
at  6^4  months,  complicated  by  faecal  impaction. 

The  following  history  was  obtained.  Patient  comes  to  the  hospital  com- 
plaining of  inability  to  have  a  bowel  movement,  persistent  vomiting  and  severe 
pain  over  the  sigmoid  flexure.  Father  died  of  asthma,  mother  of  tuberculosis. 
No  history  of  malignant  disease  obtainable. 

She  iiad  chicken-pox  and  measles  in  early  childhood.  Is  subject  to  colds 
and  has  a  cough  most  of  the  time.     Otherwise  she  has  enjoyed  good  health. 

Born  in  the  United  States.  Puberty  at  13  years.  Menstrual  history 
without  interest.  Married  when  22  years  old.  She  has  had  one  child  and  one 
miscarriage.  Labor  was  normal  and  the  miscarriage  without  complication. 
Present  illness  began  in  October,  1908.  It  started  with  difficulty  in  having  a 
stool.  She  would  have  frequent  desire  to  defascate  but  would  be  unable  to 
empty  her  bowels.  This  effort  was  always  associated  with  severe  pain  in  the 
left  inguinal  region.  She  soon  developed  constant  pain  in  this  locality.  She 
does  not  remember  if  this  was  associated  with  any  symptoms  of  inflammation. 
Vomiting  was  persistent.  At  first  the  vomitus  was  dark  green  eventually 
becoming  faecal  in  character.  The  abdomen  became  greatly  distended  and 
there  was  marked  rigidity  especially  over  the  left  side  low  down. 

Physical  Examination. — Patient  appears  debilitated  and  weak.  Heart, 
apex  beat  barely  visible,  palpable  in  fifth  interspace,  one  finger's  breadth  out- 
side the  mid-clavicular  line.  Heart  slightly  enlarged  on  percussion.  Muscles 
sounds  of  poor  quality.  Systolic  murmur  heard  at  the  apex  transmitted  to 
the  axilla.  No  thrill  palpable.  Lungs,  expansion  poor  but  equal  over  both 
sides.  Tactile  fremitus  slightly  increased  on  right  side  over  apex.  Slightly 
diminished  over  the  left  lower  lobe  posteriorly.  Eesonance  impaired  over  the 
right  apex  posteriorly.  Scattered  rales  heard  all  over  right  lung.  Abdomen, 
greatly  distended;  tender  all  over  and  rigidity  is  marked.  There  is  appar- 
ently a  small  mass  in  the  left  inguinal  region.     Temperature  on  admission  98 


REPORTS  ON  INTESTINAL  OBSTRUCTION  IN  PREGNANCY.  433 

degrees,  pulse  100,  respirations  24.  Urine  negative  for  casts,  albumin,  sugar 
and  indican.  A  leucocyte  count  made  two  daj'S  after  admission  showed  16,000 
white  cells.  A  differential  count  was  not  made.  The  pulse  and  temperature 
remained  normal  and  the  patient's  general  condition  improved.  There  was  no 
vomiting  while  she  was  in  the  hospital  and  all  her  pain  disappeared.  On 
accoimt  of  the  improvement  in  the  condition  of  the  patient  we  felt  that  we 
might  be  dealing  with  a  faecal  impaction  and  every  effort  was  made  to  obtain 
a  bowel  movement.  In  this  we  were  unsuccessful  and  an  operation  was 
decided  upon. 

Operation. — Under  ether  anaesthesia  a  median  abdominal  incision  was 
made  and  a  growth  the  size  of  an  orange  involving  the  sigmoid  was  found. 
The  colon  above  the  point  of  obstruction  was  greatly  distended  and  filled 
with  liquid  fasces.  The  colon  was  opened  and  drained.  The  mass  was  excised 
and  an  end-to-end  anastomosis  was  made.  The  walls  of  the  gut  both  above  and 
below  the  growth  were  very  friable,  so  that  we  had  difficulty  in  preventing  the 
sutures  from  tearing  through.  Fearing  for  the  integrity  of  the  anastomosis  a 
small  gauze  drain  was  carried  down  to  the  site  of  operation  and  brought  out 
of  the  lower  angle  of  the  wound.  The  incision  was  closed  in  layers  and  great 
difficulty  was  experienced  in  bringing  the  edges  of  the  incision  together  though 
the  uterus  was  not  taken  out  of  the  abdominal  cavity.  I  regretted  at  the  time 
that  I  did  not  do  a  Caesarean  section  as  I  felt  sure  that  the  incision  would  break 
down  and  that  the  patient  would  abort. 

The  bowels  moved  the  day  following  operation  without  recourse  to  any 
measures  to  provoke  the  same.  The  temperature  remained  normal  though  the 
pulse  rate  was  slightly  increased.  The  drain  was  removed  on  the  third  day 
and  was  followed  by  a  serous  discharge.  Several  days  later  this  discharge  had 
a  slight  faecal  odor.  This  ceased  in  two  days  and  the  sinus  entirely  closed 
about  the  eighth  day  after  operation.  The  sutures  in  the  middle  part  of  the 
woimd  cut  through  and  the  incision  separated  without  infection.  The  patient's 
post-operative  history  was  without  further  complication  for  some  days.  The 
temperature  and  pulse  remaining  normal.  On  the  sixteenth  day  after  opera- 
tion the  temperature  was  normal  and  pulse  90.  Blood  examination  showed 
haemoglobin  65  per  cent.,  red  cells  3,110,500,  leucocytes  9,500.  Polymorpho- 
nuclear 80  per  cent.,  small  l}Tnphocyte8  10  per  cent.,  large  l}Tnphocytes  6  per 
cent.,  transitional  3  per  cent.,  eosinophiles  1  per  cent. 

On  the  morning  of  the  seventeenth  day  she  was  seized  with  excruciating 
pain  over  the  appendix.  At  first  we  thought  that  this  might  be  due  to  oncom- 
ing labor  but  an  examination  failed  to  confirm  this  opinion.  At  no  time 
during  the  day  did  she  have  any  signs  of  labor.  The  temperature  rose  to  100% 
and  pulse  to  134,  and  respirations  to  34.  A  blood  examination  showed  the 
following:  leucocytes  24,000;  pol}Tnorphonuclear  90  per  cent.,  small  lympho- 
cytes 7  per  cent.;  large  lymphocytes  1  per  cent.;  transitional  1  per  cent.; 
eosinophiles  1  per  cent. 

A  diagnosis  of  acute  appendicitis  was  made  but  the  husband  of  the  patient 
could  not  be  located  to  obtain  consent  to  reopen  the  abdomen.  The  patient 
refused  operation  herself.  Early  in  the  evening  of  the  same  day  labor  began 
6 


434  MEDICO-LEGAJ^. 

and  was  terminated  in  two  hours.  A  seven  months'  foetus  was  delivered  which 
lived  four  hours.  The  uterus  failed  to  contract  and  the  patient  had  a  severe 
post-partum  haemorrhage  which  was  controlled  by  packing  with  gauze.  After 
the  labor  the  patient's  condition  was  extremely  bad  and  we  did  not  feel  justi- 
fied in  attempting  any  further  surgical  interference  though  by  this  time  we 
had  obtained  full  consent  to  do  whatever  was  thought  best  for  the  patient.  The 
following  day  the  patient  was  still  desperately  ill  and  we  decided  again  not 
to  interfere.  On  the  third  day  there  was  a  localized  mass  in  the  appendiceal 
region  apparent  in  close  relationship  with  the  uterus.  The  patient's  condition 
was  better  and  the  pulse  and  temperature  showed  a  tendency  to  fall.  As  the 
process  was  apparently  localizing  itself  it  was  decided  to  wait  until  the  patient's 
condition  would  justify  an  abdominal  section.  On  this  day  the  hemoglobin 
was  60  per  cent.;  red  cells  3,200,000;  leucocytes  20,000;  polymorphonuclear 
89  per  cent.;  small  l^nrnphocytes  6  per  cent.;  large  lymphocytes  2  per  cent.; 
transitional  1.5  per  cent.;  eosinophiles  1.5  per  cent.  Five  days  later  the  mass 
seemed  more  superficial  and  closely  attached  to  the  uterus.  The  incision  as 
has  been  noted  had  separated  and  a  gi'ooved  director  was  run  underneath  the 
fascia  until  it  reached  the  outer  margin  of  the  mass  when  it  was  plunged  into 
the  abscess  cavity  and  a  large  quantity  of  pus  escaped.  With  the  escape  of  pus 
the  temperature  and  pulse  fell  to  normal  and  the  patient  has  made  a  good 
recovery.  Of  course  we  are  not  prepared  to  say  in  the  light  of  previous 
drainage  that  this  was  an  attack  of  appendicitis  but  the  location  of  the  lesion 
and  the  history  of  acute  onset  after  sixteen  days  of  afrebile  convalescence  leads 
us  to  strongly  suspect  the  correctness  of  the  inference.  Pathologic  report  of 
mass  showed  it  to  be  inflammatory  in  character. 
113  South  Twentieth  Street. 


MEDICO-LEGAL. 

Bt  E.  S.  McKEE,  M.D., 
Associate  Editor  New  York  Medico-Legal  Journal. 

CINCINNATI,    OHIO. 
POST-MORTEM    RIGHTS. 

A  BROAD  and  sane  verdict  has  been  recently  rendered  by  the  Court  of 
Appeals  of  Georgia.  It  had  reference  to  the  rights  of  the  physician-in-charge 
to  hold  a  post-mortem  in  case  of  death  in  which  he  is  seriously  in  doubt  as  to 
its  cause.  The  court  held  that  the  plaintiff's  contention  tliat  the  body  of  his 
wife  had  been  unlawfully  mutilated  to  gratify  professional  curiosity  was 
unjustified,  and  that,  while  the  husband  was  entitled  to  the  body,  the  laws  of 
health,  duly  enacted  in  order  that  the  living  might  be  protected,  are  salutary 
and  ought  to  be  obsei-ved.  Plaintiff's  wife  was  taken  ill  and  was  placed  by  her 
family  doctor  in  the  free  ward  of  a  hospital  where  she  was  entrusted  to  the 
care  of  the  hospital  surgeon.  In  a  short  time  she  died.  It  was  necessary  to 
know  the  cause  of  death  in  order  to  make  out  a  burial  certificate.     The  hospital 


MEDICOLEGAL,  435 

surgeon  made  a  slight  incision  in  the  side  of  the  corpse,  which  was  sewed  up 
and  was  not  perceptible.  Common  sense  suggests  to  a  few  friends  of  deceased 
patients  that  it  was  a  matter  of  importance  to  them  as  well  as  to  science  to  be 
sure  as  to  exactly  what  killed  their  parent  or  friend.  Some  few  are  not  only 
willing  but  anxious  that  the  interests  of  science  should  be  served  by  not  only  a 
post-mortem  on  their  friends  but  also  themselves,  when  dead.  The  majority, 
however,  in  this  land  of  the  free,  object  and  some  dead-beats  will  sue  for 
imaginary  infringements  of  their  feelings.  A  few  yield  to  that  broader  con- 
ception, the  common  good.  Contrast  the  state  of  affairs  in  Austria  where 
practically  every  person  who  dies  is  post-mortemed,  without  any  question,  or 
interference  from  the  relatives.  An  autopsy  there  is  taken  for  granted  while 
in  this  countiy  it  must  often,  if  taken  at  all,  be  by  force,  strategy  or  persuasion. 
If  more  courts  were  as  broadly  humane  as  that  of  Georgia,  pathology  would 
grow  in  our  country  as  it  has  in  Austria.  Our  vital  statistics  would  then  be 
more  complete  and  accurate  than  at  present  possible.  If  a  patient  and  his 
friends  have  confidence  enough  in  a  physician  to  employ  him  in  a  serious  illness 
and  to  stick  to  him  till  the  end  why  should  this  confidence  not  continue  when 
he  advises  an  autopsy? 

THE  MARRIAGE  STATE  REGULATED  BY  THE  STATE. 

It  seems  surely  settled  that  about  eighty  per  cent,  of  the  men  of  our  time 
have  or  have  had  the  gonorrhoea.  This  being  without  denial  it  can  not  be 
denied  that  it  is  time  that  the  government  of  this  great  country  steps  in  and 
protects  its  children.  It  is  confessed  that  this  condition  is  responsible  for  a 
large  per  cent,  of  the  childless  marriages  and  sightless  children.  This  govern- 
ment of  the  people,  for  the  people  and  by  the  people  can  not  continue  unless 
the  ravages  of  this  diplococcus  of  Neisser  be  not  checked.  The  State  of 
Pennsylvania  has  pending  before  its  legislature  a  law  the  vital  section  of  which 
provides  that  the  clerk  of  the  court  "shall  not  issue  to  any  person  a  marriage 
license  until  each  of  the  parties  applying  therefor  shall  severally  present  to  the 
clerk  a  certificate,  under  oath  of  affirmation  from  a  medical  doctor,  duly 
authorized  to  practice  medicine  under  the  laws  of  the  Commonwealth,  setting 
forth  that  he,  the  said  medical  doctor,  does  declare,  to  the  best  of  his  knowledge 
and  belief  the  applicants  for  the  license  are  not  afflicted  with  pulmonary  tuber- 
culosis, epilepsy,  insanity,  imbecility,  idiocy  or  other  hereditary  diseases  as 
such  would  affect  the  other  contracting  party  to  the  marriage  or  offspring 
therefrom."  It  is  very  much  to  be  regretted  that  gonorrhoea  was  not  included 
in  this  list  that  twenty  per  cent,  of  the  blindness  and  seventy  per  cent,  of  the 
g}Tia3Cological  operations  might  be  prevented.  No  disease  to  which  flesh  is 
heir  to  is  so  readily  transmitted  in  the  conjugal  bed  as  this  spoiler  of  conjugal 
happiness  nor  is  there  any  which  is  hidden  more  vigilantly. 

THE  CENSORSHIP  OF   SEX  LITERATURE. 

Mr.  Theodore  Schroeder  of  the  New  York  bar,  has  an  article  of  much 
value  in  the  March,  1909,  issue  of  the  Medical  Council,  of  Philadelphia.  He 
says  that  physicians  have  sat  by  unconcerned  while  political  theologasters  have 


436  MEDICO-LEGAL. 

developed  a  censorship  over  sex  discussions  which  by  its  compulsory  ignorance 
and  theological  misrepresentation  of  a  most  vital  function  is  filling  our  insane 
asylums  to  overflowing  and  even  keeping  the  American  physician  in  relative 
ignorance.  Indeed  you  have  been  so  indifferent  to  this  censorship  that  you 
haven't  discovered  of  what  it  has  deprived  you.  We  have  upon  Federal  and 
State  statute  books  penal  laws  against  "obscene  and  indecent  literature,"  but 
no  criteria  of  "obscenity  or  indecency,"  are  furnished.  He  then  proceeds  to 
give,  by  examples,  what  may  and  has  been  suppressed  adding  that  much  which 
has  been  suppressed  is  done  so  by  merely  threatening  suppression  as  the  threat- 
ened publishers  are  only  too  glad  to  withdraw  their  publications  and  keep  the 
matter  quiet.  Mr.  Schroeder,  after  relating  a  number  of  instances  where  valu- 
able writings  were  suppressed  on  the  say-so  of  some  post  office  clerk  or  some 
scientist  was  fined  on  the  interpretation  of  a  jury  of  farmers,  asks.  What  are  you 
physicians  going  to  do  about  it?  A  bill  has  been  introduced  into  the  United 
States  Congress  which  adds  the  term  "filth"  to  the  other  adjectives.  Who  is  to 
be  the  judge  as  to  what  is  filth  in  literature  and  art  ?  Is  it  not  about  time  that 
the  medical  profession  asserts  itself  in  resisting  these  aggressions  of  moral 
sentimentalism.  Isn't  it  about  time  that  you  wrote  your  United  States  Senator 
a  protest  against  the  passage  of  this  new  amendment  to  the  postal  laws  ?  Isn't 
it  about  time  that  you  have  some  discussion  on  these  things  at  the  meeting  of 
your  medical  societies?  If  not,  then  it  must  be  that  you  are  unwilling  to 
assume  the  responsibility  of  becoming  the  sane  and  scientific  leaders  which 
your  profession  should  qualify  you  for,  and  you  are  willing  to  let  matters  drift 
along  under  the  pernicious  influences  of  those  who  deal  only  in  the  physiology 
of  sex. 

THE   BIBLE    JUDICIALLY   DECLARED  OBSCENE. 

That  distinguished  eccentric,  George  Francis  Train,  in  1872,  was  arrested 
for  circulating  obscene  literature.  This  proved  to  consist  of  quotations  from 
the  Scriptures.  Train  and  his  attorneys  sought  a  decision  on  the  obscenity  of 
the  matter  maintaining  that  it  was  not  so.  The  prosecutor  in  his  perplexity 
and  in  spite  of  the  protest  of  the  defendant  insisted  that  Train  was  insane. 
The  court  refused  to  discharge  the  prisoner  as  one  not  having  circulated  obscene 
literature  and  directed  the  jury  against  their  own  judgment  to  find  him  not 
guilty  on  the  ground  of  insanity,  thus,  by  necessary  implication,  deciding  the 
Bible  to  be  criminally  insane.  Upon  writ  of  habeas  corpus  Train  was  adjudged 
insane  and  discharged.  Thus  an  expressed  decision  on  the  obscenity  of  the 
Bible  was  avoided  though  the  inference  was  of  its  criminality.  A  Cleveland 
paper  was  later  seized  and  destroyed  for  publishing  this  same  quotation.  Here 
then  was  a  direct  adjudication  that  parts  of  the  Bible  are  indecent  and  there- 
fore unmailable.  John  B.  Wise,  of  Clay  Center,  Kansas,  in  1895,  was  arrested 
and  fined  for  sending  obscene  literature  through  the  mails  which  again  con- 
sisted wholly  of  quotations  from  the  Bible.  On  precedents  already  established 
juries  of  irreligious  men  could  wholly  suppress  the  circulation  of  the  Bible. 
In  some  States  the  existing  laws  would  authorize  its  seizure  and  destruction. 
This  is  possible  because  the  maxim,  now  scientifically  demonstrable  is  not 


COLD  STORAGE  CHICKEN  AS  FOOD.— STROPHANTHUS.       437 

heeded,  viz :  to  the  pure  all  things  are  pure.  Mr.  Theodore  S.  Schroeder  of  the 
New  York  bar,  who  has  written  on  "Censorship  of  Sex  Literature,"  denounces 
this  law  because  under  it  may  be  destroyed  books  containing  records  of  human 
folly  and  error  from  which  we  may  learn  valuable  lessons  for  avoiding  the 
blight  from  violating  nature's  laws.  Under  our  present  statutes,  says 
Schroeder  from  whose  paper  in  the  Medical  Council  so  much  of  this  is  obtained, 
some  of  the  writings  of  the  greatest  historians  and  literary  masterpieces  have 
been  suppressed.  Unknown  injury  has  been  done  to  science  by  the  suppression 
of  books  of  which  the  public  has  never  heard,  the  authors  being  too  sensitive 
to  let  the  matter  become  public. 


OBSERVATION  ON  THE  EFFECT  OF  TASTELESS  COLD  STORAGE 
CHICKEN  USED  AS  FOOD.' 

By  EPHRAIM  CUTTER,  M.D. 

To  all  students  of  many  years  new  phenomena  happen.  After  fifty-five 
years  of  urinoscopy  the  following  is  a  new  experience,  and  the  writer  would 
like  to  know  if  it  is  not  new  to  others.  A  patient  I  have  watched  carefully, 
as  he  had  once  in  a  while  epithelia,  caudate,  acute,  and  right-angled,  double 
nucleated,  etc.,  which,  as  his  family  is  cancerous,  the  writer  has  deemed  a 
valuable  sign.  Said  patient  dined  out  the  other  day,  and  partook  of  taste- 
less stewed  chicken,  long  in  cold  storage.  The  next  day  he  did  not  feel  well 
and  urinoscopy  revealed  much  albumin  and  many  cells  of  the  cancer  type 
(mobtiss),2  but  intensely  typical  in  all  respects,  and  more  so  than  usual. 
Quite  a  number  had  two,  some  three,  some  four  and  some  five  nuclei  well 
marked.  But  the  next  day  the  mobtiss  were  all  gone,  save  albumin.  Possi- 
bly it  may  be  exceptional.  This  is  what  I  want  to  know,  and  thus  I  ask  the 
readers  of  this  medical  journal  to  tell  if  they  have  known  like  cases;  for,  if 
true,  it  goes  to  show  the  dangers  of  cold  storage  chickens  to  some  people. 

West  Falmouth,  Mass., 
April  24,  1909. 


Editorial 


STROPHANTHUS. 

The  natural  habitat  of  strophanthus  is  Africa  and  tlie  varieties  oflScial  and 
recognized  to  possess  medicinal  principles  are  strophanthus  kombe,  strophan- 
thus hispidus  and  strophanthus  gratus.     The  kombe  variety  is  probably  the 

1  Op.  170,  Series,  July,  1905. 

2  Mobtiss  is  my  new  name  for  cancer.  See  Journal  American  Association.  May  22, 
1909,  page  1725,  "Early  Diagnosis  of  Gastric  Carcinoma  from  Cytologic  Examination  of 
the  Rinsing  Water,"  Dr.  G.  Marim,  from  Archiv.  fiir  VerdaUungs  Krankheiten,  Berlin. 


438  STROPHANTHUS. 

most  plentiful,  while  the  hispidus  variety  is  quite  extensively  cultivated  in  the 
German  colony  of  Togo. 

Its  chief  active  principle  is  strophanthin,  a  glujcoside  obtained  from  the 
seed,  which  is  easily  decomposed  by  mineral  acids,  precipitated  by  tannic  acid, 
readily  soluble  in  water  and  alcohol,  but  almost  insoluble  in  ether  and  chloro- 
form. A  bright  green  color  is  produced  when  a  portion  of  this  glucoside  is 
brought  in  contact  with  sulphuric  acid  containing  a  trace  of  ferric  chloride. 

There  is  probably  no  other  drug  in  the  domain  of  medicine  that  has  such  a 
variability  in  physiological  activity  as  have  the  different  specimens  of  strophan- 
thus.  It  is  claimed  that  in  order  to  obtain  a  reliable  preparation  of  this 
drug  the  seeds  should  be  bought  in  the  follicles  and  tested.  An  assay  based  on 
the  amount  of  extractives  contained  in  a  given  tincture  of  strophanthus  is  of 
little  value  since  the  extractives  consist  largely  of  chlorophyl  and  other  inert 
substances.  Hence  the  poor  results  so  often  observed  in  the  administration  of 
strophanthus.  The  writer  knows  of  a  popular  and  successful  physician  who 
administered  a  half  drachm  of  the  tincture  of  strophanthus  four  times  daily 
to  a  patient  suffering  from  mitral  regurgitation  with  loss  of  compensation 
without  any  appreciable  results.  Consequently,  he  condemned  strophanthus 
as  possessing  any  medicinal  value  in  heaii;  diseases.  Of  course  he  has  had  a 
preparation  that  possessed  very  little  of  the  active  principle,  strophanthin.  Not 
only  is  the  crude  drug  often  found  mixed  with  other  vegetable  substances,  but 
the  strophanthin  supplied  by  different  manufacturers  is  also  unreliable  and 
one  sample  has  been  found  to  be  ninety  times  as  strong  as  another.  Owing  to 
the  extreme  toxicity  of  strophanthin,  caution  should  be  exercised  in  prescribing 
it  and  to  secure  a  standard  preparation. 

Locally  it  acts  as  an  anesthetic  and  irritant. 

Internally  it  is  a  bitter  tonic,  promoting  the  appetite  and  digestion,  if 
given  in  small  doses.  Its  principle  use  is  a  cardiac  tonic,  resembling  digitalis. 
Strophanthus  slows  the  heart-beat,  lengthens  the  intervals  between  the  con- 
tractions and  increases  the  energy  of  the  muscular  tissue.  Some  effect  is  also 
seen  upon  the  arteries,  but  the  rise  of  blood-pressure  is  due  principally  to  the 
increased  force  of  the  cardiac  contractions.  In  cases  poisoned  by  the  use  of 
this  drug  the  heart's  action  is  arrested  in  diastole,  and  there  is  marked  irritation 
of  the  gastro-intestinal  tract  and  kidneys. 

In  medicinal  doses  strophanthus  acts  quicker  than  digitalis.  It  does  not 
disturb  the  gastro-intestinal  canal,  and  does  not  possess  an  accumulative  action. 
But  on  the  other  hand,  the  good  effects  are  not  so  lasting  as  are  those  of 
digitalis.  It  also  has  a  quieting  effect  upon  the  brain  and  medulla  and  has 
some  diuretic  power. 

Strophanthus  possesses  distinct  advantages  over  digitalis  and  it  is  equally 
certain  that  it  is  free  from  the  greatest  danger  which  the  use  of  digitalis  entails 
— namely,  vasoconstriction.  With  a  wider  and  more  rapid  dissemination  of 
knowledge,  concerning  this  drug  and  its  therapy,  we  hope  that  within  a  com- 
paratively few  years  we  may  have  strophanthus  used  as  carefidly  as  digitalis 
to-day. 


ALOPECIA  OF  DENTAL  ORIGIN. 


AMCEBIC  DYSENTERY. 


439 


Materia  ^cdica  and  Therapeutics 


ALOPECIA  OF  DENTAL  ORIGIN. 

Dr.  Eousseau-Decelle  gives  the  fol- 
lowing characteristics  of  alopecia,  as- 
scrihed  first  by  Jacquet  to  dental 
troubles.  It  often  follows  a  painful 
attack  of  trigeminal  neuralgia  caused 
by  the  teeth  (eighteen  out  of  twenty- 
five  cases).  This  attack  may  precede 
the  depilation  by  two  or  three  months, 
but  more  commonly  it  occurs  in  the 
preceding  month.  2.  It  occurs  on  the 
same  side  as  the  trigeminal  attack, 
more  frequently  on  the  left  side, 
because  dental  lesions  are  more  common 
on  the  left  side.  3.  It  appears  by  pref- 
erence in  certain  predisposed  zones,  as 
if  there  was  a  relation  between  the  seat 
of  the  dental  irritation  and  the  seat  of 
the  initial  area  of  alopecia.  Thus  in 
sixteen  cases  of  trouble  with  the  lower 
wisdom  tooth  the  author  found  alopecia 
localized  on  the  same  side  of  the  nucha 
in  fourteen.  4.  It  follows  alveolar  and 
gingival  irritation  rather  than  dental 
irritation  proper.  Thus  in  twenty-five 
cases  of  dental  alopecia  the  author 
traced  the  cause  in  three  cases  to  in- 
flammation of  the  dental  pulp,  in  the 
remaining  twenty-two  to  troubles  out- 
side the  teeth.  These  irritations  seem 
to  act  differently  upon  the  trigem- 
inus. 5.  It  is  accompanied  by  certain 
phenomena,  such  as  hyperaesthesia, 
erythrosis,  hyperthermia,  adenopathy, 
lymphangitis,  and  oedema,  grouped  by 
Jacquet  under  the  name  of  the  dental 
syndrome.  6.  The  areas  are  generally 
small  in  size  and  few  in  number.  7. 
The  prognosis  is  good.  8.  The  cure  is 
rapid  and  often  immediate  after  dental 
intervention  alone.  (Presse  Medicale, 
February  6,  1909.) 


AMCEBIC    DYSENTERY. 

Dr.  Granville  S.  Hanes,  Louisville, 
Ky.,  remarks  that  it  was  recently  be- 
lieved that  amoebic  dysentery  was  purely 
a  tropical  disease  or  acquired  only  in 
those  regions.  A  theory  has  been  sug- 
gested, that  cases  occurring  in  our  cli- 
mate are  due  to  eating  uncooked  tropical 
fruits  on  which  the  amoeba  had  been 
imported.  There  is  no  scientific  evidence 
in  the  support  of  this  theory  and  cases 
occur  in.  which  its  possibility  can  be 
excluded.  He,  and  his  partner  Dr. 
Mathews,  have  had  half  a  dozen  such 
cases  imder  their  care  in  the  past  few 
months,  two  of  which  are  reported.  In 
both  of  these  the  evidence  was  strongly 
in  favor  of  impure  drinking  water  as  the 
cause.  He  thinks  that  amoebas  are 
indigenous  in  this  country,  but  the  less 
favorable  environment  than  in  the  trop- 
ics, render  them  less  in  number  and 
virulence,  and  the  disease  caused  by  them 
is  consequently  rarer  and  less  severe. 
The  diagnosis  is  always  made  with  the 
microscope  and  he  does  not  rely  on  the 
examinations  of  the  dejections  alone,  but 
inverts  the  patient  and  scrapes  the  ulcers 
with  a  sharp  curette.  In  this  way  the 
amoebas  will  be  observed  at  once  if  they 
can  be  found  at  all.  It  may  be  difficult 
to  find  motile  amoebas  while  the  patient 
is  under  actual  treatment,  and  in  such 
cases  he  discontinues  the  treatment  for  a 
few  days  and  they  appear  again.  Warm- 
ing the  stage  is  also  an  important  meas- 
ure in.  detecting  them  under  the  micro- 
scope. He  is  convinced  that  there  are 
large  numbers  of  people  in  this  country 
suffering  from  unrecognized  amoebic  dys- 
enter}^  cancer  or  tuberculosis  being  the 
most  usual  diagnosis  after  the  patient 


440    CHLOROFORM  IN  HEMOPTYSIS. 


COPPER  SUBACETATE  INHALATION. 


becomes  emaciated.  No  one  plan  of 
treatment  has  been  f  omid  universally  suc- 
cessful and  relapses  are  always  to  be 
anticipated  as  possible.  When  the  inter- 
val, however,  is  a  number  of  years,  Hanes 
thinks  we  should  consider  reinfection  as 
the  possible  cause.  There  is  nothing 
that  will  prevent  possible  reinfection  as 
long  as  the  patient's  environment  is 
unchanged.  Too  restricted  diet  he  thinks 
is  a  great  mistake  in  these  cases,  but  rest 
is  an  important  feature  in  the  treatment 
of  the  disease.  Of  remedies  given  inter- 
nally, ipecacuanlia  is  the  most  to  be  relied 
on.  It  does  not  perhaps  kill  the  amoeba 
but  it  destroys  its  pathogenic  power.  A 
large  number  of  parasiticide  injections 
have  been  employed  but  none  is  univer- 
sally effective.  Quinine  has  been  largely 
used  but  it  is  sometimes  an  absolute 
failure.  Hanes  has  employed  coal  oil, 
knowing  its  generally  parasiticidal  ef- 
fects. He  at  first  employed  it  with 
great  caution,  but  latterly  has  come 
to  use  it  with  boldness,  and  he  now  has  no 
hesitancy  in  injecting  a  quart  or  more  of 
undiluted  coal  oil  through  the  rectum  or, 
in  the  cases  of  appendicostomy,  through 
the  appendix,  the  patient  being  then 
requested  to  keep  the  recumbent  posture 
for  half  an  hour  or  longer.  He  is  not 
prepared  to  make  definite  statements  as 
to  the  influence  of  oil  on  the  amoibas, 
but  expects  to  be  able  to  do  so  in  the 
future.  All  the  patients  in  whom  he 
has  employed  this  treatment  except  two 
have  responded  beautifully.  In  the  two 
cases  mentioned  he  was  not  allowed  to 
carry  out  the  method  in  detail,  and  he 
has  advised  appendicostomy  and  will 
keep  the  patients  under  observation  and 
report  later  on  the  results.  (Journal 
American  Medical  Association,  June  19.) 


successful  use  of  chloroform  in  pulmo- 
nary hemorrhage  (Journal  American 
Medical  Association,  March  13,  1909, 
page  883),  says  that  he  has  continued  his 
experiments  and  now  practices  this  treat- 
ment alone  in  such  cases.  The  effect  of 
chloroform  on  the  circulation  is  chiefly 
to  decompress  the  vasomotor  system, 
causing  an  extraordinary  fall  of  blood- 
pressure.  Complete  vascular  relaxation 
follows  and  the  patient,  so  to  speak,  is 
bled  into  his  own  vessels.  There  is  also 
some  cardiac  enfeeblement  and  dilatation, 
which  also  contribute  to  lowering  the 
blood-pressure.  Chloroform  has  also  a 
depressant  effect  on  the  respiration,  and, 
as  it  produces  the  coagulation  of  the 
blood  in  vitro,  it  is  possible  that  some 
direct  contact  with  the  bleeding  point  by 
the  vapor  may  also  have  some  effect.  He 
describes  his  mode  of  administration  of 
from  2  to  4  c.c.  of  chloroform  on  an 
ordinary  inhaler  or  wad  of  cotton  held 
near  the  nostrils  of  the  patient.  The 
ha3morrhage  will  cease  within  5  or  10 
minutes,  and  during  the  following  24  or 
48  hours  the  patient  will  be  bringing  up 
blood  clots.  The  inhalation  of  from  15 
to  20  drops  every  hour  is  continued  for  a 
few  days  and  ammonium  chlorid,  with 
small  doses  of  codein,  is  given  internally 
every  4  hours  to  expel  the  retained  secre- 
tions and  prevent  excessive  coughing.  It 
is  a  good  plan,  he  says,  also  to  give  a 
teaspoonful  of  magnesium  sulphate  to 
keep  the  bowels  free.  In  the  limited 
number  of  cases  in  which  he  has  used  this 
treatment  the  results  have  been  all  that 
could  be  desired,  and  he  recommends  it  to 
further  trial  by  others.  (Journal  Ameri- 
can Medical  Association,  June  12th.) 


CHLOROFORM  IN  HEMOPTYSIS. 

Dr.  Joseph  B.  Fish,  Edgewater,  Colo., 
after  referring  to  a  previous  paper  on  the 


COPPER    STJBACETATE    INHALATION    IN 
THE  TREATMENT  OF  TTJBERCTILOSIS. 

Billard  noticed  improvement  in  the 
condition  of  two  consumptives  after  they 
obtained  work   in   a  factory  producing 


FERRATIN. 


441 


copper  subacetate.  Tliey  were  employed 
in  packing  the  verdigris,  and  soon  began 
to  improve  and  had  no  further  hasmor- 
rhages  from  the  lungs,  while  they  re- 
gained appetite  and  weight.  The  verdi- 
gris dust  is  thick  in  some  of  the  rooms, 
but  none  of  the  employes  seem  to  notice 
it,  and  no  coughing  is  heard  in  the 
factory.  These  and  other  facts  observed 
led  Billard  to  attribute  healing  power  to 
the  verdigris  dust  inhaled  and  he  decided 
to  use  it  in  treatment.  He  has  been 
treating  thirty  patients  systematically  in 
this  way  since  last  August  and  with 
encouraging  results.  He  orders  the  pa- 
tient to  buy  about  2  poimds  of  pulverized 
copper  subacetate,  as  chemically  pure  as 
possible.  It  is  poured  into  a  basin  and 
some  is  taken  up  on  a  card  and  poured 
back  into  the  basin  from  a  height;  this 
process  is  repeated  again  and  again  and 
the  dust  is  inhaled  as  it  rises.  The  ver- 
digris ceases  to  give  off  dust  in  about 
two  weeks,  and  it  is  ground  over  again. 
Half  an  hour  morning  and  evening  is  the 
general  rule  for  this  treatment.  In 
every  case  in  which  the  patients  followed 
it  the  cough  and  expectoration  subsided 
or  ceased,  while  the  patients  gained  in 
weight  and  strength  and  the  stethoscope 
showed  a  retrogression  of  the  lesions. 
The  only  exceptions  to  this  were  in  the 
acute  cases  with  fever;  these  patients 
did  not  seem  to  be  benefited  by  the  treat- 
ment. (Presse  Medicale,  Paris,  April, 
1909.)  , 

FERRATIN. 

In  1894  Schmiedeberg  prepared  a  sub- 
stance from  pig's  liver  by  maceration 
with  boiling  water  and  subsequent  pre- 
cipitation with  tartaric  acid,  which  he 
designated  ferratin.  It  contained  6  per 
cent,  of  iron  in  organic  combination, 
unaffected  by  ammonium  sulphide.  No 
compound  of  a  similar  nature  had  ever 


been  prepared  from  liver  before,  nor,  so 
far  as  Schmiedeberg  Imew,  from  any 
other  organ  of  the  body.  Later  on,  by 
heating  white  of  egg  with  an  alkali  in  the 
presence  of  an  iron  salt  he  obtained  ferri- 
albuminic  acid,  v/hich  he  holds  to  be 
identical  with  the  original  ferratin. 
Moreover,  he  considers  from  the  mode  of 
preparation  that  ferratin  is  the  form  into 
which  iron  must  be  converted  before  ab- 
sorption into  the  system.  If  his  con- 
tention were  true  it  would  raise  ferratin 
to  a  position  of  extreme  importance  in 
the  treatment  of  ancemia.  Experiments 
carried  out  by  Salkowski  did  not  indicate 
that  ferratin  was  in  any  way  superior, 
but  slightly  inferior,  to  paranucleinate  of 
iron,  a  substance  introduced  by  Salkowski 
himself  (Zeit.  fiir  Physiol.  Chemie,  Bd. 
84,  iv,  1909).  Moreover,  no  subsequent 
observer  had  obtained  any  compound  with 
such  a  high  percentage  of  iron  from  the 
liver.  Hammarsten  prepared  a  nucleo- 
proteid  from  the  pancreas  by  a  method 
similar  to  Schmiedeberg's  for  making 
ferratin,  but  substituting  hydrochloric 
for  tartaric  acid.  In  1903  Beccari  pre- 
pared ferratin  by  Schmiedeberg's  method, 
and  found  that  it  only  contained  1.67 
per  cent,  of  iron  (0.52  per  cent,  if  made 
from  ox  liver).  Scaffidi  also  found  a 
nucleoproteid  in  the  liver  of  the  dog, 
containing  0.18  to  0.44  per  cent,  of  iron; 
he  also  obtained  a  nucleoproteid  from 
the  liver  of  the  pig,  containing  1.93  per 
cent,  of  iron,  rising  to  3.59  per  cent, 
after  repeated  washing.  Salkowski  re- 
peated tliese  experiments  on  the  pig's 
liver,  and  obtained  a  nucleoproteid  witli 
a  fairly  constant  percentage  of  phos- 
phorus in  the  case  of  each  liver  examined, 
but  the  amount  of  iron  varied  consider- 
ably. Without  prejudice  to  the  value  of 
ferratin  in  therapeutics,  he  agrees  with 
Beccari  and  Scaflidi  that  the  substance 
prepared    by    Sclmiiedeberg   from    pig's 


442 


HYDROCYANATE  OF  IRON. 


MUSTARD  PACKS  IN  BRONCHITIS. 


liver  was  not  a  new  variety  of  com- 
pound or  a  ferri-albuminic  acid,  but  a 
nucleoproteid  with  a  variable  percentage 
of  iron,  and  that  the  ferri-albumiaic  acid 
prepared  from  white  of  egg  has  no  con- 
nection with  the  iron-containing  proteid 
in  the  liver  substance.  Scaffidi's  results 
are  published  in  the  same  number  of  the 
journal.    (British  Medical,  May  1.  '09.) 


HYDROCYANATE  OF  IRON. 

This  preparation,  which  is  advertised 
as  being  "unexcelled  as  a  remedy  for  epi- 
lepsy, hysteria,"  etc.,  was  subjected  to 
analysis,  and  the  results  appear  in  (The 
Journal  American  Medical  Association, 
June  19th.)  The  term  "hydrocyanate  of 
iron"  is  an  unfamiliar  one  and  was  to  be 
found  in  any  available  reference  work  on 
chemistry.  Thinking  the  term  might 
have  been  loosely  applied  to  ferrocyanid 
of  iron,  or  Prussian  blue  (a  compound 
once  suggested  for  epilepsy,  but  long  ago 
considered  useless),  the  manufacturers 
were  asked  if  such  were  the  case.  They 
replied  that  their  preparation  was  "not 
Prussian  blue  in  any  sense  of  the  word," 
and  added  that  "Prussian  blue  has  no 
curative  properties  as  applied  to  all  forms 
of  epilepsy."  The  inference  dravm  from 
the  company's  literature  was  that  "hydro- 
cyanate  of  iron"  is  a  definite  chemical 
compound.  The  preparation  was  then 
analyzed  and  "from  the  analysis  it  is 
concluded  that  Oiydrocyanate  of  iron 
(Tilden)'  is  essentially  a  mixture  of 
approximately  equal  parts  of  talc  and 
Prussian  blue,  containing  traces  of  or- 
ganic matter  having  the  general  proper- 
ties of  alkaloids." 


MUSTARD  PACKS  IN  BRONCHITIS. 

Dr.  A.  A.  Herzfeld,  New  York,  dis- 
cusses the  excellent  properties  of  mus- 


tard as  a  counter-irritant  in  the  treat- 
ment of  capillary  bronchitis  and  bron- 
chopneumonia in  infants  and  children. 
He  and  his  colleagues  have  been  using 
a  method  devised  by  him  for  the  past 
thirteen  years  with  great  advantage. 
His  method  is  as  follows :  Two  hundred 
and  fifty  cubic  centimeters  of  water  and 
250  cubic  centimeters  of  alcohol  are 
mixed  in  a  large  bowl ;  to  this  are  added 
from  25  to  50  cubic  centimeters,  accord- 
ing to  the  severity  of  the  case,  of  freshly 
prepared  spirit  of  mustard.  The  spirit 
of  mustard  is  prepared  according  to  the 
German  Pharmacopoeia,  as  follows:  Oil 
of  mustard  1  part,  pure  alcohol  49  parts. 
A  large  piece  of  flannel  is  moistened 
with  the  mixture  and  wrapped  around 
the  child  from  the  neck  to  the  knees. 
The  child  is  then  enveloped  in  a  dry 
sheet,  and  the  pack  is  left  on  until  the 
skin  is  a  bright  red,  usually  in  from 
fifteen  to  thirty  minutes.  The  child  is 
then  taken  out  and  wrapped,  and  left 
for  another  half  hour  in  a  pack  wet 
with  1  part  alcohol  and  2  parts  water. 
At  the  end  of  this  time  the  child  is 
wrapped  in  a  dry  sheet.  Usually  one 
pack  causes  marked  improvement,  but 
relapses  are  frequent,  and  it  may  need 
renewal.  Once  in  twenty-four  hours  is 
enough,  unless  the  indications  are  una- 
voidable. The  physician  should  apply 
the  first  pack  himself,  to  determine  the 
strength  needed,  and  to  instruct  the 
parents  or  nurse.  Dr.  Herzfeld  sums  up 
the  advantages  of  the  method  as  fol- 
lows: (1)  It  is  surprisingly  rapid  in 
effect.  (2)  Its  light  weight  does  not 
materially  embarrass  respiration.  (3) 
It  can  be  applied  without  removing  the 
enfeebled  patient  from  the  bed.  (4)  It 
is  inexpensive.  (5)  It  is  clean.  (Jour- 
nal of  the  American  Medical  Associa- 
tion, January  9,  1909.) 


NEW  NOSES,  PROCESS  FOR. 


OBESITY,  TREATMENT  OF. 


443 


NEW  NOSES  IN  TWENTY  MINTITES,  NEW 
PROCESS  FOR. 
Dr.  H.  E.  Allon,  Indianapolis,  Ind., 
gives  the  following  method : — 

1.  Make  a  plaster-of -Paris  cast  or  re- 
production of  the  noseless  face. 

2.  Model  a  half-dozen  or  more  different 
noses  that  are  appropriate  to  the  other 
features  of  the  face. 

3.  If  desirable,  model  other  features  of 
the  face  that  need  improvement. 

4.  Construct  a  hollow  metallic  bridge 
or  supporting  frame  which  will  reproduce 
the  shape  of  the  nose  selected  when  placed 
beneath  the  skin. 

5.  Operation. — Pull  the  upper  lip  for- 
ward, and  then  about  one  centimeter  be- 
low the  gingivolabial  fold  make  an  in- 
cision about  one-third  the  thickness  of 
the  lip  and  running  parallel  with  the  gum 
margins  of  the  upper  teeth.  Let  this 
incision  terminate  about  the  first  molar 
tooth.  Then  complete  the  incision  ver- 
tically and  dissect  the  soft  tissues  of  the 
nose  and  face  free  from  the  skull,  care 
being  taken  not  to  injure  the  nerves 
coming  out  from  the  infra-orbital  fora- 
men nor  the  tear  ducts. 

6.  Then  place  the  nostril  hook  in  the 
nostrils  and  pass  the  points  around  so 
that  they  come  out  underneath  the  upper 
lip. 

7.  Make  traction  upward  and  outward 
upon  the  hook  and  the  entire  field  for 
supporting  the  nose  frame  comes  into 
plain  view. 

8.  Stretch  the  nasal  tissues  forward 
and  prepare  the  foundation  for  the  bridge 
or  metallic  support  for  the  new  nose. 

9.  Place  the  new  hollow-metallic  bridge 
under  the  lip  where  it  is  to  rest  perma- 
nently. 

10.  Suture  the  original  wound. 

In  the  event  there  is  no  soft  tissues  of 
the  nose  and,  consequently,  nothing  under 


which  to  place  a  metallic  bridge  the  con- 
structive principles  differ,  inasmuch  as 
it  is  necessary  to  dissect  up  the  skin  on 
each  side  of  the  nasal  orifice  and  draw 
the  skin  together  and  suture  it  in  the 
median  line.  Make  periosteal  openings. 
Later  on,  when  a  firm  union  is  estab- 
lished, the  regular  gingivolabial  incision 
is  made  and  the  nose-construction  opera- 
tion proceeds  as  described.  (The  Lancet- 
Clinic,  May  8,  1909.) 


OBESITY,  PRINCIPLES  FOR  TREAT- 
SIENT  OF. 

Dr.  Kisch  believes  that  the  fatter  the 
organism  the  lesser  amount  of  albumin 
required  in  proportion.  Obesity  result- 
ing from  too  hearty  food  a  man  weighing 
200  pounds  can  do  well  on  1,100  calories, 
remembering  that  1  Gm.  of  albumin,  as 
also  of  carbohydrates,  produces  4.1  cal- 
ories and  1  Gm.  of  fat  9,1  calorics.  Kisch 
does  not  believe  in  overloading  such 
patients  with  bulky  salads,  apples,  pota- 
toes and  the  like  on  account  of  the  tend- 
ency to  dyspepsia.  Systematic  exercise 
is  important  for  this  form  of  obesity — 
Mastfettleibigkeit.  The  obesity  result- 
ing from  constitutional  causes,  congenital 
or  acquired  in  consequence  of  some  path- 
ologic process,  requires  different  treat- 
ment. The  aim  here  should  be  to  im- 
prove the  blood  production  and  influence 
the  cellular  processes.  Iron  is  useful 
and  the  diet  must  be  regulated  to  supply 
plenty  of  albmnin,  while  avoiding  sub- 
stances that  produce  fat.  The  diet  for 
twenty-four  hours  should  average  for  the 
ordinary  patient  200  Gm.  albumin,  13 
Gm.  fat  and  100  Gm.  carbohydrates. 
The  intake  of  fluid  should  be  regulated 
by  the  amount  of  diuresis.  Exercise 
should  be  very  cautiously  taken,  in  order 
not  to  fatigue  the  easily  exhausted  heart. 
(Therapie  der  Gegenwart,  April,  1909.) 


444 


PHOSPHORUS  AS  BRAIN  FOOD. 


PROTARGOL. 


PHOSPHORUS  AS  BRAIN  FOOD. 

Dr.  W.  Koch,  Chicago,  has  investigated 
the  phosphorus  content  of  the  brain  in 
health  and  disease  and  finds  that  even  in 
conditions  of  extreme  exhaustion,  the 
brain  is  plentifully  supplied,  not  only 
with  phosphorus,  but  also  with  its  special 
form  of  phosphorus,  namely,  lecithin. 
He  concludes,  therefore,  that  there  is  no 
evidence  of  any  need  to  supply  phos- 
phorus to  the  brain  in  such  conditions. 
The  actual  amount  lost  in  the  exhaustion 
of  general  paralysis  can  not,  of  course,  be 
replaced  on  account  of  the  inability  of 
the  central  nervous  system  to  regenerate. 
The  phosphorus  required  for  the  growth 
of  the  brain  is  amply  supplied  by  the 
phosphorus  of  our  daily  diet.  If  desired, 
the  addition  of  phosphorus-rich  foods, 
such  as  eggs,  sweetbreads,  liver  and  some 
meats,  can  be  made  and  meet  further 
requirements,  and  will  do  far  better  in 
this  way  than  dosing  with  the  various 
phosphorus-containing  drugs  in  commer- 
cial use.  The  use  of  such  foods,  however, 
is  limited  by  their  richness  and  their 
tendency,  on  account  of  their  fat  con- 
tents, to  disturb  gastric  digestion.  So 
far  as  the  nervous  system  is  concerned, 
the  addition  to  the  diet  of  commercial 
phosphorus  compounds,  such  as  hypo- 
phosphites,  glycerophosphite,  phytin,  lec- 
ithin, etc.,  is  to  be  discouraged,  since 
there  is  no  conclusive  evidence  that  they 
affect  the  growth  of  the  brain,  and  the 
amount  usually  recommended  to  be  thus 
taken  would  be  a  very  insignificant  addi- 
tion to  that  supplied  by  our  daily  food. 
(Journal  American  Medical  Association, 
May  1st.)  

POKEBERRY  POISONING. 

Dr.  Lester  reports  a  case  of  a  boy,  age 
12  years,  whom  he  found  completely 
relaxed.  Eespiration  was  very  shallow 
and  quiet.     The  pulse  was  soft,  full  and 


slow,  about  60,  regular  and  not  the  pulse 
of  collapse.  The  boy  salivated  freely 
from  his  mouth,  there  being  a  constant 
raising  of  thick,  frothy  saliva.  His 
reflexes  were  gone,  the  eye  bearing  the 
touch  of  finger  without  any  lid  contrac- 
tion. In  the  absence  of  any  history  of 
poisoning,  Lester  administered  stimu- 
lants, and  with  the  use  of  warm  water 
obtained  free  emesis;  the  vomitus  deter- 
mined the  nature  of  the  patient's  seizure, 
being  largely  composed  of  the  poke- 
berries.  The  use  of  liberal  doses  of 
castor  oil  at  short  intervals  was  persisted 
in  for  some  hours,  the  patient  becoming 
graduall}''  better,  until  consciousness  was 
regained  nine  and  one-half  hours  after 
the  initial  attack.  The  whole  picture  was 
one  of  motor  relaxation.  There  was 
even  evidence  of  this  in  the  widely  open 
pupil,  hanging  jaw,  tongue  settled  back 
in  the  pharynx,  and  inability  to  swallow, 
for  an  hour.  Yawning  and  stretching 
were  evident  as  the  patient  became  better, 
but  no  sweating  of  body  or  tremor  was 
present.  (New  York  State  Journal  of 
Medicine,  April,  1909.) 


PROTARGOL  IN  THE  TREATMENT  OF 
OPHTHALMIA  NEONATORUM. 

Motais  (Bull,  de  I'Acad.  de  Med.,  May 
4,  1909),  discussing  the  treatment  of 
ophthalmia  neonatorum,  pays  tribute  to 
the  service  rendered  by  nitrate  of  silver, 
which  has  been  so  long  used;  he,  how- 
ever, considers  it  dangerous  when  ulcera- 
tion of  the  cornea  is  present.  He  con- 
siders that  great  credit  is  due  to  Darier 
for  his  researches  in  the  organic  com- 
pounds of  silver — namely,  argyrol,  col- 
largol  and  protargol,  the  later  of  which 
he  considers  by  far  the  most  valuable. 
The  method  he  adopts  is  as  follows:  The 
lids  are  washed  frequently  with  a  luke- 
warm solutioii  of  weak  permanganate  of 
potash  25  centigrams  to  1,000.     If  the 


RADIUM,  ITS  THERAPEUTIC  APPLICATIONS. 


445 


secretion  causes  the  lids  to  adhere  they 
should  be  smeared  with  iodoform  oint- 
ment. Every  six  hours  he  uses  2  drops 
of  a  20-per-cent.  solution  of  protargol, 
no  matter  whether  a  corneal  ulcer  be 
present  or  not;  this  never  does  the 
cornea  any  damage.  In  severe  cases  with 
abundant  secretion,  and  especially  if  the 
cornea  is  affected,  he  uses  the  protargol 
drops  every  three  hours,  and  he  considers 
that  accidental  injury  of  the  cornea  is  far 
less  liable  to  occur  than  if  the  lids  be 
painted.  If  this  treatment  is  regularly 
carried  out  the  secretion  is  diminished 
from  the  first  day,  and  in  three,  or  at 
most  four,  days  there  is  but  little  dis- 
charge. The  protargol  is  used  at  half  its 
strength  for  several  days  after  the  case 
is  apparently  cured.  Should  recurrence 
take  place,  which  he  has  never  seen  if  the 
treatment  is  fully  carried  out,  he  reverts 
to  that  first  recommended.  If  a  corneal 
ulcer  is  present  it  quickly  heals.  Atro- 
pin  is  also  recommended  in  order  to 
avoid  the  occurrence  of  posterior  syn- 
echia?. He  claims  for  this  treatment  that 
it  is  simple,  without  danger,  and  it  gives 
the  best  results.  He  describes  ten  typical 
cases.     (British  Medical,  May  22,  '09.) 


RADIUM,  ITS  THERAPEUTIC 
APPLICATIONS. 

Drs.  Wickham  and  Degrais  in  studying 
the  influence  of  radium  on  certain  tumors 
of  the  breast,  especially  carcinomata  con- 
clude as  follows: — 

The  technical  advantages  of  radium 
are  due  to 

1.  The  ease  in  application,  and  its 
painless  character  allows  the  apparatus  to 
be  left  in  position  for  a  great  length  of 
time  without  inconvenience  to  the  patient 
in  his  daily  occupation. 

2.  The  use  of  lead  filtration  screens 
reduces  the  radiations  in  such  proportions 


that  their  action  on  the  neoplasmic  cells 
is  slow,  and  the  patient  is  not  exposed  to 
any  harmful  irritation  of  the  tissues. 

3.  The  smallness  in  quantity  of  the 
radiations  can  be  compensated  for,  not 
only  by  the  long  duration  of  each  applica- 
tion of  the  radium,  but  also  by  the 
method  of  "crossed  fire,"  wliich  increases 
the  intensity  of  the  action  of  the  radia- 
tions in  the  deeper  tissues. 

4.  These  radiations,  being  composed  of 
rays  of  extreme  penetrating  power  only, 
have  little  effect  on  the  cutaneous  surface, 
but  exert  their  special  action  at  a  depth. 

The  practical  conclusion  from  the 
above  considerations  is  that  radium 
treatment  is  capable  of  rendering  differ- 
ent kinds  of  service  in  the  treatment  of 
certain  cancers  of  the  breast : — 

1.  Eadium  can  cause  the  retrogression 
of  a  cancer  of  the  breast  to  such  a  degree 
as  to  bring  about  all  the  appearance  of  a 
cure. 

2.  Eadium  can  transform  an  inoper- 
able cancer  of  the  breast  into  an  operable 
one. 

3.  Eadium  can  act  on  recurrences  of 
small  dimensions  occurring  after  opera- 
tion on  cancer  of  the  breast. 

4.  Eadium  can  act  on  some  affected 
Ij-mphatic  glands  if  they  are  not  too 
much  involved. 

5.  It  can  relieve  the  pain,  and  diminish 
for  a  time  the  hasmorrhage  and  secretions 
from  cancerous  ulcerations,  and  thus  pro- 
long life. 

G.  It  can  also  be  used  after  surgical 
operation  as  a  preventive  measure. 

These  conclusions  are  not  of  universal 
application,  and  are  limited  to  cases  in 
wliich  the  growth  is  sufficiently  localized 
and  of  small  extent;  the  benefits  must 
not  be  exaggerated,  and  a  great  drawback 
in  practice  is  the  considerable  quantity  of 
radium  necessary  for  each  treatment. 
(British  Medical^  May  22,  '09.) 


446       SCISSORS-SIAGNET  EXTRACTION. 


STYPTOL  IN  DYSMENORRHCEA. 


SCISSORS-MAGNET  EZTRACTION  OF  FOR- 
EIGN BODIES  FROM  THE  EYEBALL. 

Dr.  E.  Jackson,  Denver,  points  out 
tliat  in  a  considerable  number  of  cases  the 
electromagnet,  whatever  its  form  and 
however  used,  fails  to  remove  pieces  of 
iron  capable  of  magnetic  attraction  from 
the  eyeball  on  accoimt  of  their  being  em- 
bedded too  firmly  in  recent  exudate  or 
organized  tissue.  In  such  cases  he  thinks 
we  have  a  resource  in  the  use  of  scissors 
attached  to  the  magnet,  and  he  reports 
two  cases  in  which  tliis  method  was  suc- 
cessfully used.  Somewhat  similar  meth- 
ods with  a  knife  or  strabismus  hook 
attached  to  the  magnet  have  been  re- 
ported by  Connor  and  Lang,  but  this  is 
different  from  the  use  of  the  magnet 
force  to  direct  a  cutting  instrument  to 
the  foreign  body  as  used  by  him.  The 
special  technique  of  introducing  the  scis- 
sors and  a  description  of  the  instinment 
is  also  given.  The  article  is  illustrated. 
(Journal  American  Medical  Association, 
June  19th.)         

SEVERE  HAEMORRHAGE,  SUTURE  OF  THE 
LUNG  FOR. 

Dr.  Lotsch  reports  two  cases  in  which 
suture  of  the  lung  was  performed  for 
bleeding  which  was  very  dangerous. 
The  first  patient  was  a  workman,  aged 
26,  who  was  stabbed  with  a  knife  in  the 
left  side  of  the  back.  The  extreme 
pallor  of  the  face,  etc.,  the  soft,  small, 
rapid  pulse,  and  the  physical  signs 
pointed  to  bleeding  into  the  left  pleural 
cavity.  The  chest  was  opened  in 
Brauer's  plus  pressure  chamber,  and  on 
increasing  the  pressure  to  17  centi- 
meters about  1%  litres  of  blood  es- 
caped. The  wound  in  the  lung  was 
found  and  closed  with  catgut  sutures. 
Saline  infusion  was  given  after  the 
operation,  and  the  pulse  unproved. 
The  recovery  was  disturbed  by  a  puru- 


lent effusion  into  the  pleura,  which 
proved  to  be  sterile,  while  fibrolysin  in- 
jections were  given  to  prevent  contrac- 
tion of  the  pleural  adhesions  during 
healing  of  the  empyema.  He  was  dis- 
charged well.  The  second  patient  at- 
tempted to  commit  suicide  by  shooting 
himself  twice  through  the  chest.  The 
clinical  diagnosis  was  wound  of  the  left 
lung,  hgemopneumothorax,  and  possibly 
wound  in  the  heart.  A  large  quantity 
of  blood  was  evacuated  from  the  pleura 
at  the  operation,  and,  after  the  field  of 
operation  was  clear,  the  two  shot 
wounds  were  found  and  sutured.  This 
patient  also  got  an  empyema,  but  with 
suitable  treatment  complete  healing 
took  place,  and  the  man  was  almost  well 
when  discharged.  The  shots  were  not 
found  at  the  operation,  but  were  seen 
after  Eoentgen  examination.  In  discuss- 
ing the  cases  Lotsch  justifies  his  pro- 
cedure by  showiug  that  over  40  per  cent, 
of  such  cases  die  if  treated  expectantly. 
The  difficult  question  to  decide  is  when 
is  a  pulmonary  hfemorrhage  abundant. 
He  was  guided  by  the  degree  of  anemia. 
He  discusses  the  technique  of  the  opera- 
tion, and  also  adds  a  few  words  on  the 
treatment  of  secondary  empyema,  which 
appears  to  be  common  after  intra- 
thoracic operations.  (Muench.  med. 
Woch.,  January  19,  1909.) 


STYPTOL  IN  THE  TREATMENT  OF  DYS- 
MENORRHCEA  AND  UTERINE 
HiEMORRHAGES. 

Dr.  F.  Girardi,  of  Cervinora,  has 
used  styptol  in  menorrhagia  as  well  as 
in  metrorrhagia,  and  reports  that  its 
action  was  to  be  relied  upon.  This 
drug  diminished  the  bleeding  in  every 
instance,  even  in  those  cases  in  which 
hamamelis  and  hydrastis  had  been  of  no 
effect.    The  analgesic  action  of  styptol 


SUPPURATION  OF  PELVIS  AND  URETERS. 


SYPHILIS. 


447 


was  especially  noticeable.  The  prepara- 
tion also  proved  beneficial  in  cases  that 
had  been  operated  upon.  For  example, 
one  year  after  a  curettage,  styptol 
promptly  diminished  both  pain  and 
haemorrhage  when  these  symptoms  re- 
appeared. This  drug  was  also  found 
valuable  in  dysmenorrhoea,  as  it  not  only 
diminishes  the  bleeding,  but  relieves  the 
pain  that  is  wont  to  appear  several  days 
before  menstruation.  Styptol  also  has  a 
sedative  effect,  which  is  probably  due  to 
a  diminution  of  the  irritability  of  the 
peripheral  nerves,  especially  those  of 
the  genito-urinary  system.  (Eiv.  inter- 
naz.  di  Clinica  e  Terapia.) 


SUPPUEATION  OF  RENAL  PELVIS  AND 
URETERS,  TREATMENT  OF,  BY 
LAVAGE. 
Dr.  E.  Garceau,  Boston,  reports  a 
number  of  cases  in  which  his  treatment 
was  attended  by  marked  benefits.  The 
technique  of  treatment  is  described  in 
detail.  He  prefers  the  Kelly  cystoscope, 
and  says  that  the  operation  is  simple, 
though  some  skill  is  required.  The 
genn  usually  found  is  the  colon  bacillus, 
but  the  gonococeus  and  other  germs 
have  also  been  found.  The  solution 
which  has  given  him  the  most  satisfac- 
tion is  silver  nitrate,  beginning  with  1 
to  2000  and  gradually  increasing  in 
strength.  The  amount  should  depend 
on  the  condition  of  the  pelvis  of  the 
kidney.  If  there  is  no  dilatation,  not 
more  than  8  or  10  cubic  centimeters 
should  be  given  at  first;  the  sensations 
of  the  patient  will  be  a  good  guide  in 
this,  as  also  in  regard  to  the  frequency 
of  the  injections.  The  method  is  sel- 
dom required,  and  care  should  be  taken 
in  selection  of  cases.  As  a  nile,  the 
patient  should  be  under  observation  for 
a  considerable  time  before  it  is  under- 
taken.    Acute  pyelitis  is  not  suited  to 


this  method.  Free  drainage  of  the  kid- 
ney through  the  ureter  must  be  secured. 
The  most  suitable  cases  are  those  of 
simple  chronic  suppurative  pyelitis  v/ith- 
out  obstruction,  but  most  of  these  will 
get  well  anyhow,  unless  the  germ  is  a 
very  virulent  one.  It  may  be  used  to 
cure  an  inflammation  in  a  hydro- 
nephrotic  sac  as  a  preliminary  to 
nephropexy,  but  the  kidney  should  be 
supported  meanwhile  by  an  appropriate 
apparatus.  It  should  never  be  per- 
mitted in  severe  pyonephrosis  with  gen- 
eral systemic  infection,  and  it  is  not 
suitable  for  tuberculous  pyelitis  or 
tissue  changes  tending  sclerosis  and 
thickening.  The  only  possible  remedy 
for  such  chronic  cases  is  nephrectomy. 
A  permanent  catheter  in  the  ureter  is 
dangerous,  especially  with  acute  infec- 
tion and  general  symptoms.  Eenal 
lavage  is  seldom  followed  by  serious, 
harmful  sequels  if  properly  performed 
in  the  right  sort  of  a  case,  but  further 
experience  is  needed  to  give  the  method 
a  definite  therapeutic  standing.  (Jour- 
nal of  the  American  Medical  Associa- 
tion, January  23,  1909.) 


SYPHILIS  OF  THE  UPPER  RESPIRATORY 
TRACT,  TREATMENT  OF. 

Dr.  Livien  discusses  the  identification 
of  the  spirochseta  pallida  and  the  detec- 
tion of  specific  antibodies  in  the  serum 
of  people  infected  with  syphilis.  N"o 
serum  therapeutic  treatment  had  been 
found  effective.  Mercury  and  iodides 
remain  the  chief  remedies.  He  states 
that  mercury  is  best  administered  by 
injection  or  inunction,  and  that  atoxyl, 
given  in  efficient  doses,  has  proved  ex- 
perimentally to  produce  similar  results, 
but  is  dangerous  to  the  optic  nerve. 
The  diagnosis  should  be  certain  before 
treatment  is  started.  Spirochajta  should 
be  found,  or  time  given  for  the  serum- 


448     TUBERCULOUS  HIP  JOINT  AFFECTIONS. 


UTERINE  HEMORRHAGE. 


test,  or  the  appearance  of  the  roseola. 
In  most  of  the  cases  where  inunctions 
and  injections  are  employed  local  treat- 
ment is  unnecessary.  Mercurial  plaster 
should  be  used  to  cover  chancres  on  the 
lips  or  face.  Nosophen  is  a  good  dust- 
ing-powder, and  orthoform  may  be  used 
in  painful  cases.  Malignant  forms  of 
the  disease  responded  best  to  injections 
of  calomel.  When  inunctions  are  used 
baths  of  soap  and  sulphur  may  be  use- 
fully added.  The  iodides  are  most  use- 
ful in  the  tertiary  lesions,  but  act  well 
in  vegetating  secondary  patches  in  the 
nose  or  throat.  lodism  may  be  removed 
by  daily  administration  of  15  grains  of 
sulphanilic  acid  in  7  ounces  of  water. 
In  sensitive  cases  iodipin  is  a  useful 
substit-ute.  (British  Medical  Journal, 
February  6,  1909.) 


TUBERCULOUS  AFFECTIONS   OF  HIP 
JOINT,  TREATMENT  OF. 

Dr.  Konig  has  been  investigating  the 
present  condition  of  568  former  patients 
with  a  tuberculous  hip-joint  affection. 
All  but  294  required  operative  meas- 
ures, and  203  of  this  group  of  294 
non-operative  cases  have  been  reinvesti- 
gated; 55  of  the  patients  had  died  of 
intercurrent  affections,  and  114  were 
cured  without  necessity  for  aid  in  walk- 
ing, in  33  the  joint  had  regained  normal 
function,  and  90  had  a  more  or  less 
movable  joint.  Besides  these  114  cases 
with  excellent  results,  35  patients  still 
required  a  cane  or  crutch,  and  in  3  cases 
the  condition  was  bad;  in  13  there  is 
still  a  fistula.  In  the  group  of  274  re- 
sections, no  news  could  be  obtained  of 
60  patients;  of  the  others,  66  were 
cured,  and  in  16  of  these  cases  the  re- 
sult was  extremely  fine  and  the  patients 
were  able  to  dance  and  take  long  walks. 
Canes  and  crutches  still  have  to  be  used 
by  43  patients,  and  35  still  have  fistula. 


As  only  the  severer  cases  are  given 
operative  treatment,  he  regards  these 
results  as  extremely  favorable.  He  has 
done  resection  of  the  hip  joint  in  400 
cases,  and  remarks  that  his  technique 
seems  to  be  overlooked  by  other  sur- 
geons. The  principle  is  to  remove  every 
trace  of  diseased  tissue.  The  incision 
and  part  of  the  operation  is  the  same  as 
in  the  old  technique,  but  the  operation 
is  much  more  complete.  (Berliner 
klinische  Wochenschrift,  March,  1909.) 


UTERINE  HiEMORRHAGE,  TREATMENT 
OF,  WITH  SERUM.  , 

Dr.  W.  Busse  has  treated  ten  patients 
with  uterine  haemorrhage  resisting  pre- 
vious measures,  including  curetting  by 
serotherapy.  The  haemorrhages  became 
so  severe  that  the  general  health  was 
affected,  and  he  could  not  find  any 
anatomic  cause  for  the  haemorrhages. 
He  injected  10  cubic  centimeters  of 
human  serum  subcutaneously.  The 
serum  was  derived  from  the  blood  of 
healthy  patients  being  treated  for  dis- 
placements, under  scopolamin-morphin 
just  before  spinal  anaesthesia.  In  every 
instance  the  haemorrhages  ceased  en- 
tirely or  became  much  less  severe  after 
one  or  two  days.  Menstruation  became 
normal,  and  the  patients  felt  well.  He 
ascribed  the  haemorrhage  in  these  cases 
to  some  general  hemorrhagic  tendency, 
probably  slight  haemophilia.  This  serum 
treatment  was  applied  only  when  local 
examination  was  totally  negative.  There 
is  probably  defective  production  of 
thrombokinase,  and  he  would  prefer 
animal  serum,  if  such  proved  effectual. 
It  is  possible,  he  states,  that  this  serum 
treatment  might  be  used  in  controlling 
haemorrhage  in  cases  of  myoma  or 
tumors  of  the  adnexa.  (Zentralbl.  fiir 
Gynakologie,  February  13,  1909.) 


Monthly    Cyclopaedia 

AND 

Medical   Bulletin 


Published  the  Last  of  Each  Month 


Monthly  Cyclopedia  Section 


Vol.  II.  PHILADELPHIA,  AUGUST,  1909.  No.  8. 


Original  Articles 


Department  in  charge  of  J.  MADISON  TAYLOR,  A.M.,  M.D. 


CHOLELITHIASIS:     GALL-STONE  DISEASE. 

Bt  JOHN  C.  HEMMETER,  Ph.D.,  M.D.,  LL.D., 
Professor  of  Physiology  and  Clinical  Medicine  in  the  University  of  Maryland. 

BAI.TIMOBE. 

The  principal  factor  in  the  formation  of  gall-stone  is  a  catarrh  of  the 
biliarj^-ducts  and  gall-bladder,  which  is  traceable  in  the  majority  of  cases  to 
an  infection  of  the  gall-bladder  by  micro-organisms.  Stagnations  in  the  flow 
of  bile  favor  the  development  of  this  catarrh;  but  there  is  a  second  factor, 
which  leads  to  the  formation  of  gall-stones,  to  which  little  reference  is  made 
and  to  which  the  writer  first  called  attention.  It  consists  mainly  of  patho- 
logical alterations  in  the  chemical  composition  of  the  bile.  At  the  bottom 
of  all  this  is  an  abnormal  intermediate  metabolism  of  the  liver.  To  this 
view  we  are  inclined  because  at  many  operations  for  gall-stone  the  gall- 
bladder itself,  as  well  as  the  stone,  the  bile,  and  the  various  gall-ducts,  were 
found  to  be  free  from  bacteria;   all  cultures  were  negative. 

Naturally  it  has  been  asserted  that  there  may  be  bacteria  which  require 
such  a  culture  medium  as  cannot  be  imitated  outside  of  the  living  tissues 
of  the  body,  and  that  these  may  cause  gall-stone  or  inflammation  of  the 
biliary  apparatus.  This  is  a  very  far-fetched  hypothesis,  for  there  is  no 
doubt  that  the  only  bacteria  which  are  here  concerned  are  those  which 
originate  from  the  intestine,  and  for  all  the  more  important  intestinal  bac- 
teria there  has  been  no  difficulty  of  finding  culture  media. i 

In  speaking  of  the  direct  etiology  we  must  consider  everything  which 
could  produce  stagnation  of  the  bile-flow.     Among  these  we  must  consider 

1  See  Hemmeter,  Diseases  of  the  Intestines,  Vol.  I,  article  on  Bact«ria. 
3  (449) 


450  CHOLELITHIASIS:   GALL-STO^'E  DISEASE. 

compressing  clothing,  insufficient  bodily  exercise,  dislocation  or  compression 
of  the  bile-ducts  by  tumors,  cicatrices.  Among  the  causes  which  are  little 
recognized  I  wish  to  call  attention  to  one  of  which  I  have  convinced  myself 
repeatedly  at  autopsies;  that  is,  enteroptosis,  and  gastroptosis  especially. 
The  displacement  of  the  stomach  may  cause  traction  upon  the  hepato- 
duodenal ligament.  This  I  have  frequently  seen  at  abdominal  sections 
undertaken  for  gall-stone.  Another  cause  is  dislocated  or  floating  kidney. 
Then,  there  seems  to  me  to  be  a  form  of  atony  of  the  musculature  of  the 
gall-bladder,  which  in  some  way  is  dependent  upon  the  traction  caused  by 
dislocated  abdominal  viscera  in  enteroptosis.  The  tugging  upon  the  nerves 
may  also  have  an  effect  in  this  form  of  atony  of  the  gall-bladder.  The 
greater  frequency  of  these  etiological  factors  in  the  female  sex  explains  the 
observation  that  gall-stones  occur  three  to  five  times  more  frequently  in 
women  than  in  men.  They  also  occur  more  frequently  in  old  age.  Prior  to 
the  thirtieth  year  only  two  to  three  per  cent.,  and  after  the  sixtieth  year, 
twenty-five  per  cent,  of  the  observed  gall-stone  cases  occur. 

It  is  of  great  importance  to  bear  in  mind  the  great  role  which  certain 
infectious  diseases  play  in  the  causation  of  cholelithiasis.  As  a  rule  these 
agents  first  cause  a  cholangeitis  and  cholecystitis,  and  thereafter  the  injured 
mucous  membranes  of  these  parts  produce  altered  secretions,  and  have  less- 
ened resistance  to  the  micro-organisms  that  have  invaded  these  pastures. 
One-third  of  my  gall-stone  cases  had  a  previous  history  of  typhoid  fever,  and  I 
am  inclined  to  look  upon  this  infection  as  a  very  serious  cause  of  gall-stones. 

The  size  of  the  gall-stones  varies  from  that  of  a  sand  grain  to  that  of 
a  hen's  egg  and  larger.  Their  number  may  vary  from  a  single  one  to  a 
thousand.  The  form  is  very  manifold;  they  may  be  round,  oval,  pear  shape, 
mulberry  shape,  polygonal.  Facetted  stones  arise  by  the  friction  of  several 
concretions  v/hich  are  pressed  against  each  other  whilst  they  are  still  in  a 
rather  soft  state.  They  may  be  of  any  color,  white,  yellow,  gray,  green, 
brown,  even  black;  this  color  depends  upon  the  external  stratum  of  the 
stone,  and  need  not  necessarily  represent  the  color  of  the  interior.  Most 
gall-stones  consist  of  a  hard  stratified  shell  containing  a  soft  interior.  Gener- 
ally there  is  a  small  hollow  space  in  the  center  of  this  interior  if  it  happens 
to  be  a  perfectly  dry  stone. 

They  are  mainly  composed  of  bilirubin  calcium,  15  to  30  per  cent.,  and 
cholcsterin,  60  to  80  per  cent.  There  may  be  also  a  snuill  amount  of  calcium 
carbonate,  traces  of  copper  and  iron,  also  remnants  of  disintegrated  epithelia 
and  mucus.  The  jiurc  eholesterin  stones,  which  are  white  or  yellowish,  some- 
times even  transparent,  are  rare;  the  calcium  carbonate  stones  are  very 
rare.  The  material  for  the  formation  of  the  stone  is  furnished  by  detached 
and  disintegrated  epithelia. 

The  direct  cause  of  the  stone  formation,  then,  is  a  catarrhal  inflamma- 
tion of  the  biliary  apparatus,  due  mainly  to  micro-organisms,  but  which,  in 
my  opinion,  can  also  be  due  to  a  pathologic  metabolism  of  the  liver.  The 
stones  at  first  consist  of  soft  masses,  which  become  coated  with  a  thin 
shell.    The  continued  growth  is  produced  by  concentric  layers  of  eholesterin 


CHOLELITHIASIS:  GALL-STONE  DISEASE.  451 

and  bilirubin  calcium  on  the  outside,  but  at  the  same  time  there  may  be  a 
progressive  infiltration  of  the  hollow  space  in  the  center  with  cholesterin. 

The  stones  are  most  frequently  found  in  a  free  state  in  the  gall-bladder; 
they  are  very  rarely  adherent  or  encapsulated.  The  gall-bladder  is  always 
the  seat  of  a  cholecystitis  which  is  partially  the  cause  and  partially  the  result 
of  the  gall-stone.  Frequently  the  walls  of  the  gall-bladder  are  thickened  and 
contracted;  the  muscular  and  mucous  layers  are  atrophic.  I  have  seen  the 
walls  of  a  hypoplastic  gall-bladder  so  tightly  contracted  around  a  stone  as 
large  as  a  pigeon's  egg  that  it  could  only  be  cut  away  with  considerable  diffi- 
culty. The  gall-bladder  is  rarely  dilated.  The  bile  which  is  contained  in  the 
bladder  is  abnormally  rich  in  mucus  and  disintegrating  epithelial  cells. 
Stones  that  occur  in  the  cystic  and  common  gall-duct  originate  in  the  gall- 
bladder, but  can  grow  farther  in  the  duct.  A  most  frequent  seat  for  the 
stones  to  become  lodged  in  the  ducts  is  the  diverticulum  of  Vater,  just  in 
front  of  the  orifice  of  the  common  gall-duct.  Stones  which  lodge  here  and 
close  up  the  orifice  may  produce  a  damming  back  of  the  bile  into  the  pan- 
creatic duct  and  eventually  lead  to  inflammation  of  the  pancreas  and  con- 
sequent fat  necrosis.  The  gall-ducts  may  become  enormously  dilated  in  con- 
sequence of  stagnation,  caused  by  a  stone.  It  has  been  observed  that  small 
stones,  composed  of  bilirubin  calcium,  occur  in  the  intra-hepatic  bile-channels, 
and  this  when  the  gall-bladder  and  gall-ducts  are  normal.  Evidently  these 
tiny  stones  are  due  to  faulty  metabolism  in  the  liver  itself,  and  this  to  my 
mind  constitutes  one  of  the  important  evidences  of  the  theory  that  there  is 
a  form  of  cholelithiasis  which  does  not  depend  upon  bacterial  infection. 

Gall-stones  have  been  found  in  about  one-tenth  of  all  autopsies  reported 
from  European  and  American  hospitals.  Although  this  is  an  extraordinary 
frequency,  it  is  interesting  that  the  mere  presence  of  gall-stones  in  the 
majority  of  cases  causes  no  symptoms. 

When  symptoms  do  occur  they  are  at  first  very  indefinite,  general  dis- 
tress and  slight  pains  in  the  region  of  the  liver,  digestive  disturbances,  and 
slight  icterus,  are  among  the  first  symptoms  and  signs;  but  their  dependence 
upon  gall-stones  is  not  always  recognized  in  time.  It  is  very  rare  that  one 
is  able  to  palpate  the  gall-bladder  in  individuals  with  thin  abdominal  wall, 
and  it  is  still  rarer  that  the  actual  observance  of  a  passed  stone  in  the  stool 
permits  the  diagnosis  in  the  absence  of  any  preceding  symptoms.  I  should, 
however,  emphasize  the  following  syndrome:  If  a  person  who  has  had  an 
infectious  colitis  or  dysentery  or  typhoid  fever  frequently  complains  of 
gastralgia  two  hours  or  three  hours  after  meals,  the  clinician  should  exhaust 
his  diagnostic  resourcefulness  to  ascertain  the  existence  or  non-existence  of 
gall-stone. 

Characteristic  disturbances  occur  only,  then,  when  a  stone  has  left  the 
gall-bladder  and  entered  the  ducts,  or  after  the  presence  of  gall-stones  has 
led  to  infectious  and  inflammations  of  the  duct.  This  condition  gives  rise  to 
the  so-called  gall-stone  colic.  Thereby  the  stone  may  be  evacuated  into  the 
intestine,  and  eventually  pass  out  of  the  body;  but  rarely  do  all  the  stones 
pass  out  in  this  manner.     We  may  distinguish  the  condition  of  the  patient 


452  CHOLELITHIASIS:  GALL-STOI^E  DISEASE. 

during  the  attack  of  gall-stone  colic,  and  secondly,  an  irregular  course  of 
the  cholelithiasis. 

The  direct  and  immediate  cause  of  the  colic  is  but  little  understood. 
It  has  Leen  supposed  that  the  stones  already  existing  in  the  gall-bladder  may 
be  forced  into  the  duct  by  concussions  of  jolting  of  the  body,  by  a  fall,  by 
strong  compression  of  the  abdominal  muscles,  by  vomiting,  by  operations  on 
the  other  abdominal  organs,  by  the  act  of  labor,  by  cold,  and  by  dietetic 
errors.  The  typical  attack  is  generally  preceded  by  discomfort,  nausea,  and 
a  slight  chill;  but  the  pain  may  also  start  without  any  premonition  whatever 
and  continue  in  aggravated  paroxysms  until  it  becomes  intolerable.  But 
even  in  the  intervals  a  dull,  boring  soreness  is  always  complained  of  in  the 
center  of  the  liver.  From  here  the  pain  may  radiate  to  the  shoulder,  epigas- 
trium, spine,  even  into  the  legs.  Sensitive  patients  may  become  unconscious 
or  pass  into  a  convulsion  or  delirium;  vomiting  is  a  frequent  accompaniment. 
In  about  one  half  of  these  cases  there  is  a  pronounced  chill  followed  by  an 
elevation  of  the  body  temperature,  which  has  been  called  the  "reflex  fever," 
but  which  is  more  correctly  to  be  interpreted  as  the  index  of  an  infection  of 
the  biliary  passages. 

Enlargements  of  the  gall-bladder  only  occur  in  one  third  of  the  cases, 
and  is  a  consequence  of  the  cholecystitis.  Jaundice  is  an  important  indication 
for  the  interpretation  of  this  colic,  but  in  my  experience  it  was  absent  in  fifty-five 
per  cent,  of  all  cases  of  genuine  gall-stone  colic.  The  icterus  may  be  observ- 
able in  the  conjunctivae  after  twelve  hours,  and  bile  pigments  may  be  present 
in  the  urine.  There  may  be  icterus  without  mechanical  obstruction  of  the 
common  gall-duct;  this  is  an  inflammatory  stagnation  caused  by  the 
invasion  of  the  bile-passages  by  bacteria;  but  there  may  also  be  icterus  due 
to  functional  disturbances  in  the  liver  cells  due  to  general  infection  origina- 
ting from  the  gall-duct.  The  duration  of  this  jaundice  is  very  variable;  it 
rarely  exceeds  the  regular  attack  of  colic  more  than  several  days. 

Even  in  intense  icterus  the  stools  are  not  always  free  from  bile.  If  the 
fjBces  are  sifted  through  a  stool  sieve  it  is  sometimes  possible  to  find  the 
stone;  but  this  is  not  the  rule.  It  is  possible  that  a  stone  has  actually  passed 
and  that  it  has  become  disintegrated  in  the  intestinal  canal.  During  an 
attack  of  colic  it  would  be  an  error  to  assume  that  a  stone  has  always  passed 
the  common  gall-duet  or  the  cystic  duct,  for  the  pain  may  be  caused  by  the 
acute  cholecystitis;  or  the  stone  may  have  dropped  back  into  the  gall- 
bladder.   The  use  of  the  stool  sieve  will  be  referred  to  later  on. 

After  a  typical  attack  of  colic  they  cease  after  several  hours  as  a  rule, 
sometimes,  however,  only  to  be  resumed  with  renewed  severity;  thus  an 
attack  may  be  protracted  for  several  days.  If  a  stone  has  actually  passed 
then  the  cessation  of  pain  is  abrupt.  The  pains  may  be  very  slight  in  other 
cases,  or  entirely  absent  in  still  others,  and  the  passages  of  a  stone  only 
evidenced  by  transient  swelling  and  sensitiveness  of  the  liver  to  pressure,  or 
by  a  very  slight  icterus.  The  intensity  of  the  pain  is  by  no  means  propor- 
tionate to  the  size  of  the  stone;  for  the  irritability  and  smoothness  of  the 
biliary  passages,  the  hardness,  shape  and  configuration  of  the  stone  deter- 


CHOLELITHIASIS:  GALL-STONE  DISEASE.  453 

mine  the  pain.  It  is  a  singular  thing  that  the  largest  stones  pass  with  little 
pain  or  no  pain  at  all,  namel)',  by  formation  of  fistula.  I  possess  a  gall-stone 
which  was  vomited  by  one  of  my  patients  who  rarely  complained  of  abdom- 
inal distress.  The  stone  is  about  as  large  as  a  pigeon's  egg.  It  was  passed 
four  years  ago,  and  there  have  been  no  symptoms  since.  In  rare  cases  death 
may  result  by  heart  feebleness,  collapse  or  shock,  or  reflex  convulsions  dur- 
ing an  attack  of  colic.  The  number  and  frequency  of  the  attacks  are  very 
variable.  It  is  very  rare  that  a  patient  has  but  one  attack,  for  the  passage 
of  one  stone  renders  the  others  movable,  and  thus  we  may  have  groups  of 
attacks  that  may  be  repeated  at  longer  or  shorter  intervals,  and  may  also 
remain  away  for  several  years.  In  the  majority  of  the  cases  the  progress  of 
a  regular  attack  of  colic  is  a  favorable  one;  but  at  any  time  this  regular  form 
may  pass  into  the  irregular. 

The  irregular  manners  of  progression  may  be  classified  under  four  head- 
ings:— 

1.  Permanent  arrest  of  the  flow  of  bile. 

3.  Infectious  inflammations  of  the  biliary  passages  (cholangeitis,  chole- 
cystitis, abscess  of  the  liver). 

3.  Ulcerations  of  the  biliary  passages,  perforation,  pericholecystitis.  > 

4.  Impermeability  of  obstruction  of  the  gastro-intestinal  canal. 

It  is  evident  from  a  survey  of  these  headings  that  the  irregular  courses 
of  cholelithiasis  represent  or  lead  to  surgical  conditions  almost  exclusively, 
and  accordingly  the  reader  is  referred  to  another  part  of  this  work  where  they 
are  considered  from  the  standpoint  of  the  surgeon. 

1.  Permanent  obstruction  to  the  flow  of  bile  is  caused  by  incarcera- 
tion of  a  stone  in  the  ductus  choledochus  or  hepatieus.  It  is  rare  that  a  com- 
pression of  the  common  gall-duct  is  caused  by  a  stone  that  is  wedged  in  the 
cystic  duct;  but  strictures  and  neoplasms  that  have  been  caused  by  gall-stones 
may  also  produce  the  obstruction. 

The  consequence  is  a  chronic  icterus,  lasting  a  very  long  time,  but  which 
is  recovered  from  generally  by  the  passage  of  a  stone  through  a  fistiila 
between  the  common  gall-duct  and  the  duodeniim;  but  sometimes  a  grave 
icterus  may  lead  to  death.  In  uncomplicated  incarcerations  of  stone  this  fatal 
result  is  fortunately  rare.  The  evil  consequences  of  a  so-called  fatal  chronic 
icterus  caused  by  gall-stones  are  more  often  due  to  a  carcinoma  of  the  biliary 
passages.  I  feel  it  my  duty  to  emphasize  the  alarming  frequency  with  which 
protracted  cholelithiasis,  that  is  not  operated  upon,  later  on  becomes  compli- 
cated by  carcinoma.  This  is  one  of  the  principal  reasons  why  prolonged  purely 
merlioal,  or  clinical,  treatment  by  non-operative  methods  is  positively  unjusti- 
fiable, yes,  even  criminal. 

The  conditions  mentioned  unrler  sections  2  and  .3  are  described  in  the 
surgical  portion  of  this  work.  T  must  add  that  perforation  may  occur  from 
the  gall-bladder  outward  through  the  abdominal  wall  and  lead  to  spontaneous 
cures.  More  frequent  than  this  form  of  perforation  are  the  fistulns  between 
the  bile  passages  and  the  intestinal  canal.  Tliose  between  the  common  gall- 
duct  and  the  duodenum  are  the  most  important.    They  occur  in  the  neighbor- 


454  CHOLELITHIASIS:  GALL-STOJs'E  DISEASE. 

hood  of  the  papilla  of  Yater  and  resemble  the  passage  of  a  stone  as  if  it  had 
occurred  -per  vias  iwhirales.  Perforations  into  the  colon  may  occur,  hut 
those  into  the  stomach  and  small  intestines,  into  the  retroperitoneal  tissues, 
into  the  portal  vein,  into  the  pleura,  lungs  or  urinary  passages,  and  into  the 
vagina  are  very  rare.    Perforations  into  the  peritoneum  are  most  dangerous. 

Impermeability  of  the  gastro-intestinal  canal.  It  has  been  observed  that 
dilatation  of  the  stomach  was  caused  by  compression  of  the  pylorus  by  a  gall- 
bladder filled  with  stones,  but  this  is  fortunately  rare.  More  frequent  is  the 
obturation  ileus  caused  by  obstruction  of  the  intestinal  lumen  through  largo 
stones  that  have  gotten  into  the  intestine  through  a  fistula. 

The  diagnosis  of  cholelithiasis  is  not  difficult  in  typical  attacks  of  colic. 
It  is  important  to  accurately  map  out  the  exact  localization  of  the  pain. 
Confusion  with  intestinal  colic,  lead,  renal  and  gastric  colic,  as  well  as  car- 
dialgia  may  readily  occur.  Icterus  is  important  for  the  diagnosis,  but,  as 
I  have  said,  it  is  absent  in  55  per  cent,  of  my  cases.  When  very  slight 
attacks  of  icterus  are  associated  with  frequently  repeated  and  painful  swell- 
ing of  the  liver,  this  is  very  important  for  the  diagnosis.  The  safest  con- 
clusion can,  of  course,  be  derived  from  a  demonstration  of  the  stones  in  the 
passages.  The  X-rays  or  Eoentgen  rays  are  of  no  utility  in  the  demonstra- 
tion of  gall-stone.  I  have  personally  placed  eight  large  gall-stones  in  a  row 
one  behind  the  other  and  obtained  no  impression  on  the  plate  by  Eoentgen 
pliotography.  But  the  X-rays  may  be  useful  when  it  becomes  necessary  to 
differentiate  gastric  ulcer  or  gastric  carcinoma  from  gall-stone  disease;  for, 
according  to  my  method  described  in  the  Arcliiv  f.  Venlauungs  KranMeiten, 
P)erlin,  li)06.  Ulcers  and  cancers  of  the  stoniach  can  be  made  visible  and 
demonstrated  by  this  form  of  photography. 

For  the  diagnosis  of  the  irregular  forms,  the  previous  history  of  former 
attacks  is  of  great  importance.    For  all  this,  see  Surgical  Section. 

For  those  cases  of  gall-stone  disease  which  run  a  regular  course,  the 
prognosis  is  in  general  favorable;  but  for  those  cases  which  run  an  irregular 
course,  the  prognosis  is  favorable  or  unfavorable  according  to  the  seriousness 
of  the  complications. 

Treatmenl — Froplnjhxis: — Tlie  patient  must  avoid  all  foods  which  miglit 
possibly  lead  to  indigestion,  and  thereby  predisposing  to  infection  of  the 
biliary  passages.  It  is  very  essential  to  insist  on  small  meals,  because  a  food 
which  in  itself  is  not  harmful  may  bring  on  an  attack  of  colic  by  its  bulk.  A 
diet  that  is  rich  in  fats  must  be  strictly  avoided.  A  diet  that  gives  rise  to 
much  gas  must  be  strictly  avoided;  for  instance,  pease,  beans,  lentils,  sauer- 
kraut, pies,  mayonnaises,  salads  and  raw  fruit.  It  is  essential  to  avoid 
alcohol  in  anything  exceeding  one-half  a  pint  of  light  Ehine  wine  per  day. 
It  is  important  that  the  patient  should  attend  to  regular  evacuation  of  the 
bowels,  but  the  strong  purgative  mineral  waters  like  Hunyadi  Janos  and 
Eubinat  Condal  must  be  strictly  avoided.  These  powerful  mineral  purgative 
waters  do  more  harm  than  good.  Gall-stone  sufferers  must  avoid  all  clothing 
that  tends  to  constrict  the  abdomen. 

Treatment  During  an  Attack  of  Colic. — The  patient  must  be  put  to  bed 


CHOLELITHIASIS:   GALL-STONE  DISEASE.  455 

immediately;  a  hot  water  bag  is  to  be  applied  over  the  liver,  and  one-fourth 
grain  of  morphine  is  to  be  injected  hypodermieaily  at  once.  The  drinking 
of  small  quantities  of  hot  water  during  the  attack,  or  hot  Carlsbad-Sprudel 
water  is  to  be  recommended.  When  the  patient  has  recovered  from  his 
immediate  colic  attack  I  recommend  to  him  to  continue  the  use  of  the  hot 
Carlsbad-Sprudel  water  morning  and  evening,  one  tumbler  before  breakfast 
as  hot  as  can  be  taken;  then  allow  one  hour  to  elapse  before  taking  any 
food.  If  a  slight  chronic  icterus  continues  after  an  attack  of  colic,  and  espe- 
cially if  the  liver  and  gall-bladder  regions  are  sensitive,  I  advise  all  patients 
to  continue  this  Carlsbad  treatment  for  a  month.  In  this  period  the  patient 
must  lie  down  for  three  hours  twice  daily,  say  from  nine  to  twelve  in  the 
morning,  and  from  three  to  six  in  the  afternoon,  and  hot  cataplasms  must 
be  applied  to  the  liver  region  during  this  time.  During  the  first  hours  in 
the  morning  he  should  drink  one  hundred  cubic  centimeters  of  Carlsbad- 
Sprudel  water  every  fifteen  minutes,  as  hot  as  can  be  taken.  In  this  way 
the  patient  may  drink  six  to  eight  hundred  cubic  centimeters  in  a  day.  If 
the  patient  cannot  tolerate  so  much,  the  amount  of  Carlsbad  water  taken  can 
be  restricted,  particularly  in  the  afternoon.  During  this  treatment,  the 
meals  are  taken  at  half  past  seven,  one  p.m.  and  seven  p.m. 

Medicinal  Treatment. — Gall-stones  cannot  be  dissolved  by  any  medicines 
that  can  be  taken  by  the  mouth.  All  medicines  that  have  hitherto  been 
supposed  to  have  had  this  power  bring  about  their  only  apparent  and  very 
transient  improvement  by  their  anodyne  effect.  Thus  the  Durand  drops 
which  are  composed  of  one  part  of  turpentine,  four  parts  of  ether,  twenty 
to  thirty  grams  of  cognac  and  the  yelks  of  two  eggs,  act  simply  as  ani 
anodyne.  The  dose  is  fifteen  to  sixty  drops.  Olive  oil,  oleate  of  soda,  g\j- 
cerine,  preparations  made  from  bile  and  bile  salts  are  of  doubtful  value. 
But  I  have  seen  cases  in  which  the  salicylate  of  soda  seems  to  act  as  a  very 
effective  anodyne,  and  even  reduce  the  jaundice  and  size  of  the  liver.  We 
do  not  know  in  what  way  salicylate  of  soda  influences  the  metabolism  of 
the  liver  cells,  but  we  do  know  that  it  is  an  intestinal  disinfectant  to  a  certain 
extent,  and  I  have  convinced  myself  that  the  bactericidal  effect  of  the  bile 
is  increased  after  two  days'  taking  of  sixty  grains  of  salicylate  of  soda  in 
divided  doses.  These  tests  were  made  with  the  colon  and  typhoid  bacilli. 
But  all  this  medical  treatment  should  not  be  continued  too  long.  The 
dangers  from  the  complications  mentioned  are  too  great;  especially  should 
the  practitioner  be  cautioned  concerning  the  alarming  increase  of  cancer  of 
the  biliary  apparatus  that  is  traceable  to  the  effect  of  gall-stones. 

I  do  not  find  that  gall-stones  and  acute  gastritis,  as  they  present  them- 
selves in  practice,  offer  any  difficulty  in  the  way  of  differential  diagnosis. 
The  trouble  is  to  diagnose  gall-stones  from  gastric  ulcer  and  membranous 
colitis.  As  to  the  pain  of  gall-stones,  there  is  too  much  of  the  hypothetical 
about  all  the  speculations  on  this  point.  The  peritoneum,  when  inflamed 
or  distended,  is  always  painful.  In  making  a  diagnosis  from  the  stools  I 
dilute  the  faces  and  sift  them  through  a  Boas  or  Dudley  D.  Roberts  stool 
sieve. 


456 


THE  THERAPEUTICS  OF  PAIN. 


Certain  cases  of  gall-stones,  although  they  undoubtedly  need  operation, 
are  in  too  exhausted  a  state  to  stand  it.  The  metabolic  cases  where  the 
operation  shows  no  infection  of  the  gall-bladder,  require  careful  dieting, 
Carlsbad-Sprudel,  or  Bedford  Magnesia  water.  A  case  which  may  have 
originally  been  due  to  disturbed  hepatic  metabolism  may  later  show  infection 
of  the  gall-bladder. 

I  do  not  use  cholagogues.  There  are  no  cholagogues  except  those  that 
do  harm;  even  the  bile  salts,  when  so  administered,  injure  the  stomach.  By 
the  tune  the  cholelithiasis  is  established  it  is  impossible  to  prevent  catarrhal 
duodenitis,  because  this  as  a  rule  precedes  the  catarrh  of  the  biliary  appara- 
tus. In  treating  this  condition,  I  study  the  faeces  and  ascertain  what  foods 
are  not  digested,  and  exclude  them,  enjoin  rest  in  bed,  hot  applications  to 
the  abdomen,  and  order  a  half-pint  of  hot  Carlsbad-Sprudel  water  at  seven 
A.M.  before  breakfast  and  at  five  p.m.  It  is,  in  my  opinion,  impossible  to  dis- 
solve the  calculi,  and  any  treatment  directed  toward  this  end  is  bad  procras- 
tination. 

As  soon  as  a  diagnosis  of  gall-stones  is  made  deiinitely,  and  the  con- 
dition of  the  patient  permits  it,  I  recommend  surgical  treatment,  even  if 
the  gall-stones  are  not  due  to  infection  but  to  abnormal  liver  metabolism; 
they  must  be  removed.  I  have  nothing  to  say  about  the  surgical  precedure; 
my  surgical  friends  attend  to  that  part  of  it.  As  regards  the  direct  indica- 
tions for  operation  all  signs  are  misleading  in  these  cases,  but  (1)  fever, 
(2)  constant  and  extreme  tenderness  over  the  liver,  and  (3)  leucocytosis  are 
the  most  reliable  signs  of  suppuration.  The  mortality  in  those  cases  which 
1  was  obliged  to  treat  medically  is  much  greater  than  those  which  I  submit 
to  the  surgeon,  as  cancer  often  supervenes  in  cases  treated  medically. 

To  diet  these  patients  guardedly,  examining  the  faeces  carefully,  is  the 
first  rule.  But  there  are  no  hard  and  fast,  cast  iron  dietetic  regimes.  The 
rule  to  follow  is  to  study  and  find  out  what  agrees  the  best.  After  the 
operation  the  Carlsbad  waters  are  very  elfective  in  preventing  recurrence. 
A  recurrence  of  the  stones,  gastritis,  enteritis  and  colitis  are  the  commonest 
complications.  The  best  prophylactic  for  those  who  are  inclined  to  gall- 
stones is  Carlsbad-Sprudel  or  Bedford  water,  as  hot  as  it  can  be  drunk,  and 
living  on  such  a  diet  as  has  proven  itself  to  be  best  digested  according  to 
the  methods  above  referred  to. 


THE  THERAPEUTICS  OF  PAIN. 

By  LAWRENCE  F.  FLICK, 

Director  of  the  Phippa  Institute, 

PniLADEM'HIA. 


My  subject  as  announced  is  the  treatment  of  pain,  when  due  to  toxaemia 
I  would  prefer  to  make  it  the  therapeutics  of  pain. 

There  is  an  old  description  of  pain  as  "the  prayer  of  the  nerves  for  good 
blood."     For  many  purposes  this  description  still  holds  good.     In  the  light 


THE  THERAPEUTICS  OF  PAIN.  457 

of  modern  medicine  pain  may  be  due  to  pressure,  to  fatigue,  or  to  a  toxic  irrita- 
tion of  a  nerve.  The  probabilities  are  that  all  of  these  factors  usually  enter 
into  the  production  of  pain. 

Pressure  as  a  factor  in  pain  may  be  purely  mechanical  from  an  outside 
force  or  hypercemic  from  an  inside  force.  When  mechanical,  the  pain  is 
relieved  as  soon  as  the  pressure  is  withdrawn  unless  the  pressure  has  been 
maintained  long  enough  to  produce  secondary  hypersemia  or  an  inflammatory 
process  due  to  the  entrance  of  micro-organisms  into  the  injured  parts.  When 
hyperffimic,  the  pain  usually  continues  as  long  as  the  hypersemia  lasts,  and  may 
continue  after  it  has  disappeared  if  the  hyperaimia  has  led  to  changes  in  tissues. 

Hypersemia  and  inflammatory  processes  may  be  caused  primarily  by  a 
mechanical  injury  or  by  micro-organic  parasitism.  The  growth  of  micro- 
organisms in  the  tissues  sets  up  hyperemia  and,  later  on,  change  in  the  tissues. 
When  this  process  goes  on  in  parts  which  are  well  supplied  with  nerves  of  sensa- 
tion, pain  ensues  and  continues  until  the  nerve  becomes  paralyzed  or  the  pres- 
sure is  relieved. 

Pain  may  also  be  caused  by  pressure  from  deposits  of  inorganic  matter  in 
the  sheathes  of  the  nerves.  This  is  the  kind  of  pain  which  comes  from  gouty 
deposits  and  calcareous  changes  in  blood-vessels. 

Another  cause  of  pain  is  toxins  circulating  in  the  blood  and  irritating  the 
nerve  ends.  To  this  kind  of  pain  probably  belong  all  the  fugitive  pains  of 
the  body  which  one  so  frequently  experiences,  a  moment  here  and  then  there, 
flying  from  part  to  part. 

Pain  may  be  due  to  fatigue  when  muscles  have  been  used  too  continuously 
or  excessively.  Such  is  the  pain  from  eye  strain  and  back  strain.  The 
mechanism  of  this  kind  of  pain  is  probably  hypersemic  and  traumatic. 

Many  remedies  for  pain  have  been  found  in  our  armamentarium.  This 
is  quite  natural  because  one  of  the  chief  functions  of  the  physician  is  to 
relieve  suffering.  !Most  of  the  remedies  act  by  destroying  sensation.  They 
have  been  empirically  introduced  because  they  were  found  to  relieve  pain. 
Unfortunately  little  attention  has  been  paid  to  the  secondary  injury  wliich  may 
follow  their  use. 

Most  of  the  drugs  are  valued  for  their  capacity  to  relieve  pain  rather  than 
to  remove  the  cause  of  pain.  Eational  therapeutics  should  really  be  concerned 
first  with  the  removal  of  the  cause  of  the  pain  and  second  with  the  alleviation 
of  the  suffering.  In  administering  drugs,  moreover,  we  should  be  quite  sure 
that  we  are  not  doing  a  secondary  injury  which  in  the  end  is,  perhaps,  a  more 
serious  matter  to  the  patient  than  is  tlie  pain  from  which  we  are  trying  to 
relieve  him.  In  every  case  the  first  thing  is  removal  of  both  the  mechanical 
and  the  toxic  causes  of  the  pain. 

When  the  mechanical  cause  of  the  pain  can  be  promptly  removed,  removal 
of  such  cause  is  all  that  is  necessary.  Where  the  pressure,  however,  is  due  to 
a  deposit  of  some  kind,  to  hypersemia  or  to  changes  in  the  tissue  which  are  the 
result  of  micro-organic  parasitism,  the  treatment  should  look  not  only  to  tlie 
removal  of  the  pressure  but  also  to  the  elimination  of  the  foreign  bodies  or 
poisons  and  the  arrest  and  removal  of  the  micro-organic  process. 


458  THE  THERAPEUTICS  OF  PAIN. 

Most  of  our  drugs  known  as  analgesics  act  either  by  dulling  sensation 
through  the  brain  itself  or  by  relieving  pressure  through  depression  of  the  cir- 
culation. When  the  drug  acts  through  the  brain  it  probably  does  so  by  paralysis 
of  the  nerves  of  sensation.  Such  drugs  are  usually  hypnotics  as  well  as  anal- 
gesics and  to  some  extent  relieve  pain  by  producing  stupefaction.  The  best 
exemplification  of  this  class  of  drugs  is  opium  and  its  derivatives. 

Drugs  which  are  analgesics  through  the  relief  of  pressure  usually  exercise 
tlieir  power  through  the  heart.  They  depress  the  heart  action  either  by 
inhibition  from  the  brain  centre  or  by  weakening  the  muscular  power  of  the 
heart. 

In  the  light  of  modern  knowledge  of  disease  there  is  a  way  of  relieving 
pain  which  is  more  philosophical  and  safer  than  the  methods  which  have  been 
in  vogue,  namely,  by  elimination  of  the  toxins  which  produce  the  pain.  Elimi- 
nation may  be  excited  through  any  of  the  excretory  organs  but  can  be  accom- 
plished most  quickly  through  the  skin  and  the  alimentary  canal. 

The  eliminative  process  is  particularly  valuable  and  desirable  when  the 
pain  is  due  to  hypera?mia  set  up  by  an  acute  micro-organic  infection.  In  such 
cases  depletion  of  the  circulation  by  a  very  free  action  of  the  skin  or  the  bowel 
will  bring  prompt  relief.  A  profuse  sweat  in  a  Turkish  bath,  a  hot  scrub  bath 
Avith  a  flesh  brush  and  soap,  or  a  free  purgation  with  sulphate  of  magnesia,  or 
some  of  the  saline  purgatives  will  nearly  always  give  prompt  relief. 

Pains  which  can  be  relieved  in  this  way  are  headaches  and  neuralgias 
caused  by  acute  colds.  These  pains  are  most  frequently  caused  by  pressure 
on  the  nerves  along  the  upper  respiratory  tract,  especially  in  the  nose.  Relief 
of  tlie  pressure  brings  prompt  relief  of  the  pain,  and  a  depletion  of  the  circula- 
tion with  an  elimination  of  the  toxins,  which  produce  the  hyperjemia,  brings 
prompt  relief  of  the  pressure. 

Pains  which  are  set  up  at  the  onset  of  acute  infectious  diseases,  as,  for 
example,  in  grippe,  can  be  relieved  in  the  same  way.  Here  the  pain  no  doubt 
is  due  in  a  measure  at  least  to  the  poisoning  of  the  nerve  ends  by  tlie  toxins  and 
not  entirely  to  pressure  from  hyperemia.  Elimination  of  the  toxins  and 
depletion  of  the  circulation  brings  relief.  It  was  in  such  cases  that  the  old 
time  bleeding  was  so  useful  and  soothing. 

For  depiction  tlirough  the  bowel  the  best  drug  at  our  command  is  sulphate 
of  magnesia.  This  should  be  given  in  teaspoonful  doses  at  intervals  of  an 
houi'  or  two  until  many  liquid  stools  have  been  produced.  Depletion  of  this 
kind  can  be  kept  up  for  a  long  time  without  producing  weakness  or  discomfort. 

Pains  which  are  caused  by  deposits  in  the  nerve  sheathes  and  by  poisoning 
of  the  nerves  from  toxins  can  be  relieved  by  a  gradual  continuous  elimination 
through  both  the  skin  and  the  alimentary  canal.  A  slower  process  is  necessary 
in  these  conditions  and  the  elimination  should  be  kept  up  on  a  lower  scale  for 
a  longer  period  of  time.  In  these  cases  daily  scrub  baths  with  soap  and  hot 
water  over  the  entire  body  and  the  administration  of  small  doses  of  sulphate  of 
magnesia  at  short  intervals  give  most  excellent  results.  Pains  which  are  usually 
known  as  hmibago,  myalgia  and  chronic  rheumatism  will  often  yield  to  a 
treatment  of  this  kind  when  they  yield  to  no  other.     For  this  purpose  sulphate 


THE  THERAPEUTICS  OF  PAIN.  459 

of  magnesia  should  be  used  in  five  to  ten  grain  doses  every  hour  for  weeks  and 
even  longer  periods  if  necessary.  The  valuable  results  obtained  at  some  of 
the  Spas  undoubtedly  are  due  to  the  continuous  use  of  small  doses  of  sulphate 
of  magnesia  and  other  salines  in  the  waters.  As  good  results  can  be  produced 
in  the  home  of  the  patient  at  much  less  expense  by  a  proper  use  of  salines. 

Pains  set  up  by  hypersemia  or  inflammatory  conditions  of  the  serous  mem- 
branes can  best  be  relieved  by  rest  and  depletion.  When  such  pains  occur  in 
the  pleura  almost  immediate  relief  can  be  secured  by  strapping  with  adhesive 
plaster  and  depleting  the  patient  with  saline  purgatives.  When  pain  occurs 
in  a  joint  relief  can  be  obtained  by  the  same  methods.  It  is  only  when  the 
pain  occurs  in  such  an  organ  as  the  pericardium  and  the  peritoneum,  where 
splints  cannot  be  applied,  that  an  opiate  must  absolutely  be  resorted  to  for  the 
relief  of  the  pain  and  even  in  these  cases  something  can  be  accomplished  by 
relative  rest  and  depletion.  Especially  when  the  pain  is  in  the  peritoneum  is 
it  possible  to  produce  good  results  with  small  doses  of  salines  at  short  intervals 
for  a  considerable  period  of  time.  Nothing  will  give  quicker  relief,  for  instance, 
in  the  pain  of  appendicitis  than  small  doses  of  sulphate  of  magnesia  every  half 
hour  day  and  night  until  the  pain  is  relieved.  This  treatment  not  only  relieves 
the  pain  but  frequently  depletes  the  appendix  sufficiently  to  reduce  the 
inflammatory  process. 

Applications  of  ice  or  heat  are  of  use  in  the  treatment  of  pain  where  it  is 
due  to  hyperamiia  of  a  beginning  inflammatory  process.  In  these  cases  the 
heat  and  cold  act  in  the  same  way  by  stimulating  the  nerve  ends  away  from  the 
injured  part  and  drawing  the  blood  away  from  it.  Dry  cupping  is  valuable 
over  an  inflamed  organ  and  acts  in  the  same  way  with,  perhaps,  the  addition  of 
drawing  some  of  the  serum  into  the  tissues.  Dry  cupping  is  of  particular 
service  in  the  early  stages  of  pneumonia  and  pleurisy.  To  get  the  full  benefit 
of  dry  cupping  in  pneumonia,  however,  they  should  be  applied  daily  for  the 
first  five  or  six  days. 

A  method  of  relieving  pain  which  is  somewhat  similar  to  the  dry  cups,  but 
perhaps  more  heroic,  is  the  application  of  a  fly-blister.  The  fly-blister  not  only 
depletes  the  parts  in  which  the  disease  process  is  going  on  but  it  draws  to  the 
surface  blood  serum  which  contains  the  antitoxin  set  up  by  the  disease  process. 
If  this  blood  serum  is  allowed  to  absorb  after  it  has  been  drawn  into  the 
cuticle  it  sets  up  a  reaction  and  produces  a  certain  amount  of  immunity  against 
the  micro-organisms  which  produce  the  disease.  By  leaving  the  fly-blister  on 
only  a  short  time,  say  an  hour,  and  then  raising  the  blister  with  hot  towels  the 
cuticle  retains  sufficient  flrmness  to  hold  the  serum  until  it  can  be  absorbed. 
This  method  of  applying  a  blister  is  a  valuable  resource  in  the  treatment  of  dis- 
eases in  which  an  immimity  has  to  be  set  up  before  recovery  takes  place.  It  is 
one  of  our  most  valuable  assets  in  the  treatment  of  tuberculosis. 

Not  only  is  the  eliminative  method  of  dealing  with  pain  preferable  to  the 
analgesic  and  depressant  methods  because  it  gets  rid  of  the  cause,  but  also 
because  it  is  safer.  Opiates  and  all  the  analgesics  which  operate  by  dulling 
the  sensation  interfere  to  a  greater  or  lesser  extent  with  elimination  and 
block  up  the  poisons  in  the  body.     As  these  poisons  all  have  a   damaging 


460  THE  PRESENT  KNOWLEDGE  OF  THE  ACTION  OF  CATHARTIC  DRUGS. 

influence  on  the  tissues  their  retention  in  the  body  even  for  a  relatively  short 
time  may  cause  injury,  which  ultimately  results  in  an  unfavorable  termination 
of  the  disease.  Depressants  may  also  do  serious  injury  to  the  patient.  By 
weakening  the  circulation  they  may  deprive  him  of  a  physical  resource  which 
is  of  great  importance  to  him  at  the  end  of  a  long  struggle  against  disease. 

If  we  are  to  keep  step  with  modern  progress  of  scientific  medicine  we  must 
learn  to  relieve  pain  by  elimination  and  by  methods  which  do  not  pen  up  the 
toxins  of  micro-organisms.  We  must  stop  treating  pain  as  a  symptom  and 
treat  it  on  a  rational  basis.  Eelief  of  pain  must  be  aimed  at  but  in  such  a  way 
as  not  to  do  greater  injury  than  the  pain  itself  can  produce. 


THE  PRESENT  KNOWLEDGE  OF  THE  ACTION  OF  CATHARTIC  DRUGS.* 

Bt  frank  p.  UNDERBILL, 

Assistant  Professor  of  Physiological  Cliemistry  in  Sheffield  Scientific  School,  Yale  Uni- 
versity;   from  the  Shefiield  Laboratory  of  Physiological  Chemistry,  Yale  University. 

Saline  cathartics  were  practically  unknown  until  the  middle  of  the  seven- 
teenth century  when  the  attention  of  physicians  was  drawn  to  the  sal  mirable 
(sodium  sulphate)  of  Glauber.  The  discovery  of  the  purgative  properties  of 
this  salt  proved  to  be  the  impetus  which  led  to  further  investigations  of  other 
similar  compounds,  as  was  attested  by  the  rapidly  increasing  number  of  saline 
bodies  soon  sho^vTi  to  have  similar  action;  thus,  Seignette,  an  apothecary  of 
Piochelle,  prepared  in  1675  the  double  tartrate  of  potash  and  soda.  A  little 
later  the  cathartic  effect  of  a  salt  present  in  the  springs  at  Epsom  was  shown 
to  be  due  to  magnesium  sulphate.  Phosphate  of  soda  was  found  in  the  urine 
in  1737  by  Hellot  and,  fifty  years  later,  was  introduced  into  medicine  as  a 
purgative. 

The  discovery  of  the  effects  of  these  salts  preceded  by  many  years  any 
attempt  to  determine  their  mode  of  action  in  the  body.  With  the  beginning 
of  the  nineteenth  century,  however,  there  is  to  be  noted  the  appearance  in  the 
literature  of  a  large  number  of  papers  on  the  topic  leaving  in  their  wake  certain 
theories  which  are  more  or  less  familiar  to-day.  Poissueille  and  Liebig,  for 
example,  believed  that  in  the  then  newly  discovered  physical  property  of  salts, 
called  osmosis,  was  to  be  found  a  satisfactory  explanation  of  the  purgative 
action  of  these  compounds.  Their  view  that  the  salts  excite  a  flow  of  fluid 
into  the  intestine  by  virtue  of  their  osmotic  properties  was  readily  accepted 
and  was  maintained  by  a  large  number  of  physiologists.  It  was  not  until  the 
problem  was  attacked  by  Claude  Bernard  that  this  extreme  physical  theory 
received  a  check.  It  was  further  called  into  question  by  the  researches  of 
Aubcrt,  and  Buchheim  and  Wagner,  who  clearly  demonstrated  that  this  theory 
did  not  offer  a  complete  and  satisfactory  explanation  of  cathartic  action.     In  its 

•  Read  before  the  American  Therapeutic  Society  in  the  SjTnpo.sium  on  Diet,  New 
Haven,  Conn.,  May  7,  1909. 


THE  PRESENT  KNOWLEDGE  OF  THE  ACTION  OF  CATHARTIC  DRUGS.  461 

place  increased  peristalsis  and  mechanical  irritation  were  suggested  as  the 
cause  of  purgation. 

The  one  man  who  has  probably  done  most  to  bring  order  out  of  the  chaos 
of  conflicting  theories  prevalent  in  the  middle  of  the  last  century  was  Mathew 
Hay,  a  medical  student  in  Edinburgh.  He  began  his  extended  and  truly 
remarkable  series  of  investigations  with  the  assumption  that  the  alimentary 
canal  is  not  alone  a  neuromuscular  mechanism  but  that  it  has  other  equally 
important  functions,  namely,  those  peculiar  to  secreting  glands.  These  func- 
tions must  be  fully  considered,  according  to  Hay,  before  definite  conclusions 
can  be  drawn  regarding  the  mode  of  action  of  cathartics.  A  resume  of  his 
conclusions  is  worthy  of  brief  consideration.  First  of  all  saline  cathartics 
produce  their  effects  only  when  given  by  mouth.  They  are  without  purgative 
effect  when  administered  subcutaneously  or  intravenously.  Saline  cathartics 
do  not  directly  increase  peristalsis  and  except  in  concentrated  solutions  do  not 
produce  enteric  irritation.  Their  primary  action  is  not  upon  extrinsic  nervous 
elements  nor  upon  muscular  fibres,  but  is  exerted  upon  the  intestinal  gland 
cells.  The  first  step  in  purgation  by  salines  is  the  accumulation  of  fluid  within 
the  intestine,  the  production  of  which  is  caused  by  the  excitation  of  the 
secreting  cells  of  the  intestinal  follicular  glands.  This  excitation  is  caused 
either  by  the  saline  coming  in  contact  with  the  cells,  or  by  acting  upon  them 
reflexly  through  the  agency  of  the  intra-intestinal  nerves.  Owing  to  the  cells 
being  deeply  situated  within  the  gland  and  thereby  removed  from  contact 
with  the  contents  of  the  intestine  it  is  unlikely  that  the  salts  act  directly  on  the 
cells.  Even  were  it  assumed  that  the  salt  could  diffuse  into  the  cavity  of  the 
gland  and  thus  reach  the  cells,  it  could  hardly  reach  the  cells  more  readily  than 
if  it  had  been  injected  into  the  blood-stream.  But  in  the  blood  it  is  without 
action.  The  saline  cathartics  would  therefore  appear  to  stimulate  the  glands 
reflexly,  by  producing  a  certain  impression  on  the  sensory  nerves  terminating 
in  the  surface  of  the  mucous  membrane  of  the  intestine,  which  impression, 
conveyed  probably  through  the  plexus  of  Auerbach,  and  that  of  Meissner  to 
the  secreting  cells  of  the  glands,  excites  them  to  action.  In  regard  to  osmotic 
properties  Hay  further  claimed  that  the  salt  does  not  penetrate  the  cavity  of 
the  gland  sufficiently  far  to  exert  appreciable  osmotic  influences  upon  the  secret- 
ing cells.  The  properties  possessed  by  saline  cathartics  which  Hay  considered 
responsible  for  the  excitation  of  the  intestinal  fluid  are  bitterness  and  a  more 
or  less  specific  action.  The  more  bitter  the  salt  the  more  efficacious.  The 
purgatives  are  not  more  irritant  than  other  inorganic  salts,  for  example,  sodium 
chloride  is  much  more  irritant  than  sodium  sulphate  but  is  a  much  weaker 
cathartic.  Indifl'usibility  is  also  another  important  factor.  This  does  not  aid 
the  secretion  but  hinders  absorption  after  secretion  has  taken  place,  and  also 
retards  the  absorption  of  the  original  intestinal  contents.  While  increased 
peristalsis  usually  accompanies  catharsis  it  is  not  essential.  Peristalsis  is 
merely  subsidiary,  being  induced  by  the  distention  resulting  from  the  accumula- 
tion of  fluid  within  the  intestine.  Simultaneous  with  secretion  into  the 
intestine  there  is  a  concentration  of  the  blood  and  a  correspondingly  diminished 
excretion  of  urine  which  is  later  followed  by  the  re-establishment  of  the  normal 


462  THE  PRESENT  KNOWLEDGE  OF  THE  ACTION  OF  CATHARTIC  DRUGS. 

condition  of  the  blood  and  diuresis.  The  latter  causes  a  second  concentration 
of  the  blood  considerably  less  in  degree  than  the  first  concentration  but  con- 
tinuing throughout  a  longer  period.     So  much  for  Hay's  views. 

Since  the  time  of  Hay  various  other  investigators  have  attempted  to 
explain  the  action  of  saline  cathartics  differently.  Thus  Wallace  and  Cushny, 
at  Ann  Arbor,  promulgated  the  theory  that  salts  are  efficient  purgatives  because 
their  solutions  retard  absorption,  thus  keeping  the  intestinal  contents  fluid  and 
rendering  easy  their  passage  along  the  alimentary  canal.  It  is  also  clearly 
shown  that  the  acid  ion  is  the  detennining  factor  here.  For  example,  sodium 
sulphate,  sodium  phosphate,  sodium  citrate,  potassium  citrate,  etc.,  are  all 
looked  upon  as  cathartics  while  sodium  chloride,  potassium  chloride,  etc.,  are 
believed  to  be  indifferent  in  this  respect.  It  is  the  acid  ion,  the  sulphate,  phos- 
phate, etc.,  which  is  the  effective  agent.  In  magnesium  salts  the  magnesium 
would  also  appear  to  be  involved,  for  magnesium  sulphate  and  citrate  are  gen- 
erally believed  to  be  more  effective  than  the  corresponding  salts  of  the  alkalies ; 
and,  in  addition,  magnesium  oxide,  chloride  and  carbonate  possess  cathartic 
properties.  The  presumption  is,  therefore,  strong  that  the  magnesium  ion  is 
not  indifferent  as  are  the  potassium  and  sodium  ions.  The  basis  for  the  theory 
of  these  investigators  is  to  be  found  in  their  observations  on  absorption.  The 
salts,  i.e.,  the  acid  ions,  like  the  sulphate,  and  phosphate  which  cause  purgation, 
are  less  readily  absorbed  from  the  intestine  than  are  those  like  the  chloride, 
which  are  without  cathartic  action.  Moreover,  those  acid  ions  which  form 
insoluble  calcium  salts  are  not  easily  absorbed  and  are  the  most  effective 
cathartics.  The  suggestion  is,  therefore,  obvious  that  the  ions  which  are  con- 
cerned in  purgation  bring  about  this  condition  by  preventing  absorption  owing 
to  the  formation  of  insoluble  salts. 

Loeb  has  stated  that  those  salts  which  produce  purgation  are  identical 
with  those  that  induce  irritability,  muscular  twitchings  and  hypersensitiveness 
of  the  nervous  system.  He  suggests  that  the  increased  peristalsis  may  be  due 
to  an  augmented  irritability  of  the  nerves  and  muscles  of  the  intestine.  J.  B. 
MacCallum  working  on  this  hypothesis  has  demonstrated  that  the  saline 
cathartics  do  indeed  increase  peristalsis  and  are  responsible  for  a  flow  of 
secretion  into  the  intestinal  lumen,  but  it  is  also  maintained  that  the  presence 
of  the  salts  in  the  blood  is  the  essential  factor  in  purgation.  This  was  cor- 
roborated by  Bancroft,  but  Auer  has  lately  clearly  sliown  that  increased  peris- 
talsis and  purgation  are  not  synonymous  tei'ms.  Purgation  may  take  place 
without  increased  peristalsis  and  whereas  parenteral  administration  of  saline 
cathartics  may  lead  to  an  augmented  peristalsis,  purgation  never  occurs.  On 
the  other  hand,  constipation  may  result  from  the  subcutaneous  injection  of 
some  of  the  saline  cathartics,  as  sodium  sulphate  and  yet  peristalsis  may  be 
increased.  In  the  future  we  must  distinguish  between  motor  effects  and  the 
discharge  of  the  intestinal  contents.  At  present  at  least  two  types  of  intestinal 
movements  are  recognized :  a  progressive  peristalsis  in  which  the  intestinal 
contents  are  passed  onward,  and  a  pendular  peristalsis  whereby  the  enteric 
contents  are  merely  moved  backward  and  forward.  It  is,  therefore,  easy  to  see 
how  a  cathartic  drug  may  produce  increased  peristalsis  without  causing  a  dis- 


THE  PRESENT  KNOWLEDGE  OF  THE  ACTION  OF  CATHARTIC  DRUGS.  463 

charge  of  the  intestinal  contents.  It  is  true,  however,  that  purgation  can  be 
induced  at  least  in  animals  by  subcutaneous  injection  of  salines  if  a  large 
quantity  is  introduced.  On  the  basis  of  these  experiments  Auer  has  calculated 
that,  for  an  average  man,  over  a  pound  of  sodium  sulphate  dissolved  in  a  quart 
and  a  pint  of  water  would  be  necessary  for  purgation  if  subcutaneously  intro- 
duced.    This,  however,  is  hardly  a  therapeutic  measure  to  induce  purgation. i 

Chemically  the  cathartic  drugs  of  vegetable  origin  may  be  conveniently 
divided  into  three  great  groups:  (1)  the  purgative  oils,  as  castor  and  croton 
oils,  (2)  the  purgatives  of  the  anthracene  series,  comprising  such  compounds 
as  senna,  aloes,  rhubarb,  etc.,  and  (3)  the  group  of  glucoside  and  acid  bodies, 
consisting  of  substances  like  podophyllum,  colocynth,  jalap,  gamboge,  etc.  All 
the  vegetable  cathartics  must  be  regarded  as  local  irritants.  It  is  obvious, 
however,  in  view  of  their  varied  chemical  nature  that  certain  differences  in 
behavior  should  be  manifested.  In  general,  the  vegetable  purgatives  require 
a  longer  period  of  time  to  produce  their  effects  than  do  the  saline  cathartics. 
The  reason  for  this  is  that  nearly  all  these  substances  undergo  a  change  of  one 
kind  or  another  before  they  are  capable  of  causing  purgation.  Castor  oil  is 
ordinarily  a  neutral  oil  which  is  inactive  in  the  stomach  and  undergoes  little 
or  no  change  in  that  organ.  In  the  intestine,  however,  it  is  hydrolyzed  by  the 
lipolytic  enzymes,  there  present,  giving  rise  to  glycerine  and  the  sodium  salt 
(a  soap)  of  ricinoleic  acid.  This  is  the  body  which  is  the  effective  agent  in 
catharsis,  since  it  is  an  irritant  to  the  intestine,  inducing  a  greatly  augmented 
peristalsis.  In  addition,  a  certain  quantity  of  intestinal  secretion  is  to  be 
observed.  Magnus,  in  his  recent  observations  with  the  Eoentgen  ray  method, 
has  shown  that  castor  oil  when  neutral  causes  a  long  delay  in  the  emptying  of 
the  stomach.  This  is  essentially  a  characteristic  of  all  fats,  as  has  been  shown  by 
Pawlow  and  his  pupils.  In  case  castor  oil  has  stood  and  has  become  rancid, 
that  is,  a  partial  hydrolysis  has  taken  place  leading  to  the  formation  of 
ricinoleic  acid,  or  has  been  shaken  with  soda  solutions,  the  movements  and 
emptying  of  the  stomach  are  greatly  stimulated.  Indeed  peristalsis  may 
become  so  active  that  vomiting  is  induced,  AYhen  castor  oil  has  been  saponified 
in  the  intestine  greatly  accelerated  peristalsis  occurs  and  the  intestinal  contents 
are  hurriedly  passed  through  the  remainder  of  the  alimentary  canal.  The 
force  of  the  peristaltic  movements  is  sufficiently  gi-eat  to  break  the  food  masses 
into  small  bits  which  hurry  back  and  forth  like  tadpoles  in  a  pool.  Defa3cation 
does  not  occur,  however,  until  the  large  intestine  has  been  filled  even  to  the 
rectum.  The  action  of  croton  oil  is  similar  to  that  of  castor  oil.  The  salt 
of  the  fatty  acid,  crotonoleic  acid,  resulting  from  its  hydrolysis  is,  however, 
very  much  more  irritant  than  the  corresponding  salt  derived  from  castor  oil, 
hence  its  more  drastic  effects.  Since  croton  oil  generally  contains  some  of  the 
free  acid,  irritation  of  the  gastric  mucous  membrane  may  also  occur. 


1  The  controversj'  concerning  the  activity  of  saline  purgatives  acting  through  <he 
blood  has  been  reopened  very  recently  by  the  observations  of  Hertz,  Cook  and  Schlcsinger 
(Proc.  Roy.  Soc.  Med.,  1908,  ii.  No.  2),  who  assert  that  in  man  these  compounds  must 
get  into  the  blood  before  watery  stools  are  produced. 


464  THE  PRESENT  KNOWLEDGE  OF  THE  ACTION  OF  CATHAETIC  DRUGS. 

The  principal  effect  of  this  group  of  compounds  is  the  production  by  local 
irritation  of  a  very  active  peristalsis  which  hurries  the  intestinal  contents  along 
the  alijnentary,  thereby  interfering  with  the  absorption  of  the  entire  contents 
and  of  a  certain  quantity  of  secretion  which  is  poured  into  the  intestinal  lumen. 

The  introduction  into  the  body  of  such  substances  as  senna,  cascara, 
rhubarb,  etc.,  leads  to  purgation  whether  the  drug  is  administered  by  mouth, 
subcutaneously  or  intravenously.  The  active  substances  are  di-  or  tri-oxy- 
methylanthraquinones  which  possess  more  or  less  specific  irritant  properties 
for  certain  portions  of  the  alimentary  canal,  and  the  principal  visible  effect 
is  the  production  of  a  greatly  increased  peristalsis.  Senna  may  be  taken  as  a 
typical  example.  It  has  lately  been  shown  by  Magnus  that  senna  has  a  specific 
influence  upon  the  movements  of  the  large  intestine.  Observed  by  means  of 
the  Roentgen  ray  the  progress  of  food,  through  the  alimentary  canal,  given  with 
senna,  is  uneventful  until  entrance  is  made  into  the  large  intestine.  As  soon 
as  the  food  masses  enter  the  large  intestine  there  is  observed  a  very  active 
peristalsis  which  rapidly  leads  to  defgecation.  The  mechanism  by  which  this  is 
accomplished  is  not  clear  unless  it  is  assumed  that  the  active  principles  are 
specific  stimuli  for  certain  intra-intestinal  nerves,  for  it  is  probable  that  a 
large  portion  of  the  drug  is  absorbed  before  the  large  intestine  is  reached. 
Elliott  and  Barclay-Smith  have  ascribed  to  a  nerve  centre  in  the  sacral  portion 
of  the  spinal  cord  this  control  of  the  movements  of  the  large  intestine.  Mag- 
nus has  demonstrated  that  the  action  of  senna  is  in  no  way  inhibited  after 
destruction  of  this  portion  of  the  spinal  cord.  The  senna  effect  if  of  a  nervous 
nature  can  be  produced  only  through  a  local  reflex  centre  in  the  intestine. 

In  general  the  vegetable  cathartics  act  much  less  rapidly  than  the  salme 
purgatives.  This  becomes  readily  intelligible  when  it  is  remembered  that 
nearly  all  of  the  preparations  are  bodies  which  are  more  or  less  insoluble  in 
certain  portions  of  the  alimentary  canal.  They  are  insoluble  in  acid  solutions, 
but  are  readily  soluble  in  alkaline  media.  When,  therefore,  a  dose  of  cascara 
is  given  by  mouth  precipitation  occurs  as  soon  as  the  acid  medium  of  the 
stomach  is  reached.  The  drug  remains  insoluble  until  it  comes  in  contact  with 
the  alkaline  contents  of  the  small  intestine.  These  alkaline  solutions  are 
partially  absorbed  from  the  intestine  and,  since  they  are  effective  whichever 
way  administered,  it  may  be  that  their  presence  in  the  blood  is  the  essential 
factor. 

Concerning  the  glucoside-containing  group  of  bodies  like  jalap,  colocynth, 
podoph5dlum,  but  little  can  be  said.  The  investigations  that  have  been  carried 
out  make  it  probable  that  this  heterogeneous  class  of  substances  has  much  the 
same  type  of  action  as  that  of  the  anthracene  group. 

Clinicians  have  long  sought  a  cathartic  drug  which  can  be  given  sub- 
cutaneously. Such  a  drug  would  be  of  great  advantage  in  a  variety  of  condi- 
tions :  in  gastric  inflammation  where  purgation  may  be  necessary,  in  apoplexy, 
in  coma,  and  other  conditions  of  unconsciousness,  after  certain  abdominal 
operations,  in  the  treatment  of  epileptics  and  the  insane,  etc.  Many  such 
drugs  have  been  suggested  nearly  all  of  which  will  produce  the  desired  effects. 
Invariably,  however,  they  give  rise  to  complications,  which  prohibit  their  use 


THE  PRESENT  KNOWLEDGE  OF  THE  ACTION  OF  CATHARTIC  DRUGS.  465 

in  the  form  of  a  subcutaneous  injection.  Podophyllin  injected  hypodermically 
will  cause  purgation  but  will  also  lead  to  the  development  of  ulcers  or  other 
similar  troubles  at  the  point  of  injection. 

Eecently,  quite  by  accident,  a  new  cathartic  has  been  discovered  which 
promises  to  fill  the  long-felt  need  for  a  cathartic  suitable  for  parenteral  use. 
For  governmental  reasons  it  became  necessary  in  Austria-Hungary  to  ear-mark 
a  certain  wine.  A  substance  was  therefore  added  to  it  which  was  colorless  in 
acid  solution  but  which  became  red  on  the  addition  of  an  alkali.  The  body  was 
phenolphthalein,  the  common  laboratory  indicator.  When  the  wine  was  placed 
on  the  market  its  consumers  were  troubled  with  a  diarrhoea  which  persisted  so 
loDg  as  the  wine  was  taken.  On  investigation  it  was  shown  that  phenol- 
phthalein  (a  derivative  of  tri-phenol-methane),  is  a  very  active  cathartic. 
In  the  stomach  it  is  unchanged  but  in  the  intestine  the  sodium  salt  is  formed 
which  is  even  more  effective  than  phenolphthalein  itself.  Its  use  is  attended 
by  no  irritation  to  the  enteric  tract.  It  does  not  provoke  peristalsis  but  acts 
by  exciting  a  hypersecretion  of  fluid  in  the  intestine.  It  has  no  deleterious 
influence  upon  the  kidney  and  is  non-toxic.  According  to  Fleig  its  sodium  salt 
is  especially  well  adapted  for  subcutaneous  injection.  Abel  maintains  that  the 
sodium  salt  is  not  as  good  for  the  purpose  as  certain  new  halogen  derivatives 
especially  the  chlor  derivatives,  which  have  not  yet  however  been  fully  investi- 
gated. The  latter  are  only  slowly  absorbed  from  under  the  skin  and  a  small 
dose  is  capable  of  producing  watery  stools  for  several  days. 

Quite  recently  another  distinct  type  of  substance  has  been  introduced. 
This  is  agar-agar,  a  seaweed  which  is  being  prescribed  in  habitual  constipation. 
Unlike  the  bodies  thus  far  considered  it  does  not  produce  watery  stools  but  the 
excreta  are  well  formed  and  apparently  normal.  Agar-agar  is  an  indigestible 
carbohydrate  which  has  the  property,  like  gelatin,  of  absorbing  a  large  volume 
of  water  and  it  is  to  this  combination  of  indigestibility  and  power  of  absorbing 
water  that  it  owes  its  value  as  a  laxative.  What  probably  happens  is  that  the 
agar  absorbs  fluid  from  the  intestines  and  swells,  thereby  distending  the 
intestine.  The  distention  of  the  intestine  and  the  increased  weight  of  the 
intestinal  contents  are  sufiicient  to  account  for  a  moderately  increased  peris- 
talsis which  results  in  dofaecation. 

From  the  foregoing  considerations  it  is  apparent  that  the  cathartic  drugs 
may  act  upon  the  alimentary  tract  in  a  variety  of  ways,  involving  physical, 
chemical  and  physiological  activities.  Thus  for  the  saline  cathartics  osmosis, 
mechanical  irritation,  nerve  stimulation,  inhibition  of  absorption,  acceleration 
of  secretory  processes  and  increased  peristalsis,  together  or  alone,  have  been 
proposed  as  the  effective  factors  in  purgation.  The  consensus  of  evidence 
indicates  that  osmosis  plays  but  a  subsidiary  role  while  mechanical  irritation  is 
absent.  The  essential  factor  is  the  production  of  an  intestinal  secretion  by 
nerve  stimulation  with  a  simultaneous  inhibition  of  absorption.  Peristalsis 
is  secondary. 
4 


466  THE  PRESENT  KNOWLEDGE  OF  THE  ACTION  OF  CATHARTIC  DRUGS. 

Most  of  the  vegetable  cathartics  are  peculiar  in  tliat  they  will  produce 
their  characteristic  effects  by  whatever  channel  introduced  although  certain 
untoward  results  may  follow  from  the  subcutaneous  injection.  It  is  possible 
that  the  proposed  derivatives  of  phenolphthalein  will  obviate  the  difficulty. 
Unlike  the  saline  cathartics  the  presence  in  the  blood  of  vegetable  purgatives 
appears  to  be  the  essential  factor  in  bringing  about  purgation.  The  principal 
effect  of  this  class  of  compounds  is  the  production  by  local  irritation  of  a  very 
active  peristalsis  which  hurries  the  intestinal  contents  along  the  alimentary 
canal.  From  the  recent  observations  on  the  vegetable  cathartics  we  have 
learned  that  different  drugs  may  act  upon  entirely  different  portions  of  the 
alimentary  canal.  Thus,  the  purgative  oils,  according  to  their  condition,  i.e., 
presence  or  absence  of  decomposition  products,  may  influence  the  movements 
of  the  stomach  and  intestine  or  the  intestine  alone,  whereas  a  drug  like  senna 
shows  no  action  until  the  large  intestine  is  reached.  Peristalsis  and  purgation 
are  not  s}Tionymous  terms.  Peristalsis  may  be  of  two  distinct  types  either 
pendular  movements,  without  progression  of  the  intestinal  contents,  or  peris- 
talsis, by  which  the  contents  of  the  alimentary  are  passed  along.  It  is  the 
latter  type  which  is  effective  in  purgation. 

In  complications  where  it  is  undesirable  to  induce  hypersecretion  along 
the  alimentary  canal  the  salines  should  be  avoided.  On  the  other  hand,  in 
conditions  of  sluggish  secretory  activities  they  are  indicated.  Since  secretory 
activity  necessitates  increased  blood-supply  to  the  parts  involved  the  drawing 
of  blood  from  other  portions  of  the  body  may  or  may  not  be  desirable.  The 
increased  secretion  poured  into  the  alimentary  canal  accounts  for  the  efficacy 
of  the  salines  in  removing  fluid  from  the  body  in  oedematous  conditions. 

The  employment  of  the  vegetable  cathartics  is  contraindicated  in  condi- 
tions where  the  alimentary  canal  is  already  in  a  state  of  irritation  for  these 
bodies  are  primarily  irritants.  They  are  indicated  where  the  intestinal  move- 
ments are  sluggish  and  certain  of  them  may  be  given  when  specific  portions  of 
tlic  alimentary  tract  need  stimulation. 

BIBLIOGRAPHY. 

Hay:     Jour.  Anat.  and  Physiol.,  1883,  xvii,  p.  405. 
Wallace  and  Cusiiny:     Amor.  Jour.  Physiol.,  1898,  i,  p.  411. 

MacCallum,  J.  E.:     "The  IMcehanism  of  the  Physiological  Action  of  the  Saline  Cathar- 
tics," Berkeley,  lOOG. 
Dixon:     Brit.  Med.  Jour.,  1902,  p.  1244. 
Tunnicliffe:     Brit.  Med.  Jour.,  1902,  p.  122.-). 
Bancroft:     Jour.  Biol.  Chcm.,  1907,  iii,  p.  191. 

AuEE:     Amer.  Jour.  Physiol.,  1906,  xvii,  p.  15;    also  Jour.  Biol.  Chcm.,  1908,  iv,  p.  197. 
Fbankl:     Archiv  f.  exper.  Path.  u.  Pharm.,   1907,  Ivii,  p.  386. 
Magnus:     Archiv  f.  d.  ges.  Physiol.,  1908,  cxxii,  p.  261  and  p.  252. 
Fleig:     Archiv  internat.  Pharmakodynam.  u.  Therapie,  1908,  xviii,  p.  327. 
Cushny:     Pharmacology  and  Therapeutics,   1906. 


DIABETES  MELLITUS  AS  AN  INFECTIOUS  DISEASE.  467 


DIABETES  MELLITUS  AS  AN  INFECTIOUS  DISEASE.* 

Bt  ALFRED  KING,  M.D., 

PORTLAND,   ME. 

This  paper  is  based  upon  investigations  and  experiments  consequent  upon 
the  following  line  of  thought:  Glucose,  diacetic  acid  and  acetone  compounds 
are  products  of  fermentation.  They  are  due  to  some  unnatural  ferments  in 
the  body.     Is  diabetes  a  fungus  disease?     If  so,  what  treatment  is  necessary? 

The  fungus  to  suggest  itself  was  the  saccharomyces  cerevisise,  found  in 
every  diabetic  urine.  The  first  question  to  be  answered  was,  Does  this  fungus 
produce  glucose-forming  ferments?  This  was  easily  answered  for  much  study 
has  been  made  of  this  fungus.  While  it  is  generally  understood  that  its  action 
is  the  fermentation  of  sugar  into  alcohol  and  carbonic  acid,  yet  it  is  found  that 
the  sugar  must  be  of  a  certain  kind,  like  glucose.  Other  sugars  must  therefore 
be  changed  to  this  fermentable  form.  It  has  been  demonstrated  that  one  of 
the  functions  of  this  fungus  is  the  production  of  soluble  ferments,  or  enzymes, 
whose  presence,  by  catalytic  action,  will  change  certain  sugars  into  glucose  and 
also  the  animal  starch,  glycogen,  into  glucose.  One  of  these  enzymes  is 
invertase.  This  will  change  100,000  times  its  own  weight  of  cane  sugar  into 
glucose  and  levulose.  It  will  change  milk  sugar  into  glucose  and  galactose  and 
also  maltose,  the  product  of  salivary  and  pancreatic  digestion,  into  glucose. 
Another  enzyme,  more  recently  discovered  is  sucrase,  which  will  change 
glycogen  into  maltose,  which  in  turn  will  be  changed  by  the  invertase  into 
glucose.  We  find  then  that  this  yeast  fungus  forms  enzj'mes  which  produce 
glucose,  the  sugar  of  diabetes. 

The  next  question  to  solve  was,  If  this  fungus  is  found  in  the  urine,  is  it 
eliminated  by  the  kidneys  from  the  blood?  In  examining  the  blood  for  it,  it 
was  found  that  the  coagulation  hindered  its  growth  on  the  culture  media  and 
that  if  coagulation  was  prevented  by  mixing  the  blood  with  a  solution  of  the 
citrate  and  chloride  of  soda,  one  and  a  half  per  cent,  of  the  former  and  one  per 
cent,  of  the  latter,  a  pure  culture  of  the  saccharomyces  cerevisiae  was  obtained 
in  a  few  hours.  As  the  blood  used  was  less  than  a  drop  and  obtained  from  a 
sterile  finger  tip,  it  is  evident  that  this  glucose-forming  fungus  exists  in  great 
abundance  in  diabetics.  Sixteen  cases,  all  that  could  be  obtained,  were 
examined  with  the  same  result. 

Examinations  were  made  to  determine  the  resisting  power  of  diabetics  to 
this  fungus.  Opsonic  indices  were  taken  in  the  sixteen  cases  and  were  found 
to  vary  from  .56  to  1.23,  normal  being  1.  The  opsonic  index  of  each  patient 
was  a  fair  estimate  of  the  physical  condition.  After  a  little  experience  it  was 
possible  to  estimate  with  a  fair  degree  of  accuracy  the  index  of  a  patient.  A  case 
of  diabetes  of  pregnancy  was  found  to  be  a  mild  one,  the  index  was  1.04,  but 
the  blood  and  even  the  milk  gave  a  pure  culture  of  the  fungus. 


*  Author's  abstract,  of  paper  read  before  the  American  Tlicrapeutic  Society,  May 
1909. 


468       REQUISITES  FOR  THE  TREATMENT  OF  THE  PSYCHO-NEUROSES. 

Vaccines  were  tried  on  six  patients,  with  no  local  or  general  disturbance. 
Three  or  four  doses  bring  the  index  or  resisting  power  above  normal,  even 
though  diabetics  do  not  resist  infection  strongly.  The  vaccmes  were  found 
also  to  increase  the  sense  of  strength,  give  a  feeling  of  well  being,  relieve  or 
remove  thirst  and  diminish  the  amount  of  sugar  and  urine  excreted,  even  when 
the  patient  was  on  a  mixed  diet.  More  study  of  the  use  of  vaccines  is  necessary. 
Lowered  resistance  is  an  important  factor  in  the  causation  of  diabetes  as  is 
seen  by  its  occurrence  in  connection  with  obesity,  pregnancy,  syphilis,  neuras- 
thenia, nervous  shock  and  certain  nervous  diseases. 

Pathological  findings  are  confirmatory  of  this  theory  of  diabetes.  The 
first  thing  to  this  time  noted  in  the  body  is  the  increase  of  glucose  in  the  blood. 
Later  come  congestions  of  liver,  pancreas,  spleen  and  kidneys,  found  in  systemic 
infections.  Still  later  come  sclerotic,  fatty  and  atrophic  degenerations  from 
the  same  cause.  No  other  theory  than  that  of  infection  explains  such  changes. 
It  is  curious  that  these  late  changes  should  be  considered  as  causes. 

Since  the  saccharomyces  cerevisias  are  found  abundantly  in  the  blood,  since 
they  produce  enzymes  forming  glucose  out  of  certain  foodstuffs  and  glycogen, 
since  the  system  shows  a  disturbed  resisting  power  to  this  fungus,  since  this 
resisting  power  is  increased  and  all  diabetic  symptoms  are  relieved  by  the  use 
of  vaccines,  and  since  the  pathological  findings  are  confirmatory,  the  author 
believes  that  diabetes  is  a  fungus  disease  and  should  be  treated  accordingly. 

The  indications  for  treatment  are  to  remove  the  cause,  increase  the  power 
of  resistance  and  relieve  the  symptoms.  To  remove  the  cause  we  should  use 
antiseptics,  increase  the  phagocytic  action  of  the  leucocytes  by  the  use  of 
vaccines  and  promote  elimination  by  the  kidneys  if  necessary.  To  relieve  symp- 
toms we  should  use  diet,  vaccines,  tonics,  alkalies  in  acidosis,  and  deep  breathing 
exercises  to  aid  oxidation  and  eliminate  more  carbonic  acid.  When  boils,  car- 
buncles or  gangrene  occur  antiseptics  and  surgery  are  also  necessary. 


REQUISITES  FOR  THE  TREATMENT  OF  THE  PSYCHO-NEUROSES: 
PSYCHOPATHOLOGICAL  IGNORANCE,  AND  THE  MISUSE  OF 
PSYCHOTHERAPY  BY  THE  NOVICE.* 

By  TOM  A.  WILLIAMS,  M.B.,  CM.   (Edin.), 
WASHINGTON,   D.    0. 

We  hear  much  about  the  neuroticism  of  modern  days,  the  popular  belief 
being  that  neurasthenia,^  as  it  is  loosely  called,  hardly  existed  until  the  latter 
end  of  the  19th  century.  It  is  supposed  that  this  state  of  matters  is  due  to  the 
fatigue  to  the  nerves  of  the  modem  strenuous  life. 

As  a  matter  of  fact,  confessions,  memoirg,^  and  the  pictures  of  the 
time  show  that  neurotic  states  occurred  in  tbe  Middle  Ages  even  more  widely 
than  they  do  to-day.     Again,  the  "vapours"  so  often  alluded  to  in  the  literature 

•  Read  by  invitation  at  tlie  SjTnposium  on  Psychotherapy  before  the  Washington 
Therapeutic  Association,  April  10,  1909. 


REQUISITES  FOR  THE  TREATMENT  OF  THE  PSYCHO-NEUROSES.       469 

of  Queen  Anne's  time,  would  nowadays  be  called  nervous  prostration,  and  a 
"rest-cure"  would  be  prescribed;  but  in  that  less  enlightened  age,  they  were 
appraised,  empirically  it  is  true,  at  their  real  value — mental  vacuity,  discontent 
or  failure  of  adjustment  to  environment. 

The  last  factor  is  shown  by  a  close  analysis  to  be  the  real  cause  of  most 
cases  of  so-called  nervous  prostration^ ;  and  the  indiscriminate  administration 
of  the  rest-cure  without  a  clear  psycho-diagnosis  will  in  the  future  be  relegated 
to  the  limbo  of  such  other  medical  superstitions  as  blood-letting  and  anti- 
pyretics. 

Of  course,  adjustment  fails  when  the  nerve  cells  are  poisoned,  injured, 
receive  insufficient  oxygen  or  irregular  supply  of  blood;  but  these  are  not 
psychic  diflBculties,  and  can  be  provided  against  by  the  internist  and  the  patho- 
logical chemist.  He  succeeds  in  virtue  of  the  precision  with  which  he  estimates 
the  derangements  in  a  body  whose  normal  functions  he  has  spent  years  in 
studjdng. 

Similarly,  the  psychiatrist  can  succeed  only  by  an  understanding  of 
normal  mental  reactions,  and  by  a  profound  study  of  the  data  of  morbid  psy- 
chology. It  must  be  recollected  that  the  patients  referred  to  him  are  those 
in  whom  empirical  methods  have  failed.  For  example,  they  are  "suggestioned" 
ad  nauseam ;  one  patient  told  me  how  thankful  she  was  that  I  did  not  tell  her 
she  was  better  or  minimize  her  mental  suffering;  for  she  hated  the  sight  of  a 
doctor;  as  each  in  turn  made  light  of  her  state,  and  said  she  would  soon  be  bet- 
ter; whereas  she  became  worse,  and  the  confidence  she  had  reposed  in  her  first 
physician  had  become  profound  distrust  at  the  end  of  three  years,  at  which  time 
I  was  called  in. 

Another  gross  empirical  error  is  the  injudicious  appeal  *to  the  patient's 
will-power.^  The  doctor  who  commits  this  solecism  does  not  realize  that  the 
patient  has  by  now  exhausted  his  volitional  power  of  response,  previously  highly 
stimulated  by  the  complexities  of  social  and  professional  environment.  It  is 
as  if  a  lost  traveller  in  a  jungle  which  he  does  not  know  were  directed  to  find 
his  way  back  to  the  camp  from  which  he  had  strayed.  The  real  guide  will 
show  the  way. 

Such  symposia  as  this  are  a  sign  that  in  psychotherapy  blundering  empiri- 
cism has  had  its  day.  We  should  laugh  at  the  surgeon  who  tried  to  tie  the 
lingual  artery  while  ignorant  of  the  anatomy  of  the  sub-lingual  triangle,  or 
even  to  set  a  dislocation  without  understanding  the  structure  of  the  joints; 
but  the  arrest  of  a  morbid  train  of  thought  and  the  setting  a  mind  at  rest  are 
much  more  delicate  operations  than  those  of  the  surgeon;  and  yet  although 
the  art  requires  finesse  for  its  acquirement  and  years  before  the  tadus  eruditus 
is  acquired,  very  few  men  hesitate  to  rush  in  where  angels  fear  to  tread — into 
the  sacred  precincts  of  the  soul.  A  bull  in  a  china  shop  would  be  less  out  of 
place. 

Such  assumptions  of  confidence  where  skill  has  not  been  acquired  have  in 
the  field  of  g5'nocology  called  down  just  reproach  from  the  masters  of  that 
art.^  In  morbid  pathology,  the  result  has  been,  if  not  less  disastrous  to  our 
patients,  certainly  much  more  so  to  ourselves,  both  in  wealth  and  prestige. 


470       REQUISITES  FOR  THE  TREATMENT  OF  THE  PSYCHO-NEUROSES. 

The  Christian  Science  Church  is  a  growing  canker  of  contempt  for  science 
and  its  medical  exponents;  and  its  doctrine  is  inculcated  to  the  plastic  mind 
of  childhood,  to  be  there  ineradicably  fixed,  even  though  enlightenment  may 
come.  The  Emmanuel  movement  will  become  another  source  of  malign 
influence;  for  it  has  now  been  publicly  repudiated,^  even  by  the  few  neurol- 
ogists who  were  weak  enough  to  countenance  its  apparently  ethical  commence- 
ment. 

We  can  overcome  these  influences  only  by  acting  together,  as  is  done  in 
all  successful  organizations,  Tlie  public  requires  and  demands  psychic  treat- 
ment. They  receive  from  the  medical  man,  burdened  with  the  complexities 
of  his  art,  only  indifiierence  or  an  affectation  of  knowledge  which  they  are 
quick  to  penetrate.  I  even  know  of  a  case  where  a  medical  man  sent  a  patient 
to  a  mental-healer  who  advertises  in  the  newspaper. 

Xow  the  remedy  should  be  obvious  enough.  It  is  to  provide  facilities  for 
instruction  of  medical  men,  first  in  psychology  and  psycho-pathology,  and  then 
in  psychotherapeutics.  To  do  this,  wards  and  out-patient  clinics  must  be 
provided  in  the  hospitals,  to  which  competent  teachers  must  be  appointed.  In 
the  meanwhile,  the  doctor  who  endeavors  to  bungle  through  the  treatment  of 
a  psychoneurotic  case,  without  understanding  psychophysiology  and  pathology, 
and  with  only  a  rough  empirical  experience,  is  guilty  of  a  crime  to  his  pro- 
fession. Such  cases  should  be  treated  at  least  under  the  advice  of  a  specialist, 
until  the  physician  has  learned  to  do  so  himself  by  observation  and  study  under 
expert  direction. 

It  is  impossible  in  ten  minutes  to  even  indicate  the  kind  of  problems 
which  psychotherapy  studies,'''  all  of  them  depending  upon  analytic  diagnosis 
of  mental  make  up,  as  well  as  of  the  physical  factors  which  contribute  to 
psychic  insufiiciency. 

I  may  mention  firstly  the  mythomanic^  tendency,  that  is  the  impulse  to 
take  what  appears  the  easier  way  of  complete  indifference  with  regard  to  truth. 
It  is  fundamentally  a  lack  of  foresight  due  to  a  deficiency  of  intelligence ;  but 
it  has  been  acquired  in  early  childhood,  and  has  become  an  alTective  habit, 
which  the  intelligence  is  not  powerful  enough  to  overcome.  Its  prevention, 
and  later  the  cure,  depends  upon  the  principle  of  "conditioning  the  reflexes," 
as  shown  in  its  most  simple  terms  by  Pawlow^  in  dogs,  when  he  changed  at 
will  the  stimulus  needed  to  provoke  gastric  or  salivary  secretions.  The  whole 
art  of  education  is  based  upon  tliis  principle  of  associating  pleasant  feelings 
with  useful  activities,  of  which  truth  telling  is  certainly  one  of  the  greatest. 
The  re-education  of  a  bad  habit  is  similar  in  principle,  but  more  difficult  of 
accomplishment,  and  is  best  illustrated  in  the  arts  of  playing  a  musical  instru- 
ment or  of  speaking  and  singing. 

Time  forbids  to  trace  the  stages  between  such  simple  measures  and 
the  full  complexily  of  the  intellectual  readjustments  which  psychotherapy 
attempts. 

The  problem  is  comparatively  easy  compared  with  that  where  the  emo- 
tions and  feelings  are  concerned,  as,  for  instance,  in  such  cases  of  sexual 
perversion  as  the  classic  one  of  Krafft-Ebing,i^  where  the  sexual  act  could 


REQUISITES  FOR  THE  TREATMENT  OF  THE  PSYCHO-NEUROSES.       47 1 

be  performed  only  when  the  patient's  wife  was  dressed  in  a  white  apron, 
owing  to  the  circumstance  that  it  was  with  a  maid  so  dressed  that  he  had  first 
had  connection.  Still  more  striking  in  this  connection  is  the  case  recently 
reported  by  Stcherbak,ii  in  which  the  only  means  of  producing  orgasm  was 
the  placing  upon  the  knees  the  elegantly  booted  lov.-er  extremities  of  a  fash- 
ionably dressed  woman.  (The  sexual  factor  in  the  production  of  neuroses  is 
most  important,  and  it  is  time  the  reticence  we  display  towards  it  cease, 
and  be  replaced  by  thorough  discussion.) 

But  emotion  may  be  conditioned  too.  Indeed,  it  is  the  affective  accom- 
paniments which  give  intellectual  attitudes  their  dynamic  power. 

This  is  an  important  element  in  cases  of  traumatic  neuroses.  Here,  the 
replacement  of  the  morbid  feeling  tone  by  another  cannot  be  direct,  but  must 
be  accomplished  through  the  replacement  of  the  causative  idea  by  another 
one.  Ex  cathedra  affirmation  or  cold  appeal  to  the  intellect  cannot  change  an 
attitude  or  mood  of  any  standing.  The  method  of  doing  this  may  be  illus- 
trated by  the  gastric  neuroses,  ^^  where  a  false-fixed  idea  creates  a  feeling  of 
disgust  while  food  is  being  eaten,  which,  in  turn,  inhibits  the  digestive  secre- 
tions. As  I  have  pointed  out  elsewhere,  this  morbid  conditioned  reflex  has 
usually  its  source  in  the  unskilful  suggestions  of  doetors^^  who  have  not 
understood  the  role  of  the  psyche  in  patholog}%  and  who  have  gone  on  treat- 
ing the  s}Tnptoms  by  referring  them  to  the  stomach  itself,  thereby  only 
fortifying  the  patient's  error;  so  that  by  the  time  he  reaches  the  psycho- 
therapist, he  is  inaccessible  to  conviction  that  the  trouble  is  really  in  his  head, 
as  Dejerinei'*  puts  it.  Accordingly,  he  cannot  be  convinced  by  assertion  or 
argument,  as  he  has  lost  confidence  in  these;  but  is  convinced  by  the  stern 
logic  of  events,  shown  by  his  rapid  gain  in  weight  while  isolated.  It  is  then 
that  the  physician's  dialectic  finds  its  opportunit}',!^  and  the  patient's  false 
idea  is  dispelled. 

I  have  shown  elsewhere^ ^  that  both  of  these  conditions  are  forms  of 
hysteria,  in  that  they  are  susceptible  of  "production  by  suggestion  and  of 
removal  by  suggestion-persuasion."^''^ 

Some  patients  of  the  more  intellectual  grade  are  put  on  the  road  to 
recovery  by  the  first  interview,  although  the  recovery  from  emaciation  and 
the  starvation  habit  which  the  stomach  has  acquired  requires  some  time. 

In  traumatic  neurosis  my  experience  has  been  more  favorable,!^  one 
interview  often  sufficing.  I  attribute  this,  however,  to  the  fact  that  these 
patients  are  in  a  better  position  than  the  gastric  ones  to  realize  the  truth ;  for 
until  the  psychotherapeutic  interview,  they  have  heard  only  ex  parte  opinions 
or  indiscriminate  sympathy  for  an  attitude  which  at  heart  they  would  be  glad 
to  be  rid  of.  Without  confidence  given  by  a  thorough  knowledge  of  organic 
disease  of  the  nervous  system  the  neurologist's  diagnosis  and  affirmation  can- 
not be  positive.  1*^  When  to  this  is  added  the  muddled  conceptions  so  preva- 
lent about  the  traumatic  neuroses,  one  cannot  wonder  at  the  reproaches  heaped 
upon  our  profession  as  medico-legal  experts. 

From  these  types  of  what  might  be  termed  perverted  reaction  to  environ- 
ment, I  trust  that  my  hearers  will  gain  at  least  a  slight  conception  of  tlie 


472       REQUISITES  FOR  THE  TREATMENT  OF  THE  PSYCHO-NEUROSES. 

problems  with  which  psychotherapy  deals;  and  that,  from  a  comprehension 
of  these  clearer-cut  conditions,  they  may  be  in  a  better  position  to  estimate 
the  much  commoner  cases  where  one  may  be  called  upon  to  guide  into  pro- 
ductive and  happy  channels  perversions  of  disposition,  such  as  despondence, 
suspiciousness,  facile  emotionalism,  religious  sentimentalism,  social  ashamed- 
ness,  weakness  of  character,  and  morbid  fears,  pains,  besetments  or  any  form 
of  inadequacy  to  personal  and  social  requirements.^^ 
2118  Wyoming  Avenue. 

REFERENCES. 

I  Williams:     Importance  of  Distinguishing  between  the  Psychoneuroses,  Jour.  Abnor. 

Psy.,  JIarch-April,  1909. 
2SuElN:     Soeur  Jeanne  des  Anges,  revised  by  Gilles  de  la  Tourette,  Paris,  1889. 

Ahxjmada:      (Theresa  de),  Le  Chateau  Int^reur,  French  Trans.,  Paris. 
8  Williams:     The    Diff.    Diag.    between    Neurasthenia    and    Some    AiTections    of    the 
Nervous  System,  for  which  it  is  often  Mistaken,  Arch,  of  Diagnosis,  Jan.,  1909. 

4  Williams:     The  Essentially  Different  Treatment  Required  in  Affections  often  Mis- 

taken   for  Neurasthenia,   Tri-State   Med.   Assn.,   Feb.,    1909;      Charlotte     Med. 
Jour.,  1909. 

5  Washington  Med.  Soc,  1908. 

6  Letter  Symposium  in  Boston  Herald,  1909. 

7  Taylob  :     The   Relation   of   the   Medical   Profession   to  the   Psychotherapeutic   Move- 

ment, Boston  Med.  Jour.,  1908. 
Putnam:     Psychasthenia  from  the  Viewpoint  of  Social  Consciousness,  Amer.  Jour. 

Med.  Sciences,  Jan.,  1908. 
Levy,  E.  P.:     L'Education  Rationelle  de  la  Volont6,  Paris,  1904. 
Payot:     L'Education  de  la  Volonte,  Paris,  1904. 

Meige  et  Feindehl:     Les  Tics  et  Leur  Traitment,  Paris,   1901;    Forthcoming  Sym- 
posium on  Psychotherapy,  Jour.  Abn.  Psy.,  1909. 
SDuPBlS:     La  Mythomanie,  1906. 
0  Huxley  Lecture,  Brit.  Med.  Jour.,  1906. 
10  ICR.vFFr-EciNa :     "Psychopathia  Sexualis,"  Trans.  Chaddock. 

II  SxCHEBB^ui:     Arch,  de  Neurol.,  Vol.  II,  1907. 

12  Williams:     Jour.  Abnor.  Psy.,  Feb. -March,  1908;  Old  Dom.  Jour.,  1908;  Am.  Med. 

April,  1909. 
DfijEBiNE:     Les  Fausse  Gastropathes,  La  Presse  Med.,  1906. 

13  Williams:     Le  Role  du  Medecin  en  crCant  ou  en  Maintenant  par  ses  Suggestions 

Maladroites    les   Maladies    produites    par    I'lmagination;     Congrfis    des    Neuro- 
logistes  Frangais  fl  Lille,  1906,  Trans.  vXmor.  Med.,  Aug.,  1908. 

14  In  Camus  et  Pagniez:     Isolement  et  PsychothCrapie,  Paris,  1904. 

15  Williams:     Hints  from  Experience  in  Psychotherapy,  Monthly  Cyclo.,  July,  1908. 

16  Williams:     The   Trend  of   the   Clinicians   Concept  of  Hysteria,   Boston   Med.   Jour. 

April,  1909;    sec  also  International  Clinics,  Autumn,  1908,  and  Monthly  Cyclo. 

and  Med.  Bui.,  April. 
i7BiU3iNSKi:     "Ma  Conception  de  I'Hysterie,"  Paris,  1906. 
18  Williams  :     The  Traumatic  Neurosis  and  Babinski's  Conception  of  Hysteria,  Inter. 

Congres.  for  Industrial  Accidents,  Rome,  May,  1909;    also  Monthly  Cyclo.,  Nov., 

1908. 
10  DfiJERiNE :     In  Camus  et  Pagniez,  loc.  cit. 
20  The  most  complete  discussion  of  these  is  found  in  Raymond  et  Janet,  "Les  Obsessions 

et  la  Psychasthenic,"  Paris,  1903. 


THE  HYPNOIDAL  STATE  IN  PSYCHOTHERAPEUTICS.  473 


THE  HYPNOIDAL  STATE  IN  PSYCHOTHERAPEUTICS.* 

By  BORIS  SIDIS,  M.A.,  Pn.D.,  M.D., 

Formerly  Associate  in  Psychology  and  Psychopathology  at  the  Pathological  Institute  of 

the  New  York   State   Hospitals;     Director   of   the   Psychopathic   Hospital   and 

Psychopathological    Laboratory    of    the    New     York     Infirmary     for 

Women  and  Children. 

BEOOKUNE,  MASS. 

Hypnosis  has  long  ago  been  brought  before  the  medical  profession  as  a 
state  in  which  maladies  of  a  purely  psychic  origin,  such  as  the  various  forms  of 
hysterias,  obsessions  and  phobias  could  be  greatly  alleviated  and  even  per- 
manently cured.  The  works  of  Braid,  Charcot,  Li^bault,  Bernheim,  Forel, 
Vogt,  Morton  Prince,  Breuer  and  Freud,  Schrek-Notzing,  Bechterev,  Janet, 
Babinski  and  others  are  well  known  to  the  student  of  abnormal  psychology. 
Recently,  however,  psychopathologists  have  become  more  and  more  impressed 
with  the  practical  limitations  of  hypnosis.  Many  patients  cannot  be  hypno- 
tized, others  require  special  conditions  for  their  hypnotization,  while  still  others 
positively  refuse  to  submit  themselves  to  any  hypnotic  treatment  being  afraid 
of  mystical  and  occult  influences.  There  is  no  denying  the  fact  that  there 
exists  a  good  deal  of  opposition  against  psychopathology  and  psychotherapeutics. 
It  is  certainly  a  pity  that  many  medical  men  of  note  are  not  acquainted  with  the 
scientific  work  accomplished  in  the  domain  of  abnormal  psychology  both  in 
this  country  and  abroad.  An  American  medical  journal  of  a  well  known  Ameri- 
can medical  association  rejects  works  on  psychopathology  and  psychothera- 
peutics. The  editor  is  apparently  under  the  impression  that  he  is  doing  a 
service  to  American  medical  science,  that  disquisitions  and  "researches"  on 
eczema,  diarrhoea  and  cognate  scientific  subjects  are  specially  valuable  and  suit- 
able to  the  mind  of  the  medical  reader.  In  Germany,  France,  Austria,  Russia, 
Italy,  work  in  abnormal  psychology  has  long  ago  gained  recognition  as  a  science 
of  theoretical  and  practical  importance  to  the  physician  and  to  the  lawyer,  while 
in  the  United  States  conservatism  and  even  ignorance  in  regard  to  abnormal 
psychology  are  still  paraded  as  an  honorable  badge  of  orthodox  medical  respect- 
ability. Is  it  a  wonder  that  the  European  regards  with  reserve  the  official 
scientific  work  of  American  medicine? 

Since  hypnosis  meets  with  so  much  opposition,  the  question  naturally 
arises, — Is  it  possible  to  affect  and  modify  pathological  mental  states  outside 
the  hypnotic  state?  The  problem  is  practical  and  requires  a  solution.  In  ray 
work  "The  Psychology  of  Suggestion,"  I  pointed  out  that  suggestibility  can 
also  be  induced  in  the  normal  waking  state.  I  have  also  shown  that  among 
the  conditions  of  normal  and  abnormal  suggestibility  monotony  and  limitation 
of  voluntary  movements  play  a  very  important  role.  Any  arrangement  tend- 
ing to  produce  monotony  and  limitation  of  voluntary  activity  brings  about  a 

•Author's  abstract  of  paper  read  before  the  American  Therapeutic  Society,  May 
8,  1909. 


474  THE  HYPXOIDAL  STATE   IN  PSYCHOTHERAPEUTICS. 

subconscious  state  of  suggestibility  termed  by  me  subwaking  or  hypnoidal,  a 
subconscious  state  in  which  mental  life  can  be  affected  with  ease. 

In  the  hypnoidal  state  consciousness  is  somewhat  vaguer  than  in  the 
waking  condition ;  memory  is  diffused,  so  that  experiences  apparently  forgotten 
come  in  bits  and  scraps  to  the  foreground  of  consciousness.  Emotional  excite- 
ment subsides,  voluntary  activity  is  passive  and  suggestions  meet  with  but 
little  resistance.  The  hypnoidal  state  is  a  rest  state,  a  state  of  physical  and 
mental  relaxation.  The  favorable  therapeutic  results  obtained  by  me  led  me  to 
a  closer  study  of  what  I,  some  thirteen  years  ago,  regarded  as  a  peculiar  mental 
condition. 

For  some  time  my  work  was  confined  to  observations  and  experiments  on 
human  subjects.  Eecently,  however,  I  undertook,  at  the  physiological  labora- 
tory of  Harvard  Medical  School  and  at  my  own  psychopathological  laboratory, 
a  series  of  experiments  on  sleep  in  various  animals — the  frog,  the  bird,  guinea- 
pig,  cat,  dog,  infant,  and  human  adult. ^  The  experiments  prove  that  the 
hypnoidal  state  is  also  present  in  the  lower  stages  of  animal  life.  Furthermore, 
the  experiments  clearly  show  that  the  further  we  descend  in  the  scale  of  animal 
life  the  more  prominent,  the  more  essential,  does  the  subwaking  state  become. 
The  facts  lead  to  the  conclusion  that  the  hypnoidal  state  is  the  primitive  rest- 
state  out  of  which  sleep  has  arisen.  We  may  say  that  both  hypnosis  and  sleep 
are  highly  differentiated  states  which  have  become  evolved  out  of  the  primitive, 
undifferentiated,  subwaking  hypnoidal  state  which  is  the  rest-state  still  char- 
acteristic of  the  lowly  organized  fonns  of  animal  life.  The  subwaking  or 
hypnoidal  state  is  essentially  an  intermediate  state  belonging  to  the  borderland 
of  mental  life.  On  the  one  hand  the  hypnoidal  state  closely  touches  on  waking 
life,  on  the  other  it  merges  into  sleep  and  hypnosis.  In  man  the  subwaking 
state  is  but  in  a  rudimentary  condition, — it  has  shrunk  to  a  transitory  stage  in 
the  alternation  of  waking  and  sleep. 

From  a  theoretical  and  etiological  diagnostic  standpoint  the  l^ypnoidal 
state  is  of  the  utmost  importance,  since  by  means  of  it  we  are  enabled  to  dis- 
cover the  causation  and  psychogenesis  of  the  mental  malady.  We  can  follow 
the  history  and  development  of  the  total  symptom-complex.  This  in  its  turn 
gives  an  insiglit  into  modus  operandi  of  disintegration  of  the  pathological 
mental  system  underlying  the  psychopatliic  malady.  We  can  also  by  means  of 
the  hypnoidal  state  form  a  plan  as  to  how  reconstruct,  reorganize,  synthesize 
the  disintegrated  elements  of  the  broken-up  pathological  system  obtaining 
normal  and  healthful  reactions.^ 

Tbc  present  therapeutic  aspect  of  the  hypnoidal  state  is  certainly  of  great 
value.  Our  laboratory  experiments  have  revealed  the  significant  fact  that  the 
hypnoidal  state  is  the  primordial  rest-state,  sleep  is  but  a  derivative  form  of 
rest.  In  many  forms  of  diseases,  especially  nutritional  ones,  it  is  often  advis- 
able to  revert  to  a  more  simple  form  of  nutrition,  to  a  simpler  and  more 
primitive  form  of  life.     Similarly  in  psychopathic  maladies  a  reversion  to  a 

iSidis:      "An  Expciinientul  Study  of  Sleep." 

2Sidis:  "Psychopatliological  Eescarehes;  iliiltiplc  Personality;  Studies  in  Psy- 
chopathology,"  Boston  Med.  and  Surgical  Journal,  1907. 


SUPERJ^ICIAL  DERMATITIS  OF  THE  EXTERNAL  AUDITORY  CANAL.     475 

simple,  primitive  form  of  rest-state  proves  to  be  of  great  therapeutic  value. 
Now  in  plunging  the  patient  into  the  subwaking,  hypnoidal  state  we  have  him 
revert  to  a  primitive  rest-state  with  its  consequent  beneficial  results. 

An  important  result  of  my  investigation,  a  result  which  I  can  only  give 
here  in  a  general  statement  is  the  access  gained  through  the  agency  of  the 
hypnoidal  state  to  the  stores  of  dormant,  potential  reserve  energy  possessed  by 
the  patient.  The  therapeutic  value  of  the  hypnoidal  state  consists  in  the  libera- 
tion of  reserve  energy  requisite  for  the  synthesis  of  the  dissociated  systems 
which  form  the  pathological  basis  of  the  psychopathic  malady.'^ 

I  may  add  here  in  passing  that  there  are  good  reasons  to  suppose  that 
Weir-Mitchell's  rest-cure  has  derived  some  of  its  therapeutic  value  from  the 
unconscious,  empirical  use  of  the  subwaking,  hypnoidal  rest-state. 


SUPERFICIAL  DERrylATITIS  OF  THE  EXTERNAL  AUDITORY  CANAL.  * 

By  CLARENCE  JOHN  BLAKE,  M.D., 

Professor  of  Otology  in  Harvard  University  Medical  School. 

BOSTON,    MASS. 

The  peculiar  provision  in  the  epidermal  lining  of  the  inner  half  of  the 
external  auditory  canal  for  the  removal  of  normal  detritus,  as  well  as  the  ready 
separability  of  the  epidermis  itself  under  conditions  of  congestion,  and  of  serous 
exudation  from  the  underlying  derma,  add  to  the  interest  attaching  to  what 
would  be  a  comparatively  unimportant  subject,  but  that  it  has  to  do  with 
relationship  to  the  function  of  an  organ  of  special  sense. 

The  epithelial  layer  which  fonns  the  outer  coat  of  the  drumhead  has  a 
defined  movement  outward  from  the  center  toward  the  posterior  superior 
periphery  of  the  meml^rana  vibrans,  and  this  movement  is  continued  outward 
along  the  inner  half  of  the  external  auditory  canal,  in  two  spiral  lines,  until  that 
part  of  the  canal,  the  junction  of  the  osseous  and  cartilaginous  portions,  thickly 
beset  with  hairs  and  ricli  in  glandular  elements,  has  been  reached. 

Under  normal  conditions  when  the  epidermis,  in  its  progressive  movement 
outward,  has  attained  tliis  point  the  efl'ete  epidermal  cells  separate  themselves, 
as  on  other  parts  of  tlie  body,  and  are  individually  extruded,  or  mingle  with 
the  product  of  the  sebaceous  and  ceruminous  glands  and  are  extruded  in  mass. 

Under  conditions  of  irritation,  either  directly  mechanical,  or  reflexly 
incident  to  a  systemic  condition,  resulting  in  hypera^mia  and  congestion  of  the 
derma,  with  serous  exudate,  the  epidermal  layer  becomes  separated,  its  outward 
progress  hindered,  and  its  continuity  destroyed,  the  maceration  of  the  epidermis 
by  the  serous  outflow  still  further  impeding  tlie  natural  process. 

Aside  from  cases  of  mechanical  causation,  or  those  coincident  with  an 
acute  process  in  the  middle  ear,  this  form  of  superficial  dermatitis  is  found  in 

3  ±\  fnll  account  is  to  appear  in  the  Boston  ]\Iod.  and  Surgical  Journal. 
*  Autlior's  abstract  of  paper  read  before  the  American  Tiierapcutic  Society,  May 
8,  1909. 


476 


ATROPIN  IN  DIABETES  MELLITUS. 


COLLES'S  FRACTURE. 


persons  of  a  rheumatic  or  gouty  habit,  as  an  occasional  concomitant  of  diabetes, 
and  sometimes,  in  3'Oimg  women,  recurring  with  the  menstrual  epoch.  The 
local  aural  s}Tnptoms  are,  in  all  instances,  much  the  same  and  amenable  to  the 
same  simple  treatment,  consisting  in  careful  cleansing  of  the  canal  from  all 
discharge  and  detritus  by  means  of  a  weak  warm  solution  of  bicarbonate  of 
soda,  careful  drying  by  means  of  successive  pledgets  of  sterile  absorbent  cotton, 
and  the  touching  of  the  denuded  surface  with  a  nitrate  of  silver  solution  of  a 
strength  from  60  to  80  grains  to  the  ounce. 


Cyclopaedia  of  Current  literature 


ATROPIN  IN  DIABETES  MELLITUS. 

Atropin  has  been  administered  by  the 
author  in  diabetes,  in  the  fonn  of  the 
methylbromid  and  the  sulphate.  As  the 
initial  dose  of  the  methylbromid  he  has 
given  gr.  %5  t.i.d.  to  adults,  gradually 
increasing  this  by  gr.  %5  imtil  gr.  %5 
t.i.d.  are  being  taken.  In  one  case  three 
grains  were  given  daily  over  a  short 
period  with  no  other  toxic  effect  than 
dr}Tiess  of  the  throat.  The  initial  dose 
of  atropin  sulphate  should  be  gr.  ^/iso 
t.i.d.,  which  may  be  gradually  increased 
to  gr.  K>o  t.i.d.  Children  require  a 
dosage  proportionate  to  their  age.  It  is 
noteworthy  that  these  unusually  large 
amounts  of  atropin  are  well  tolerated, 
provided  the  initial  dose  is  small  and  the 
increase  gradual.  It  is  not  necessary  to 
attain  the  maximum  dose  in  the  majority 
of  cases,  however,  much  smaller  amounts 
often  causing  the  glycosuria  to  disappear. 
With  the  appearance  of  the  first  toxic 
symptom,  usually  a  marked  dryness  of 
throat,  the  atropin  was  either  stopped 
entirely,  or,  more  often,  the  attempt  to 
increase  the  dosage  was  temporarily 
abandoned.  It  was  always  possible  to 
resume  the  drug  after  a  period  of  rest. 
The  action  of  atropin  may  be  summed  up 
under  the  following  heads:  (1)  Reduc- 
tion in  the  amount  of  sugar  excreted ; 


(2)  increase  in  carbohydrate  tolerance. 
J.  Eudisch  (Medical  Eecord,  June  26, 
1909). 

COLLES'S  FRACTURE. 

Typical  Colles's  fracture  presents  an 
anteroposterior  and  lateral  deformity  of 
the  lower  end  of  the  radius  with  impac- 
tion of  the  upper  into  the  lower  fragment. 
In  severe  cases  this  is  complicated  by 
fracture  of  the  ulnar  styloid  and  injury 
of  the  ligaments  and  cartilage.  Treat- 
ment demands  efficient  reduction  of  the 
bony  fragments  in  the  beginning.  For 
this  an  ana3sthetic  is  desirable,  because 
impaction  must  be  broken  up  to  avoid 
lateral  deformity  and  widening  of  the 
wrist.  Eestoration  of  the  functional  and 
anatomical  integrity  of  the  wrist  de- 
mands immobilization  till  the  bone  is 
united.  This  period  is  three  to  five 
weeks.  Protection  of  the  joint  must  be 
continued  till  healing  is  completed  and 
all  of  the  original  traumatic  inflamma- 
tion has  subsided.  This  period  is  six  to 
eight  weeks  when  the  ligaments  are 
injured  and  eight  to  ten  weeks  when  the 
cartilage  is  injured.  Gradual  return  to 
use  favors  a  perfect  result  and  avoids 
unnecessary  complications  and  sequelas. 
P.  P.  Swett  (New  York  Medical  Journal, 
July  24,  1909). 


CRETINISM,  THYROID  TREATMENT  IN. 


EXOPHTHALMIC  GOITER.       477 


CRETINISM,   THYROID  TREATMENT  OF. 

Since  1905,  the  Austrian  govenmient 
has  been  supplying  thyroid  tablets  free  of 
charge  in  seven  endemic  foci  of  cretinism 
with  medical  inspection  twice  a  year. 
About  108,600  tablets  were  thus  dis- 
tributed in  1907,  and  157,900  in  1908, 
the  number  of  persons  taking  them  was 
1,011,  and  608  were  still  under  the  thy- 
roid treatment  at  the  close  of  1908.  The 
results  are  tabulated  under  various  head- 
ings, special  attention  being  paid  to  the 
increase  in  height  as  the  most  certain 
index  of  the  benefit  derived.  Other  find- 
ings are  more  liable  to  be  influenced  by 
subjective  impressions.  The  report  states 
that  the  results  have  been  extremely  sat- 
isfactory, confirming  the  efficacy  of  thy- 
roid treatment  as  a  prophylactic  measure 
especially  in  endemic  foci  of  cretinism. 
In  677  cases  followed  to  date  marked 
improvement  was  obtained  in  48.6  per 
cent.,  and  only  8.6  per  cent,  showed  no 
benefit  from  the  course.  The  most  strik- 
ing proof  of  the  beneficial  influence  of 
thyroid  treatment  on  the  growth  is  the 
fact  that  in  377,  that  is,  in  85.7  per  cent, 
of  all  cases,  the  former  dwarf  cretin 
children  grew  to  be  taller  than  the 
normal  standard  for  their  age.  As  a 
rule,  treatment  was  restricted  to  school 
children;  the  oldest  cretin  was  26  years 
old.  Even  after  20,  a  number  of  the 
cretins  grew  much  taller  and  the  other 
BjTnptoms  of  cretinism  became  attenu- 
ated. This  growth  at  this  age  is  so  sur- 
prising, that  it  seems  as  if  the  growing 
power  of  the  preceding  years  had  been 
held  in  reserve,  until  suddenly  released 
by  the  thyroid  treatment,  when  it  made 
all  its  force  felt  in  a  relatively  short 
period.  A  large  number  of  the  more 
interesting  cases  are  cited  in  detail. 
One  cretin,  20  years  old,  grew  11  centi- 
meters, but  then  refused  to  continue 
treatment  as  he  outgrew  his  clothes  too 


fast.  He  did  not  lose  his  milk  teeth 
until  after  thyroid  treatment  was  com- 
menced, although  those  of  the  second 
dentition  were  in  place.  A.  von  Kuts- 
chera  (Wiener  klinische  Wochenschrift, 
June  3,  1909;  Journal  American  Medi- 
cal Association,  July  17,  1909). 

EXOPHTHALMIC    GOITER    AND    THE    RE- 
PRODUCTIVE FUNCTION. 

The  writer's  experience  includes  nine 
cases  in  which  exophthalmic  goiter 
showed  an  unmistakable  connection  with 
ovulation.  In  several,  restoration  of 
normal  ovulation  was  accompanied  by  the 
subsidence  of  the  exophthalmic  syn- 
drome. He  does  not  accept  the  German 
view  that  pregnancy  aggravates  the  tend- 
ency to  the  latter,  but  rather  agrees  with 
Charcot  that  improvement  is  liable  to 
follow  measures  to  regulate  the  menstrual 
function.  In  his  first  case  the  exoph- 
thalmic goiter  developed  at  puberty,  but 
subsided  as  menstruation  became  regular ; 
it  returned  in  typical  form  duriQg  a 
period  of  amenorrhoea,  but  subsided 
again  during  a  pregnancy,  and  this 
fluctuation  occurred  during  three  preg- 
nancies. In  another  case  exophthalmic 
goiter  developed  during  a  period  of 
amenorrhoea  and  persisted  for  five  years 
with  varying  intensity.  The  genital  ap- 
paratus was  infantile,  but  it  developed 
between  25  and  30  and  menstmation 
returned  and  became  regular  about  30,  at 
which  time  the  exophthalmic  triad  van- 
ished completely.  Pregnancy  occurred 
in  the  next  year;  disturbing  vomiting 
occurred  at  first,  ceasing  about  the  fourth 
month,  and  conditions  have  been  normal 
since,  for  eleven  years.  The  confinement 
and  lactation  were  nonual.  In  one 
family  exophthalmic  goiter  was  ob.^erved 
in  three  generations,  the  affection  becom- 
ing attenuated  or  disappearing  with 
regular  menses.    A  number  of  other  cases 


478 


GASTRIC  DIGESTION  OF  INFANTS. 


GASTRIC  ULCER. 


showed  the  constant  sequence  of  increas- 
ing corpulence,  suppression  of  the  menses 
and  development  of  the  exophthalmic 
goiter.  Nearly  all  these  patients  were 
practically  cured  under  treatment  which 
generally  included  hydrotherapy,  restric- 
tion to  a  milk  diet  or  electricity,  or 
all  combined.  A.  Pinard  (Annales  de 
gynecologic  et  d'obstetrique,  May,  1909 ; 
Journal  American  Medical  Association, 
July  10,  1909). 

GASTRIC  DIGESTION  OF  INFANTS. 

The  motility  of  the  infant  stomach 
varies  inversely  to  the  concentration  of 
the  food.  The  more  dilute  the  food  the 
more  frequently  may  the  feedings  be 
given.  Lime  water  does  not  reduce  the 
acidity  of  the  gastric  contents,  the  neu- 
tralizing of  a  portion  of  the  acid  being 
overcome  by  an  increased  stimulation  of 
hydrochloric  acid  by  the  gastric  glands. 
This  may  increase  the  amount  of  the  acid 
available  for  digestion.  Sodium  citrate 
acts  on  the  acid  in  the  stomach,  convert- 
ing it  into  sodium  chlorid  and  this  mark- 
edly reduces  the  "available  hydrochloric 
acid."  Barley  water  seems  to  have  no 
constant  effect  on  the  chemistry  of  gas- 
tric digestion  in  the  infant.  The  type  of 
infants  who  vomit  persistently  may  be 
divided  into  two  classes,  hypoacidity  and 
hyperacidity.  Test  feedings  should  be 
given  to  this  type  of  infants  to  determine 
to  which  class  they  belong.  A  five-per- 
cent, milk-sugar  solution  seems  to  be  the 
most  satisfactory  feeding  to  determine 
fine  differences  in  the  gastric  contents. 
This  may  be  followed  by  a  mixture  of 
milk  of  one  part,  water  two  parts,  to 
determine  to  what  extent  the  gastric 
glands  are  capable  of  responding  to 
stimuli.  For  the  lactose  solution,  thirty 
minutes  is  the  most  satisfactory  time  to 
allow  the  feeding  to  remain  in  the  stom- 
ach ;  for  the  milk  mixture,  sixty  minutes. 


On  purely  theoretical  grounds,  it  would 
appear  that  when  the  acidity  is  low  either 
small  doses  of  alkalies  or  of  hydrochloric 
acid  are  indicated,  while  in  hyperacidity 
sodium  citrate  holds  out  the  best  hope  of 
benefit.  Protein  digestion  in  the  infant's 
stomach  is  slight  and  is  proportional  to 
the  amount  of  hydrochloric  acid  in  the 
organ.  T.  W.  Clarke  (American  Jour- 
nal i\[edical  Sciences,  June,  1909). 

GASTRIC  ULCER,  MILK-FREE  DIET  IN. 

A  milk-free  diet  was  tried  in  a  case  of 
two  years'  standing  with  entire  success 
after  the  usual  methods  employed  in  the 
treatment  of  gastric  ulcer  had  failed. 
The  white  of  one  egg  was  beaten  up  in  a 
glass  of  cold  water  and  sipped  slowly; 
this  feeding  was  given  every  three  hours, 
and  each  day  the  dose  was  increased  by 
one  egg,  so  that  at  the  end  of  two  weeks 
the  patient  was  getting  the  whites  of 
twenty  eggs  each  day — that  is,  the  whites 
of  four  eggs  to  a  glass  of  water  every 
three  hours.  The  pain  gradually  disap- 
peared, she  was  able  to  lie  on  her  right 
side,  which  was  not  possible  before,  no 
vomiting  occurred,  and  marked  mental 
improvement  was  noticed.  The  only 
medical  treatment  used  was  lavage  with 
one  pint  of  warm  water,  in  which  one- 
half  ounce  of  sodium  bicarbonate  had 
been  dissolved.  One-half  of  this  amount 
was  allowed  to  remain  in  the  stomach. 
Before  each  feeding  of  albumin  water, 
she  was  given  one-half  teaspoonful  dry  on 
the  tongue,  of  the  following  mixture : — 

I^  Magnesia3  wstse, 
Sodii  carbonatis, 
Potassii  carbonatis,  of  each,  5.0. 
Sacchari  lactis,  25.0. 

On  the  fourteenth  day,  a  meat  juice 
preparation  was  added  to  the  diet — and 
then  gradually  meat,  eggs,  vegetables  and 
bread.    On  the  forty-second  day  the  pa- 


BOOK  REVIEWS.  479 

tient   was   well   nourished,   enjoyed   her  made  three  hours  after  a  meal  found  the 

food  and  had  no  pain  for  several  weeks,  stomach  absolutely  empty,  and  no  symp- 

no    eructations    of    gas,    the    test    meal  toms  of  ulcer  could  be  found.     F.   W. 

showed  normal  acidity,  and  there  was  no  Foxworthy  (Journal  Indiana  State  Medi- 

tenderness    over    the    abdomen,    lavage  cal  Association,  June,  1909). 


8ooI(  Reviews 


Diseases  of  the  Nose,  Throat,  and  Ear  and  Their  Accessory  Cavities.  By  Seth  Scott 
Bishop,  M.D.,  D.C.L.,  LL.D.,  Author  of  "The  Ear  and  Its  Diseases;  Professor  of  the 
Nose,  Throat,  and  Ear  in  the  Chicago  Post-Graduate  Medical  School  and  Hospital; 
Surgeon  to  the  Post-Graduate  Hospital,  and  to  the  Illinois  Hospital;  Consulting  Surgeon 
to  the  Marj  Thompson  Hospital,  to  the  Illinois  Masonic  Orphans'  Home,  to  the  Chicago 
Hospital  School  for  Nervous  and  Delicate  Children,  and  to  the  Silver  Cross  Hospital  of 
Juliet;  formerly  Surgeon  to  the  Illinois  Charitable  Eye  and  Ear  Infirmary,  to  the  South 
Side  Free  Dispensary,  and  to  the  West  Side  Free  Dispensary;  one  of  the  Editors  of  the 
Laryngoscope,  etc.  Fourth  Revised  Edition.  Illustrated  with  Ninety-four  Colored  Litho- 
graphs and  Two  Hundred  and  Thirty  Additional  Illustrations.  Philadelphia:  F.  A. 
Davis  Company,  Publishers,  1908. 

The  necessity  for  the  fourth  edition  of  this  work  indicates  to  a  great  extent  its  popularity 
among  the  members  of  the  medical  profession,  and  there  is  no  doubt  but  that  the  new  edition 
will  receive  deserved  recognition,  for  the  same  high  standard  that  was  manifested  in  previous 
editions  is  here  maintained.  Although  alterations,  additions,  and  improvements  have  been 
made,  the  author  has  adhered  to  his  original  plan  of  presenting  a  book  as  compact  as  thor- 
oughness and  clearness  would  admit.  Additions  have  been  made  to  the  description  of 
Killian's  operation  for  opening  the  frontal  sinus,  and  the  author's  conservative  method  of 
employing  compressed  air  in  the  treatment  of  the  ear  has  been  further  elucidated.  Siebenn- 
mann's  treatment  of  adhesive  inflammation  of  the  middle-ear,  and  Grant's  treatment  of 
Mf^ni&re's  disease  have  also  received  attention. 

Although  the  plates  appear  rather  higli  colored,  they  are  very  instructive  and  seem  to 
well  illustrate  the  lesion  represented. — R.  B.  S. 

Tuberculosis  of  the  Nose  and  Throat.  By  Lorenzo  B.  Lockard,  M.D.,  Laryngologist  and 
Rhinologist  to  the  .Jewish  Consumptives  Relief  Society  Sanatorium,  the  Y.  M.  O.  A. 
Health  Farm  and  the  Evangelical  Lutheran  Sanatorium;  formerly  Laryngologist  to  the 
National  Jewish  Hospittil  for  Consumptives,  and  Member  of  the  Board  of  Directors  of 
the  Agnes  Memorial  Sanatorium;  one  time  Professor  of  Anatomy,  Toledo  Medical  Col- 
lege; Fellow  of  the  American  Academy  of  Ophthalmology  and  Oto-Laryngology,  etc. 
With  Eighty-five  Illustrations,  Sixtj'-four  of  Them  in  Colors.  St.  Louis:  C.  V.  Mosby 
Medical  Book  &  Publishing  Co.,  1909. 

"The  main  objects  of  this  book  are  to  place  before  the  profession  the  modern  views  con- 
cerning the  early  recognition,  the  treatment  and  prognosis  of  the  disease,  in  the  hope  that 
an  increased  faith  in  the  efiioacy  of  treatment  and  a  full  appreciation  of  the  importance  of 
early  diagnosis  and  of  routine  examinations  of  the  larynx  in  every  consumptive  will  be 
engendered." 

At  the  present  time,  when  not  only  the  attention  of  the  medical  profession,  but  also 
that  of  the  laity,  is  focused  on  the  heroic  fight  that  is  being  waged  against  the  white  plague, 
especially   in   this  country,   a   book  which   presents  the   modern   views  of  any   phase   of   thia 


480  BOOK  Rj] VIEWS. 

malady,  and  which  elucidates  many  micertain  points,  is  timely  to  say  the  least.  The  fact 
that  the  author  has  personally  come  in  contac.  with  a  great  array  of  cases,  and  that  he  has 
made  liberal  use  of  his  vast  experience,  adds  much  to  the  value  of  the  book.  In  the  opening 
pages  a  brief  historical  sketch  of  laryngeal  tuberculosis  shows  that  even  at  an  early  date  the 
significance  of  this  condition  was  recognized,  but  that  great  difficulty  was  experienced  in  the 
differential  diagnoses.  This  chapter  is  followed  by  the  treatment  of  the  subject  from  tho 
various  phases  of  clinical  medicine.  Many  statistics  have  been  compiled,  and  the  author's 
familiarity  with  the  literature  is  shown  by  his  well-selected  referencefi.  The  book  is  written 
in  a  style  which  is  clear  and  comprehensive,  making  it  easy  reading  and  no  less  interesting 
than  a  novel.     The  cuts,  sixty-four  of  which  are  colored,  are  a  valuable  adjunct  to  the  text. 

While  there  is  no  doubt  that  many  patients  suffering  from  laryngeal  tuberculosis  can  be 
greatly  relieved,  and  may  be  cured,  by  rigid  and  conscientious  treatment,  still  one  wonders 
if  the  author's  optimistic  view  of  the  ultimate  results  in  these  cases  would  be  the  same  if 
climatic  conditions  in  his  vicinity  were  not  so  favorable  to  their  improvement. 

The  only  criticism  worthy  of  note  is  the  number  of  inexcusable  typographical  errors 
which  are  evident  throughout  the  book.  The  work,  however,  can  be  highly  recommended  to 
those  who  are  interested  in  the  work. — R.  B.  S. 

Dante — Physician.  By  A.  G.  Drury,  M.D.,  Cincinnati,  Professor  of  Hygiene  in  the  Medical 
College  of  Ohio,  Medical  Department  of  the  University  of  Cincinnati.  Cincinnati:  The 
Lancet-Clinic,  1908. 

New  historical  facts  are  always  of  interest  and  deeply  appreciated,  and  when  they  pertain 
to  a  man  of  renown,  they  usually  excite  considerable  notice.  In  a  small  volume  of  some  89 
pages  the  author  has  made  an  effort  to  prove  that  Dante  was  well  versed  in  the  science  of 
medicine  and  perfectly  capable  of  practicing  the  art.  Although  numerous  quotations  are 
submitted  as  evidence,  in  which  this  celebrated  poet  showed  a  liberal  knowledge  of  medicine, 
the  question  arises  as  to  whether  he  was  any  better  versed  in  the  science  than  the  learned 
men  of  his  time.  To  strongly  substantiate  the  claim  of  the  author,  however,  is  the  fact  that 
Dante  was  supposed  to  have  studied  medicine  in  the  University  of  Bologna,  and  later  in  the 
University  of  Padua,  and  that  his  name  was  in  the  register  of  the  Arts  of  Physicians  and 
Druggists  from  1297  to  1300.  In  spite  of  existing  uncertainties  in  regard  to  the  medical 
education  of  this  great  Florentine  poet,  the  review  of  his  versatile  character  is  the  source 
of  pleasant  reading,  and  the  small  monograph  under  notice  will,  no  doubt,  appeal  even  to 
the  general  public. — R.  B.  S. 

The  Matter  with  Nervousness,  By  H.  C.  Sa^wer,  M.D.,  of  San  Francisco,  Cal.  San  Fran- 
cisco:   Cunningham,  Curtess  &  Welch,  1909. 

We  heartily  recommend  the  perusal  of  this  little  volume  by  both  physicians  and  laymen. 
It  is  full  of  wisdom,  learning,  pithy  epigrams  and  homely  illustrations.  The  literary  style 
is  peculiar,  but  good;    so  direct  as  to  be  almost  bare,  but  forceful  and  clear. 

This  is  a  good  book  for  the  clergy  to  read.  It  will  take  only  an  hour  or  two  the  first 
time.     If  they  will  read  it  twice  it  will  start  the  founts  of  reflection. — J.  M.  T. 

Insomnia  and  Nerve  Strain.  By  Henry  S.  Upson,  M.D.,  Professor  Diseases  of  the  Nervous 
System  in  the  Western  Reserve  University.  With  Skiagraphic  Illustrations.  New  York 
and  London:    G.  P.  Putnam's  Sons,  The  Knickerbocker  Press,  1908. 

Professor  Upson  has  furnished  much  food  for  thought  by  this  contribution  to  medical 
literature.  He  has  set  forth  convincingly  his  experience  and  recommendations  on  the  causes 
and  treatment  of  various  neuroses  and  psychoses  as  found  in  mental  irritations.  He  advocates 
most  wisely  the  fullest  exploration  of  the  condition  of  the  teeth  in  all  instances  of  mental 
peculiarities,  whether  simple  or  obscure,  and,  indeed,  wherever  there  is  any  groimd  for  sus- 
pecting possible  involvement  through  dead  or  diseased  teeth.  Especially  does  he  insist  on 
x-ray  studies  and  explains  how  they  may  best  be  made. — J.  M.  T. 


Monthly    CvcLOPiEDiA 

AND 

Medical   Bulletin 


Published  the  Last  of  Each  Month 


Medical  Bulletin  Section 


Vol.  11.  PHILADELPHIA,  AUGUST,   1909.  No.  8. 


Clinical  Lecture 


ARTHRITIC  MUSCULAR  ATROPHY. 

By  JOHN  V.  SHOEMAKER,  M.D.,  LL.D., 

PHILADELPHIA. 

Professor  of  Materia  Medica,  Therapeutics,  Clinical  Medicine,  and  Diseases  of  the  Skin, 
in  the  Medico-Chirurgical  College  and  Hospital  of  Philadelphia. 

Gentlemen:  The  patient  before  you  this  morning  is  suffering  from  a 
disease,  the  etiology  of  which  has  not  been  clearly  determined.  The  patient, 
A.  E.,  is  a  male,  aged  28  years;  occupation,  tailor. 

Family  History. — His  father  died  at  the  age  of  forty-eight  from  an 
unknown  cause.  His  mother  is  living  and  well  and  is  fifty-three  years  old. 
Both  his  paternal  grandfather  and  grandmother  are  living  and  well.  They 
are  eighty  and  seventy  years  old  respectively.  His  maternal  grandfather  is 
living  and  well  and  is  eighty-five  years  old,  but  the  grandmother  is  dead, 
having  died  at  the  age  of  seventy. 

Social  History. — He  is  married.  His  wife  is  twenty-four  years  old  and  in 
good  health.     Three  children  are  living  and  in  good  health. 

Previous  Personal  History. — When  a  child  he  had  measles,  small-pox  at 
the  age  of  four  years;  typhoid  fever  at  the  age  of  ten  years,  and  had  polypi 
removed  from  his  nose  at  the  age  of  twenty-three  years. 

Habits. — His  habits  are  generally  good.  He  uses  alcoholic  beverages 
sparingly.  He  drinks  one  cup  of  coffee  a  day,  and  his  sleeping  hours  are 
regular. 

Present  Hlness. — He  states  that  he  was   in  perfect  health   until   eight 

months  ago,  when  he  began  to  suffer  with  pain  in  his  joints  followed  by  cramps 

in  the  lower  extremities,  especially  in  the  soleus  and  gastrocnemius  muscles. 

He  has  pain  and  difficulty  in  walking,  and  when  he  lies  down  he  is  unable  to 

5  (481) 


482  ARTHRITIC  MUSCULAR  ATROPHY. 

extend  his  lower  extremities  owing  to  severe  pain  and  twitching  of  the  muscles. 
His  muscles  show  diminished  bulk  and  contour  and  also  diminished  contraction 
to  faradism  and  galvanisin.  The  mechanical  irritability  of  the  muscles  are 
increased  and  there  is  a  corresponding  contraction.  The  reflexes  are  exalted 
and  in  this  patient  ankle-clonus  is  observed.  The  wasting  of  the  muscles  in 
this  patient  is  uniform  from  end  to  end  and  there  is  a  corresponding  loss  of 
power.  Outside  of  this  the  patient  seems  to  be  in  good  health ;  his  appetite  is 
good;  bowels  regular,  and  he  sleeps  well. 

Diagnosis, — From  the  absence  of  degenerative  reaction,  increased  mechan- 
ical irritability  and  presence  of  a  joint  affection  we  can  easily  diagnose  this 
case  as  arthritic  muscular  atrophy. 

Pathology. — In  this  disease  the  wasting  of  the  muscles  usually  begins  in 
the  small  muscles  of  the  hand,  but  sometimes  affects  those  of  the  shoulder  joint 
and  other  joints.  The  muscles  become  pale,  rather  flabby  and  inelastic.  This 
usually  occurs  in  the  extensors  and  is  severe  in  proportion  to  the  duration  of 
the  inflammation.  There  may  be  a  little  interstitial  fibrosis  and  the  muscle 
fibers  are  diminished  in  size.  The  muscle  cells  may  proliferate  quite  exten- 
sively. The  neiTe  trunks  in  the  cord  have  been  reported  normal,  but  changes 
are  found  in  the  nerve  terminals  within  the  inflamed  joint. 

Etiology. — The  cause  of  this  affection  is  supposed  to  be  due  to  the  exten- 
sion of  an  inflammation  of  diseased  joints  either  to  the  nerves  or  directly  to  the 
muscles.  Any  joint  lesion  involving  the  articular  filaments  is  competent  to 
set  up  an  arthritic  muscular  atrophy.  The  hypothesis  that  this  affection  is 
caused  by  a  process  acting  through  a  reflex  arc  is  accepted.  That  is,  the  irri- 
tation ascends  to  the  spinal  centers  and  disturbs  the  trophic  control  of  those 
cells  related  to  the  muscle  physiologically  associated  with  the  joint  and  located 
on  the  proximal  side  of  the  affected  articulation.  This  affection  may  follow 
arthritis  of  traumatism,  gonorrhtea  and  rheumatism,  infectious  artliritis  and 
simple,  acute  or  chronic  arthritis. 

Treatment. — If  possible  the  cause  should  first  be  ascertained  and  removed. 
In  this  patient,  I  believe  the  cause  of  the  atrophied  muscles  to  be  due  to  his 
arthritic  condition,  which  is  rheumatic  in  nature.  Hence  I  will  first  give  him 
ten  grains  of  salicin  every  four  hours  until  the  rheumatism  in  his  joints  has 
subsided.  If  need  be,  I  may  later  on  employ  other  antirheumatic  agents. 
Locally  to  the  affected  joints  wc  will  apply  an  ointment  containing: — 

1}   Unguenti  belladonna, 

Ungiienti  liydrargjTi  nitratis, 

Adipis  lanae  hydrosi,  of  each    5j. 

Misce.  Signa:  Apply  to  the  afl'ected  joints,  cover  with  cotton  and  bandage.  After 
the  pain  has  entirely  subsided  we  will  turn  our  attention  to  the  atropliied  muscles. 

Massage  to  stimulate  the  circulation  and  invigorate  the  dormant  muscle 
fibers.  Also  passive  exercise  will  greatly  assist  in  restoring  and  developing  tlie 
muscles  to  their  normal  size  and  capacity. 

Electricity — faradism  and  high  frequency — will  have  a  synergistic  influ- 
ence and  at  the  same  time  exalt  the  function  of  the  tropic  centers  in  tlie 
nervous  system. 


THE  BORDER  LAND  OF  SUCCESS— ATTENTION  IN  EYE  AND  EAR  WORK.    4g3 

As  soon  as  the  muscles  develop  in  size  and  gain  in  strength,  systematic 
exercise  and  walking  should  be  instituted.  As  a  rule  the  muscles  progress 
rapidly  to  complete  restoration  and  function. 


Original  Articles 


THE  BORDER  LAND  OF  SUCCESS —THE  IMPORTANCE  OF  CAREFUL 
ATTENTION  TO  DETAILS  IN  EYE  AND  EAR  WORK. 

By  L.  HAYNES  BUXTON,  M.D.,  LL.D., 

OKLAHOMA   CITY. 

Professor  of  Ophthalmology,  Epworth   College  of  Medicine;     Oculist   to   the   Oklahoma 

State  Baptist  Orphanage  and.  St.  Anthony's  Hospital,  late  Superintendent  of  Public 

Health  of  Oklahoma,  and  Secretary  of  Medical   Examining  Board,   etc. 

Theee  is  a  land  that  is  just  over  the  hill  from  success,  where  live  men 
with  broken  idols,  men  of  education,  men  of  many  talents,  brainy  men,  but 
men  with  broken  hearts,  because  they  never  have  fulfilled  the  ambition  of  life 
to  reach  the  "Land  of  Success."  They  are  just  stranded  on  its  border — but 
yet  in  the  shadows  of  the  "Failure  Country." 

Why  is  it  that  many  who  start  out  in  life  with  golden  prospects  and 
opportunities  should  become  stranded  on  the  rocks  so  near  the  harbor  of 
success?  This  paper  will  simply  give  one  answer  of  the  many  to  this  important 
question. 

The  rock  on  which  sinks  many  a  well  constructed  craft  is  that  of  non-  atten- 
tion to  details,  the  neglect  of  little  things  of  business  and  life.  Attention  or 
non-attention  to  details  reads  success  or  failure,  not  alone  in  the  practice  of 
medicine,  but  in  nearly  or  quite  all  of  the  undertakings  of  life.  Professional 
men  can  learn  lessons  of  profit  from  the  successful  manufacturing  corporations 
of  our  land.  The  utilization  of  the  waste  by-products  of  former  days  has 
brought  to  many  of  these  riches.  Any  fool  can  handle  the  so-called  great 
events  of  life,  but  only  the  wise  can  see  the  importance  of  small  things. 

I  issued  certificates  to  practice  medicine  to  over  five  hundred  men  when 
Superintendent  of  Public  Health  of  Oklahoma.  This  gave  me  the  opportunity 
of  observing  the  careers  of  many  in  our  profession.  I  was  astonished  not  a 
few  times  to  see  men  of  splendid  educational  attainments  fail,  where,  with 
equal  astonishment,  I  saw  the  apparently  superficial  men  go  on  to  success. 
Many  of  these  apparently  illogical  results  would,  if  investigated,  })e  found  to 
be  based  on  a  failure  of  some  of  these  otherwise  well  equipped  men  to  pay 
attention  to  what  appeared  to  them  as  tlie  small  things,  to  them,  the  unessential 
details;  whereas  these  small  things  entered  largely  into  the  sum  total  of  their 
lives.  On  the  other  hand,  those  who  started  with  a  poor  chance,  had  gatliered 
as  they  ran,  from  every  wayside  bu,=h.  To  them  there  were  no  non-essentials, 
and  as  a  result  they  grasped  victory  from  defeat. 


484    THE  BORDER  LAND  OF  SUCCESS— ATTENTION  IN  EYE  AND  EAR  WORK. 

Primarily  in  the  selection  of  the  title  of  this  paper  I  had  in  mind  the 
importance  of  details  in  the  successful  treatment  of  pathological  conditions,  but 
I  will  diverge  from  the  main  line  of  thought  and  call  attention  to  some 
of  the  elements  of  financial  success  in  the  practice  of  medicine. 

The  public  judges  much  of  a  man's  ability  by  his  dress,  his  home,  his 
associates  and  his  office.  His  suit  need  not  be  of  broadcloth — in  fact,  need 
not  have  cost  over  a  dozen  dollars,  but  it  should  be  clean  and  fit  well.  A  nasty 
doctor,  with  dirty  hands,  soiled  linen,  and  a  suit  slobbered  all  over  in  front, 
need  not  expect  a  call  into  the  homes  of  decent  people,  although  he  be  as  wise- 
as  Socrates.  People  do  not  have  to  employ  such  men  in  the  twentieth  century. 
The  man  who  courts  success  does  not  have  to  live  in  a  mansion,  but  his  cottage 
and  la-WTi  must  be  well  kept,  clean  and  attractive.  He  must  remember,  also, 
that  a  man  is  known  by  the  company  he  keeps,  and  must  avoid  the  town 
toughs  and  try  to  make  friends  with  the  best  persons  in  his  community.  He 
must  remember  also,  as  Benjamin  Franklin  said,  "iC  a  man  keep  his  shop, 
his  shop  will  keep  him."  His  patrons  should  not  have  to  look  him  up,  when 
wanted,  in  a  near-by  card  room  or  in  any  public  loafing  place.  Many  an  office, 
not  as  important  as  that  of  a  doctor's — a  bank  or  a  drug  store — in  opening  for 
business,  puts  one  or  two  thousand  dollars  into  the  fixtures,  and  considers  that 
the  money  was  not  only  well  spent,  but  essential  to  success.  They  think  a 
place  of  business  should  be  attractive.  Fellow  practitioners,  do  we  exercise 
good  judgment  in  fitting  up  our  offices?  It  is  my  opinion  that  if  the  average 
doctor  would  go  to  the  bank  and  borrow  five  hundred  dollars,  put  it  into  new 
carpets,  new  easy  chairs,  new  pictures  and  other  equipments  to  make  his  office 
look  attractive,  the  investment  would  pay  the  first  year.  The  successful  man 
selects  a  good  location.  A7iy  place  will  not  do  for  liim.  He  must  and  does 
find  a  way  to  get  the  best. 

In  closing  this  section  of  my  paper,  I  want  to  say  that  a  dirty,  unswept, 
undusted  doctor's  office  is  a  bid,  and  a  successful  bid,  for  a  practice  among 
the  lowest  elements  of  the  city.  The  entrance  to  your  office  must  be  clean. 
Not  60  nasty  that  a  servant  girl  will  spoil  her  dress  going  there.  Do  you 
expect  decent  people  to  reach  you  through  such  filtli?  And  yet  many  a  man 
wonders  why  all  the  people  are  going  to  Dr.  Jones,  across  the  street,  who  never 
had  half  his  experience  and  medical  advantages. 

In  considering  the  direct  subject,  similar  questions  confront  us.  Why 
are  some  men  ol  mediocre  ability  so  successful  in  the  treatment  of  cases,  while 
others  fail?  ^Ylly  do  certain  remedies  in  the  hands  of  one  man  yield  success, 
while  they  are  discarded  by  his  brother  practitioner  as  being  useless?  My 
answer  is  that  the  metliod — the  lioio,  we  use  nn  agent  to  cure  is  as  important  as 
the  selection  of  the  special  agent  itself.  I  shall  cite  a  few  examples:  .Con- 
trary to  the  usual  custom,  as  well  as  contrai'y  to  ease,  it  has  been  my  habit  for 
years  to  treat  a  large  percentage  of  my  eye  cases  standing  behind  the  patient. 
By  this  method  you  have  perfect  control  of  the  patient's  liead;  it  cannot  ^at 
away  from  you ;  there  is  no  sudden  jerking  away  of  the  liead.  Anyone  who  has 
had  any  substance,  however  mild,  instilled  into  the  eye,  knows  how  tempting  it 
is  to  dodge  away.     The  conjunctival  sac  can  be  more  thoroughly  inspected, 


THE  BORDER  LAND  OF  SUCCESS— ATTENTION  IN  EYE  AND  EAR  WORK.  485 

cleaned  and  treated  in  this  position  than  by  sitting  in  front  of  the  patient. 
Again,  tlie  head  can  be  thrown  back  and  the  eyes  can  be  flushed  more  thoroughly 
and  to  better  advantage  with  the  operator  behind.  The  more  vigorous  and 
painful  the  treatment,  as  in  "rolling"  the  lids  in  trachoma,  and  applying  pain- 
ful remedies,  the  more  valuable  does  this  position  become.  In  diseases  of  the 
conjunctiva,  nearly  always,  we  prescribe  a  collyriuni.  The  method  in  the  use 
of  these  eye  drops  oftentimes,  even  in  the  hands  of  the  profession,  Avould  be 
ludicrous,  were  it  not  so  serious  an  error.  The  doctor  has  examined  the  case — 
the  diagnosis  is  purulent  conjunctivitis.  He  decides  to  use  at  first  a  saturated 
solution  of  boracic  acid,  and  the  prescription  reads  "Put  in  the  eyes  every  two 
hours."  At  home  the  patient  opens  the  palpebral  fissure  two  mm.,  and  a 
half  dozen  drops  of  the  right  solution  are  dropped  into  the  eyes — no,  not  into, 
for  the  involuntary  closure  of  the  eye  prevents  over  one  drop  entering  the  eye, 
and  the  remainder  runs  over  the  face.  The  doctors  and  the  patient  wonder 
why  the  eyes  are  not  better,  as  such  treatment  is  said  by  able  men  to  be 
efficacious.  Here  is  the  secret  of  why  so  many  cases  do  not  respond  to  treat- 
ment. In  a  case  like  the  above,  show  the  patient  in  your  office  how  to  use  the 
eye  drops;  tip  the  head  back  or  lay  him  on  a  couch;  make  a  cup  of  the  eye 
at  the  inner  canthus ;  pull  the  lids  wide  apart ;  raise  them,  and  let  the  collyrium 
reach  the  most  remote  parts  of  the  retrotarsal  folds.  After  the  whole  con- 
junctiva has  been  bathed  in  the  liquid  for  a  moment,  wipe  the  eye  and  tell  the 
patient  to  go  and  do  likewise,  knowing  that  he  will  secure  the  desired  results. 

]\Iore  errors  are  committed  in  this,  an  omission  to  properly  treat  the 
conjunctiva,  than  are  generally  known.  It  is  not  enough  to  direct  what 
remedy  should  be  used,  but  how  to  use  it  is  equally  as  important.  Cases  of 
gonorrhoeal  ophthalmia  have  been  sent  to  me  with  sloughing  corneas,  hopeless 
so  far ,  as  saving  the  sight  was  concerned,  cases  which  had  had  intelligent — 
in  fact,  the  most  approved — remedies  prescribed,  but  the  end  was  disaster 
because  the  proper  treatment  had  not  been  thoroughly  and  carefidly  applied. 
It  is  not  enough  to  squirt  a  little  silver  solution  between  swollen,  half  closed 
lids  to  save  the  eyes  in  this  dangerous  disease,  but  we  should  stop  at  nothing 
short  of  the  thorough  irrigation  of  the  conjimctival  sac  and  the  application 
of  the  remedies  to  these  perfectly  cleaned  surfaces.  Again,  in  many  cases  of 
conjunctivitis,  the  conjunctiva  of  the  lids  are  covered  with  purulent  and 
mucous  secretions,  the  retrotarsal  folds  are  loaded  with  such  material,  and  yet 
we  expect  that  a  few  drops,  or  even  many,  will,  by  washing  over  such  a  surface, 
change  the  whole  morbid  process.  No,  such  treatment  will  change  nothing. 
Turn  the  lids  back,  and  with  a  sponge  of  cotton,  dipped  in  a  solution,  ^vipe  the 
conjunctiva  and  retrotarsal  folds  free  of  all  foreign  material.  Then,  and  only 
then,  is  your  special  medication  ready  for  application. 

Almost  the  same  line  of  thought  is  applicable  to  the  treatment  of  otitis 
media  purulenta.  Not  all  the  cases  of  running  ears  can  be  cured  by  medica- 
tion, but  my  experience  is  that  many  can  be.  I  am  curing  fifty  per  cent,  more 
of  these  cases  and  in  a  shorter  time  than  early  in  my  practice.  The  secret  of 
success  has  been  in  cases  that  are  curable  by  medication,  to  thoroughly  clean  all 
diseased  surfaces  and  then  apply  the  medication  directly.     This  cleansing  is 


486  SEVERE  TYPES  OF  TYPHOID  FEVER. 

advantageous  not  alone  for  proper  treatment,  but  as  well  for  an  intelligent 
diagnosis  of  the  exact  conditions. 

This  brings  me  to  another  phase  of  my  paper,  viz.,  the  importance  of 
attention  to  details  in  making  a  diagnosis.  Often  we  see  a  case  of  a  foreign 
body  in  the  cornea  or  other  part  of  the  eye,  which  has  been  overlooked  simply 
because  of  a  superficial  examination.  Placing  the  patient  in  the  proper  light 
or  turning  the  lid  properly  would  have  saved  you  the  chagrin  of  having  "the 
man  over  the  way"  do  the  work  that  you  should  have  done.  What  do  3W1 
see  when  you  look  into  an  ear?  What  do  5'ou  see?  Do  you  always  know? 
Could  you  tell  just  what  you  saw?  Was  your  speculum  directed  against  the 
wall  of  the  meatus?  Was  the  ear  full  of  cerumen  or  pus?  Did  you  see  a 
normal  tympanum  ?  All  these  questions  should  be  answered  at  every  examina- 
tion of  the  ear,  and  many  more  besides  these.  One  operator  passes  a  case  of 
slight  disturbance  of  vision  over  with  the  remark  that  "in  a  few  days  all  will 
be  well,  no  doubt,  after  the  use  of  these  liver  pills."  Another,  with  his  ophthal- 
moscope, sees  in  the  retina  the  first  symptom  of  nephritis  or  a  grave  brain 
lesion.  Another  is  unsuccessfully  treating  a  case  of  iritis,  the  other  has  dis- 
covered its  specific  cause,  and  his  patient  is  singing  his  praises. 

During  my  study  in  the  clinics  of  Europe  I  was  impressed,  not  with  the 
superiority  of  the  European  surgeon  over  the  American  in  dexterity,  general 
knowledge  or  rapidity  of  work,  but  with  his  attention  to  the  details  of  his 
cases.  To  him,  time  is  nothing  if  he  may  attain  the  end  desired.  He  goes  to 
the  bottom  of  everything.  He  is  slow  in  making  a  diagiiosis,  and  writes  no 
prescription  until  he  knows  all  that  the  history  of  the  case  will  yield.  In  a 
few  cases  he  is  too  slow,  we  are  too  fast  in  many. 

The  object  of  this  paper  is  more  to  awaken  thought  upon  this  subject  than 
to  give  any  specific  instructions  as  to  details  in  eye  and  car  work.  My  endeavor 
was  to  make  it  of  interest  to  the  general  practitioner.  It  is  the  patient,  careful 
study  of  the  minor  symptoms,  if  there  be  such,  of  our  cases,  and  the  equally 
systematic  and  thorough  application  of  such  remedies  or  agents  as  we  may 
decide  to  use,  that  cannot  fail  to  bring  satisfactory  results  to  both  ourselves 
and  our  patients.     Perfection  is  made  up  of  trifles,  hut  perfection  is  no  trifle. 


SEVERE  TYPES  OF  TYPHOID  FEVER  WITH  MANAGEMENT  AND 

TREATMENT. 

By  B.  L.  HALE,  A.B.,  M.D. 

In  this  paper  only  the  severe  cases  are  taken  as  they  ai-e  more  wortliy  of 
study.  Should  we  desire,  we  could  take  the  more  favorable  cases  and  make 
the  report  very  favorable  indeed. 

In  this  we  will  show  how  a  country  doctor  works  in  the  countij,  where  he 
is  thrown  upon  his  own  resources. 

We  are  not  quoting  authorities,  consequently  there  will  not  be  paragraphs 
copied  from  text-books.     It  occasionally  occurs  that  the  physician  is  taxed  to 


SEVERE  TYPES  OF  TYPHOID  FEVER.  487 

his  utmost  in  his  efiorts  to  make  a  diagnosis  of  typhoid  fever.  There  is  no 
trouble  about  the  typical  cases  as  many  of  the  laity  can  often  diagnose  these. 
It  is  possible  that  physicians  themselves  will  sometimes  disagree  as  to  diagnosis. 
If  called  early  in  the  case  we  first  cinchonize  the  patient,  and  if  this  has  no 
effect  taken  together  with  other  symptoms,  we  then  treat  as  tj^phoid.  When 
placed  upon  the  typhoid  basis  there  is  usually  a  moderation  of  the  s}'mptoms. 
'No  set  rule  can  be  rigidly  fixed  for  treating  and  feeding  a  case  of  typhoid  fever, 
but  each  individual  case  must  be  taken  on  its  own  merits  and  studied,  treated, 
and  fed  as  an  individual  case. 

In  one  case  meat  broths  provoked  an  uncontrollable  diarrhoea,  while  placing 
the  patient  upon  toasted  bread  with  butter  checked  the  diarrhoea  at  once. 

Another  case,  a  child  of  nine  years,  after  the  fever  had  left,  had  a  wild 
delirium,  tossing  from  side  to  side,  which  was  diagnosed  as  starvation  delirium. 
We  fed  her  anything  to  get  her  to  eat,  and  when  the  stomach  was  once  filled 
she  gave  no  further  trouble. 

"\\Tiole  milk  we  do  not  like  as  a  rule,  but  there  may  be  cases  where  it  is 
advisable.  Buttermilk  is  to  be  preferred,  but  too  much  of  it  will  cause  bloating 
of  the  bowels. 

The  broths  made  from  the  wild  games,  such  as  the  squirrel  and  birds,  is 
better  than  that  made  from  the  tame  meats,  as  it  is  free  from  the  strong  oils 
and  fats  found  in  the  tame.  The  wild  birds  that  are  best  are  the  dove,  blue- 
ja}',  quail,  plover,  and  the  prairie  chicken.  When  any  bird  or  fowl  is  used  to 
make  the  broth,  always  skin  the  bird  or  fowl,  taking  only  the  leanest  parts. 
Make  the  broth,  let  it  stand  until  cool,  then  skim  off  the  fat  globules  that  con- 
geal on  top.  Any  other  broth  is  treated  in  the  same  manner.  Gelatine  made 
from  fresh  beef  bones  kept  cool  may  be  heated  when  wanted,  diluted  with  water 
and  drank.     Season  it  to  suit  the  taste  of  the  patient. 

Well-ripened  watennelons  are  relished  by  tlie  patients  and  are  usually 
beneficial. 

Albumin  water  is  an  excellent  thing  and  may  be  prepared  as  follows: 
Take  a  piece  of  thin,  clean  muslin,  place  it  over  a  clean  glass,  break  the  white 
of  one  egg  upon  it,  squeeze  the  albumin  through  the  meshes  of  the  cloth,  taking 
out  all  shell  particles  and  break  up  the  albumin  sufficiently  so  as  not  to  require 
beating.  Now  add  soft  water  until  not  string}',  then  add  sugar,  salt  and 
whiskey  to  suit  the  taste  of  the  patient.  The  whiskey  is  used  for  flavoring,  but 
any  good  flavoring  extract  may  be  used.  The  juice  of  the  lemon  is  good,  this 
makes  egg  lemonade.     The  albumin  water  may  be  taken  freely. 

If  crackers  are  used  for  food  they  should  be  browned  in  a  hot  oven  first. 
When  toasted  bread  is  given  to  the  patient  it  should  be  cut  thin  and  browned  all 
the  way  through.  It  may  then  be  served  as  milk  or  cream  toast  or  as  sweetened 
water  toast. 

When  meat  juice  is  desired  take  one  or  two  pounds  of  lean  steak,  chop  it 
fine,  put  in  a  rice  cooker  (do  not  put  any  water  on  the  meat),  let  it  simmer  for 
three  or  four  hours,  strain  out  the  juice  nnd  lot  the  patient  drink  such  quantity 
as  is  desired.     It  may  be  seasoned  to  suit  the  taste  of  the  patient.     As  to  the 


488  SEVERE  TYPES  OF  TYPHOID  FEVER. 

administration  of  solid  foods,  the  physician  in  attendance  must  use  his  own 
judgment,  having  the  case  and  all  the  circumstances  in  hand. 

See  that  the  patient  gets  an  abundance  of  pure  water.  This  may  be  given 
by  ordering  a  half  glass  following  a  dose  of  medicine  every  two  hours. 

Among  the  fruit  juices,  orange  juice  may  be  given  as  it  agrees  with  most 
patients.  To  prepare,  squeeze  out  the  juice,  strain  through  clean  muslin,  give 
as  desired.  The  juice  of  one  or  two  oranges  in  twenty-four  hours  will  not  be 
too  much.  With  some  patients  orange  juice  is  too  laxative.  The  juice  of 
cooked  or  canned  fruits  may  be  given  in  limited  quantities. 

When  feeding  a  patient,  bring  out  a  variety  of  foods  on  the  platter;  one 
small  bit  of  toast,  broth,  fruit  juice,  milk  and  coffee.     Make  it  appear  as  a  meal. 

So  far  as  medicines  go,  each  case  must  be  taken  on  its  own  merits.  In  low 
states  the  medicines  may  be  administered  hypodermically,  we  think  this  best. 

Spartein  sulphate  and  caffein  citrate  are  very  good  stimulants  and  very 
good  diuretics,  both  may  be  given  hypodermically.  Calomel  is  good  in  the 
beginning.  In  the  last  stages  of  bad  cases  when  the  fever  is  gone  and  the 
mouth  very  dry  give  one-half  grain  of  calomel  three  times  a  day  till  you  get  a 
slight  degree  of  salivation;  this  will  restore  the  secretions  of  the  salivary 
glands.  Whatever  may  be  said  of  intestinal  antiseptics  it  is  preferable  to  give 
them;  as  to  which  one,  is  left  to  the  choice  of  the  physician.  The  ones  that 
are  least  poisonous  and  still  good  are  menthol  and  thymol,  they  are  best  given 
in  combination.  Urinary  antiseptics  should  be  used,  hexamethylenetetramin  is 
the  best.  It  is  absolutely  unnecessary  to  give  febrifuges,  the  administration  of 
the  various  coal-tar  products  is  undoubtedly  harmful.  In  the  beginning  of  a 
case,  or  of  suspected  cases,  do  not  give  acetanilid  for  the  headache,  but  instead 
give  salicylic  acid  and  apply  cold  applications  to  the  head.  The  heart  should 
not  be  taxed  by  medicine  or  otherwise  at  any  time  during  the  illness. 

The  venders  of  patent  and  proprietary  medicines  will  tell  you  how  their 
medicines  cut  the  fever  down  to  three  weeks'  duration.  The  management  of 
our  cases  for  the  past  eleven  years  show  an  average  of  three  weeks'  duration  and 
without  the  use  of  the  much  lauded  proprietary  remedies.  One  man  whom  I 
met  boasted  of  a  certain  reputed  cure  as  being  first,  last  and  all  the  time  with 
him;   the  same  season  later  on  he  lost  five  cases  out  of  one  family. 

But  little  medicine  or  food  is  given  during  the  night,  lights  low,  every- 
thing quiet,  to  let  patient  rest.  There  are  cases  that  human  ingenuity  cannot 
save;  they  take  sick  to  die.  At  the  same  time,  with  proper  care  and  careful 
management  many  desperate  cases  may  be  saved. 

In  regard  to  the  bath  we  have  always  used  the  sponge  bath,  the  wet  pack, 
and  the  ice  pack.  To  properly  give  a  sponge  bath,  remove  all  the  clothing  and 
sponge  the  ventral  surface  systematically,  taking  the  lower  limbs  first,  then  the 
upper  limbs,  finishing  over  the  abdomen  and  sides.  When  sponged  sufficiently, 
turn  patient  on  side  and  sponge  the  dorsal  surface  in  the  same  manner;  always 
sponge  until  the  moisture  stands  out  on  the  surface,  then,  without  drying, 
replace  clothing.  The  evaporation  that  takes  place  from  the  moisture  on  the 
surface  will  cause  a  further  reduction  of  the  temperature. 

Kepeat  the  bath  every  hour  or  two  until  the  temperature  is  sufficiently 


SEVERE  TYPES  OF  TYPHOID  FEVER.  489 

reduced.  A  temperature  of  101°  or  102°  will  not  require  very  much  bathing. 
Bathing  is  usually  suspended  when  haemorrhage  appears.  As  a  rule,  when  the 
sponge  bath  would  control  the  fever  the  patient  recovers.  This  is  also  true  of 
the  wet  pack.  To  give  the  wet  pack,  wring  a  sheet  out  of  cold  water  and  wrap 
round  the  patient;  repeat  as  often  as  the  sheet  gets  dry.  Two  patients  we 
kept  in  wet  pack  for  48  hours  before  the  fever  fell ;  both  cases  recovered.  The 
wet  pack  is  not  used  unless  the  sponge  bath  fails.  If  both  of  these  methods  fail, 
we  then  use  the  ice  pack,  which  is  done  either  by  ice-bags  or  ice  poultice  over 
abdomen.  So  far  in  those  cases  in  which  it  was  necessary  to  use  the  ice  pack, 
the  disease  was  of  such  severity  that  the  patient  died ;  it  was  used  in  two  cases. 

To  control  nervousness  the  alcohol  bath  is  employed ;  the  strength  varying 
from  35  per  cent,  to  50  per  cent.  In  one  case  it  required  95  per  cent.  This 
bath  is  given  as  a  sponge  bath.  In  giving  these  baths  the  water  is  usually 
tempered  to  suit  the  feelings  of  the  patient.  Some  patients  will  stand  a  cold 
bath ;  some  will  enjoy  the  ice  rub,  and  some  will  refuse  the  bath  entirely.  The 
room  should  be  made  as  bare  as  possible,  removing  all  carpets,  curtains  and 
hangings,  pictures,  etc.  Mop  the  floor  at  least  once  a  day.  Have  two  narrow 
beds  in  the  room  and  change  the  patient  twice  a  day,  morning  and  evening. 
All  spoons,  vessels,  dishes,  etc.,  must  be  looked  after  carefully ;  rigid  cleanliness 
will  go  a  long  way  toward  abating  the  fly  nuisance. 

An  error  is  probably  sometimes  made  in  mistaking  typhoid  fever  for 
malarial  fever,  as  one  case  we  had  early  in  our  career,  A  young  man  was  taken 
sick  with  a  fever  that  lasted  for  three  weeks;  was  never  very  bad;  at  the  end 
of  three  weeks  the  fever  broke  for  four  or  five  days  when  fever  returned,  and 
it  lasted  another  three  weeks.  We  called  this  malarial  fever  but  when  he 
recovered  and  was  going  about  we  noticed  his  dry,  frizzled  hair,  all  of  which 
came  out;  v/e  concluded  that  we  had  made  a  wrong  diagnosis  and  were  more 
careful  afterwards.  This  same  mistake  is  made  by  others,  as  we  have  observed, 
only  very  few  ever  acknowledge  their  error. 

Case  I. — G.  Mc,  male,  clerk  in  hardware  store,  age  38.  He  had  been  an 
alcohol  addict,  but  had  taken  the  cure  several  months  previous  to  illness  and  at 
this  time  was  sober.  He  gave  the  history  of  having  had  typhoid  years  before 
at  Philadelphia,  when  traveling  with  a  circus.  The  present  attack  was  com- 
plicated with  pleurisy  v/ith  effusion.  He  gave  the  characteristic  clinical  symp- 
toms of  typhoid,  even  to  the  shedding  of  the  sloughs  from  the  bowels.  We 
were  first  called  June  17,  1903,  and  he  left  us  August  2ist.  At  that  date  he 
was  doing  well,  was  well  nourishcfl,  kidneys  and  bowels  acting  nicely.  We 
tapped  the  altected  pleural  cavity  and  drew  off  some  of  the  fluid,  which  gave  no 
evidence  of  pus.  Others  did  a  rib  resection  and,  by  some  means,  he  became 
infected,  his  health  grew  worse  and  he  never  fully  recovered.  We  afterwards 
treated  him  for  about  two  years  washing  out  the  cavity  in  his  side  four  or  five 
times  per  week.  He  is  still  alive  but  his  condition  we  do  not  know.  We 
treated  him  last  in  September,  1907;  neither  tuberculosis  nor  typhoid  bacillus 
were  demonstrated  in  fluid  from  pleural  cavity. 

Case  II. — I.  L.,  female,  age  7.  Healthy  child  previous  to  sickness,  was 
sick   during  July,    1906;    was   never   very  ill;    fever   moderate.     The   worst 


490  SEVERE  TYPES  OF  TYPHOID  FEVER. 

feature  of  the  case  was  continual  pain  in  bowels.  In  third  week  she  had 
intestinal  htEuiorrhage  when  all  symptoms  gave  way  and  she  gave  every  promise 
of  an  uneventful  recovery,  when  one  evening,  about  6  p.m.,  her  father,  who  had 
been  entertaining  her,  leit  the  room  for  a  few  moments  when  he  returned  she 
knew  notliing — was  insensible.  I  was  called  at  once  and,  when  I  reached  the 
bedside,  I  pronounced  it  a  case  of  cerebral  embolism.  The  right  half  of  tlie 
body  was  aiiected,  being  in  a  tremor  or  continuous  twitching  accompanied  by 
coma  and  paralysis.  She  never  regained  consciousness,  and  died  the  following 
day. 

Case  III. — G.  H.,  male,  farmer,  age  39.  Previous  health  good;  family 
history  good;  was  sick  during  July,  August  and  September  of  1906.  He  had 
severe  gastric  pain,  vomiting,  diarrhoea.  At  one  time  the  appendix  was 
involved.  During  third  week  he  had  a  severe  intestinal  hirmorrhage,  and  this 
was  followed  by  severe  t}^npanites.  I  used  all  the  recognized  remedies:  such 
as  turpentine,  glycerine,  asafoetida,  etc.,  but  without  avail.  Consultation  was 
called  for  and  a  learned  old  physician  was  called  in  to  aid  us,  but  he  offered  no 
hope;  in  fact,  he  said  that  every  patient  he  had  ever  seen  bloated  around  the 
stomach,  as  this  one  was,  died.  After  he  left  it  was  plain  that  the  man  was 
going  to  die  as  the  tympanites  were  crowding  his  heart  and  lungs,  so  being  left 
alone  I  decided  to  stay,  and  do  or  die.  After  studying  the  case  over  it  occurred 
to  me  to  use  alum  solution  which  I  did.  At  8  p.m.,  I  gave  colonic  injection  of 
two  quarts  of  alum  sol.,  putting  about  one  ounce  of  alum  to  the  quart  of  water, 
using  a  soft  rubber  colon  tube.  In  a  short  time  after  the  injection  the  water 
and  the  gas  both  started.  Previous  to  this  the  water  would  come  away  alone. 
He  passed  gas  at  intervals  all  night;  in  fact,  every  time  he  moved  he  passed 
gas  so  that  on  the  following  morning  he  was  about  one-half  reduced  and  at 
8  A.M.,  I  repeated  the  injection.  This  brought  him  down  to  normal  and  we 
had  no  further  trouble  along  that  line.  By  this  time  he  was  very  weak  and  very 
reduced,  his  stomach  and  bowels  both  having  given  so  much  trouble  that  it  was 
with  the  greatest  dilnculty  that  we  ever  got  him  back  on  anything  like  nourish- 
ing food.  We  fed  him  for  three  weeks  on  albumin,  water,  liquid  peptonoids 
and  similar  foods  before  we  could  feed  him.  This  made  his  recovery  very  tardy 
but  when  once  on  solid  food  he  gained  rapidly.     To-day  he  is  a  rugged  farmer. 

Case  IV. — ]\I.  B.,  age  18  years,  single,  female,  farmer's  daughter.  Was 
sick  during  September,  190G,  when  first  seen  she  had  a  temperature  of  103°. 
The  family  reported  that  she  had  been  complaining  but  a  few  days.  She  looked 
as  if  she  might  have  been  sick  for  two  or  three  weeks.  There  was  no  regularity 
about  her  temperature,  other  symptoms  were  also  irregular,  so  that  we  were  in 
doubt  until  haemorrhage  came  on,  of  v/liich  she  had  several  severe  ones.  On 
the  seventh  day  after  the  first  call  she  had  her  first  hemorrhage.  Slie  was 
delirious  the  first  week  and  more  or  less  comatose  throughout  the  second  week. 
She  seemed  completely  overwhelmed  with  the  typhoid  poison.  From  the 
first  she  complained  of  a  Imnp  in  her  stomach,  could  take  no  food,  would 
drink  no  water,  and  only  with  greatest  difficulty  did  we  get  her  to  take  any 
medicine.  In  order  to  get  water  in  her  system  we  used  a  long  colon  tube,  and 
injected  a  quart  of  water  morning  and  evening;  the  water  was  always  retained. 


SEVERE  TYPES  OF  TYPHOID  FEVER.  491 

Her  kidneys  were  extremely  bad,  acting  slowly  and  sluggishly.  Her  tempera- 
ture persisted  at  104°  with  a  weak  heart.  We  at  first  controlled  the  fever  with 
the  sponge  bath,  but  towards  the  last  it  required  the  ice  pack.  The  night  she 
died  we  got  her  temperature  down  low  and  she  seemed  to  be  resting.  I  went 
to  bed  about  10  p.m.  and  was  called  by  the  nurse  at  1  a.m.  The  fever  had 
suddenly  jumped  to  105° ;  we  saw  at  once  that  it  was  useless  to  work  further 
as  collapse  was  coming  on.  She  died  about  4  a.m.,  on  the  fourteenth  day  after 
making  my  first  visit.     We  gave  normal  saline  under  the  skin. 

Case  V. — L.  E.,  age  38,  housewife,  the  mother  of  8  or  9  children.  She 
first  had  an  attack  of  renal  colic;  this  passed  off  and  she  appeared  to  recover. 
This  attack  lasted  two  or  three  weeks  during  which  time  there  was  no  fever. 
I  told  the  husband  I  could  not  tell  how  much  of  her  siclmess  was  due  to  tjrphoid 
infection  and,  she  being  an  old  epileptic,  I  warned  him  that  she  was  not  a  fit 
subject  for  typhoid.  After  apparently  recovering  she  later  developed  typhoid 
fever  that  was  marked,  and  this  was  complicated  by  a  severe  pneumonitis;  her 
kidneys  acted  poorly,  and  her  bowels  were  stubborn.  She  would  take  uncon- 
scious spells,  and  at  one  time  lay  in  this  state  for  97  hours.  During  these  spells 
ordinary  enemata  would  have  no  effect.  At  one  time  she  took  one  gallon  of 
water  per  rectum  during  one  night;  it  was  all  retained.  We  then  fell  back  on 
our  alum  solution  which  never  failed.  When  she  was  unconscious  it  would  take 
the  alum  solution  about  one  hour  to  act.  Her  temperature  persisted  high  and 
required  the  ice  pack  to  reduce  it.  After  the  reduction  it  rose  again  and  per- 
sisted high,  being  uncontrolled  by  the  ice  pack.  She  died  in  the  third  week; 
her  death  appeared  to  be  due  to  the  pneumonia. 

Case  VI. — E.  D.,  age  18,  female,  immarried.  Was  sick  9  weeks,  vomited 
from  the  beginning  almost  continuous,  only  one  or  two  short  intervals  of  two  or 
three  days  each  when  the  vomiting  was  absent.  In  the  vomit  was  a  peculiar 
green  material  which  we  made  out  to  be  chlorophyl,  produced  by  the  'Tiydra- 
viridis"  which  belongs  to  the  animal  kingdom.  Her  fever  never  was  high,  she 
had  hemorrhage.  W^e  used  salines  hypodermically  and  per  rectum.  She  was 
very  nervous  and  a  mild  delirium  was  present  part  of  tlie  time.  The  nervous- 
ness was  best  controlled  by  alcohol  baths,  full  strength  acting  better  than  the 
dilute.  We  gave  her  inunctions  of  olive  oil  after  the  fever  was  gone,  she  died 
apparently  from  exhaustion,  having  had  no  fever  for  a  week  or  ten  days  prior 
to  her  death.  When  the  time  came  for  her  to  take  nourishment  we  couldn't 
get  her  to  take  sufficient  of  anything.  W^e  tried  every  device  and  all  sorts  of 
nourisliment,  but  without  avail.  We  gave  her  one-half  grain  codcin  snlph. 
hypodermically  every  night  to  produce  sleep.  It  acted  nicely.  She  died  at 
the  end  of  the  ninth  week. 

Case  VII. — F.  W.,  male,  farmer,  married,  age  25.  Was  called  in  consulta- 
tion October,  1908.  The  night  that  I  first  saw  him  haemorrhage  had  occurred. 
Up  to  this  time  the  attending  physician  reported  a  mild  case.  I  found  the 
patient  with  a  very  weak  pulse.  We  gave  him  about  one  pint  of  normal  saline 
solution  by  liypodermoclysis.  I  worked  on  this  case  with  tlie  attending  physi- 
cian for  ten  days.  His  haemorrhages  were  repeated  until  he  had  ten  in  all. 
He  became  very  delirious,  requiring  four  or  five  strong  men  to  hold  him  in 


492  SEVERE  TYPES  OF  TYPHOID  FEVER. 

the  bed.  On  November  4th,  he  was  reported  as  possibly  having  hydrophobia, 
having  been  bitten  by  a  dog  two  or  three  months  previous.  The  attending 
phj^sician  asked  me  to  go  out  with  him;  we  found  him  having  convulsive 
seizures,  though  apparently  rational  as  he  recognized  us.  After  giving  him  a 
drink  of  water  as  a  test,  producing  no  convulsions  we  decided  he  had  no  hydro- 
phobia and  so  informed  his  friends.  We  both  stayed  and  worked  with  him  all 
day  and,  from  10  a.m.  until  9  p.m.,  he  received  in  all  two  and  one-eighth  grains 
morphine  sulph.,  and  without  apparent  effect.  We  went  to  town  about  4.30 
P.M.,  and  at  8  p.m.  I  was  again  called,  found  four  or  five  stout  men  holding  him. 
Having  him  all  to  myself  I  carried  out  my  own  ideas  which  was  the  best  I  could 
do,  and  with  tlie  aid  of  the  nurse  we  gave  him  cliloral  and  gelsemium  per  rectum 
and  I  proceeded  to  put  him  to  sleep  with  chloroform.  The  family  being  Cath- 
olics they  of  course  prayed,  about  twelve  or  fifteen  of  them,  as  hard  and  as  loud 
as  they  could,  which  was  right.  The  patient  raved  like  a  maniac,  while  the 
nurse  and  I  worked  as  hard  as  we  could  work.  His  friends  prayed  for  a  speedy 
death,  and  for  a  while  it  looked  as  if  the  prayer  would  be  answered.  This  1 
will  say  was  the  most  weird  experience  of  my  life.  The  chloroform  following 
the  morphine  brought  about  two  and  one-half  hours'  sleep  and  as  soon  as  he 
would  wake  I  would  put  him  to  sleep  again  and  carried  him  through  the  night 
very  well  and  the  following  day  he  slept  nearly  all  day.  This  followed  up  by 
gelsemium  controlled  the  convulsions.  He  then  went  to  tlie  other  extreme, 
and  became  very  weak  and  helpless,  and  lay  this  way  hovering  between  life  and 
death  for  about  two  weeks,  when  he  began  to  rally  and  gradually  pulled  himself 
together  until  he  recovered.  He  is  to-day  healthy  and  strong.  As  soon  as  he 
was  better  I  ceased  my  attentions  and  left  him  in  the  care  of  the  attending 
physician.  At  the  time  of  the  hasmorrhagc  we  kept  his  bowels  from  moving 
for  about  one  v/eek  with  the  exception  of  the  haemorrhages,  and  at  the  end  of 
this  time  we  decided  the  bowels  must  move.  The  attending  physician  and 
nurse  thought  this  would  kill  the  patient.  However,  we  gave  him  eight  ounces 
of  glycerine  in  water,  q.  s.  ft.  two  quarts,  gave  it  per  rectum,  got  a  nice  move- 
ment, then  administered  calomel  and  castor  oil  per  mouth.  The  movements 
brought  forth  scybala  in  plenty  and  after  the  bowels  were  thoroughly  emptied 
we  had  no  further  hsemorrhage.  We  then  decided  that  the  scybala  had  much  to 
do  with  the  haemorrhage.  His  mouth  and  throat  were  exceedingly  dry,  there 
being  no  secretion,  but  we  kept  him  on  calomel  until  we  had  a  free  flow  of  saliva. 
This  man  was  the  most  grateful  patient  I  ever  attended,  and  instead  of  kicking 
on  the  bill  said  if  he  was  able  he  would  pay  mo  more. 

Conclusions:     1.  We  believe  alum  solution  to  bo  the  best  intestinal  irritant 
we  have  at  our  command. 

2.  In  low  cases  the  alcohol  bath  is  a  necessity. 

3.  Saline  solution  by  hypodermoclysis  and  per  rectum  is  of  great  benefit. 

4.  In  bad  cases  do  the  heroic  and  make  a  stand  to  save  your  patient. 

5.  In  heernorrhage,  if  the  bowels  are  hard  to  keep  quiet  or  if  the  haemor- 
rhage is  repeated  often,  move  them. 

6.  Urinary  and  intestinal  antisepsis  are  both  demanded. 

7.  In  an  active  mild  delirium  chloroform  inhalations  may  prove  beneficial. 


ACTION  OF  GLANDULAR  EXTRACTS  UPON  THE  PUPIL.  493 

8.  Delirium  exhibited  by  fear  may  be  allayed  by  gelscmium. 

9.  Ergot  is  used  in  every  case  of  hfcmorrliage  either  hypodermically  or 
per  mouth,  the  hypodermic  method  preferred. 

10.  All  our  death  losses  so  far  have  been  females,  average  age  20^  years, 
and  7  per  cent,  of  all  cases. 

11.  The  physician  that  attempts  to  cut  short  an  attack  of  typhoid  will 
have  a  funeral. 


ACTION  OF  GLANDULAR  EXTRACTS  UPON  THE  PUPIL. 

By  ISAAC  OTT,  M.D., 

Professor  of  Physiology,  and 

JOHN  C.  SCOTT,  M.D., 

Demonstrator   of   Physiology    (Physiological   Laboratory   of   Medico-Chirurgical    College 

of  Philadelphia). 

Meltzer,!  was  the  first  to  show  that  adrenalin  dilated  the  pupil  when 
locally  applied  to  an  eye  twenty-four  hours  after  extirpation  of  the  superior 
cervical  ganglion.  ]\Ieltzer  holds  that  the  ganglion  sends  out  impulses  which 
inhibit  the  dilator  and  excite  the  constrictor  elements  of  the  iris.  He  holds 
that  adrenal  extract  does  the  reverse — excites  the  dilator  and  inhibits  the  con- 
strictor part  of  the  iris. 

0.  Loewi^  found  on  cats  and  dogs,  twenty-four  to  sixty-five  hours  after 
extirpation  of  the  pancreas,  a  marked  and  strong  dilation  of  the  pupil  by 
adrenalin.  This  ensued  in  dogs  in  20  to  60  minutes  after  the  instillation 
into  the  eye  and  lasted  six  hours.  In  a  comparison  of  the  effect  of  adrenalin 
on  dogs  or  cats  with  pancreas  removed,  the  adrenalin  dilated  the  pupil  less  than 
in  animals  with  the  superior  cervical  ganglion  extirpated.  He  believes  that 
adrenalin  mydriasis  is  due  to  removal  of  an  internal  function  of  the  pancreas, 
which  reduces  the  irritability  of  the  sympathetic  nerve  elements. 

Vf.  Cramer^  noted  that  extracts  of  the  posterior  lobe  of  the  pituitary  body 
of  the  ox  produced  a  distinct  dilatation  on  the  pupil  of  the  enucleated  eye  of 
the  frog.  The  principle  is  distinct  from  that  body  in  the  pituitary  which  pro- 
duces diuresis.  Ott  and  Scott^  have  shown  that  pituitary  in  the  rabbit  dilates 
the  pupil  after  removal  twenty-four  hours  previously  of  the  superior  cervical 
ganglion.  It  was  used  locally,  by  the  jugular,  and  subcutaneously.  In  the 
normal  eyp  no  effect  enf^ued.  Pituitrin  has  the  same  effect,  showing  it  is  tlie 
infundibular  part  that  dilates  the  pupil. 

Shima^'  uncl«;r  A.  ICreidl's  direction  found  as  the  result  of  an  operation  on 
the  brain  that  between  the  anterior  part  of  the  cerebrum  and  the  sympathetic 

1  American  .Journal  of  PhysioIo»(y,  vol.  xi.   1904,  p.  28. 
2Archiv.  fiir  Experimenfollc  Pathologic,  Band  .59,  lloft  1,  p.  86,  1908. 
3  Quarterly  .Tonrnal  of  Kxpcrimental  Pliysiology,  vol.  i,  p.   187,  April,  1908. 
•*  "The   Effttct   of  Mammalian   Pituitary  on   Tetany   after   Parathyroidectomy   and 
upon  the  Pupil."     New  York  Medical  Journal,  December,  1908. 
5  PflUger's  Archiv.,  Band  126,  p.  269. 


494  ACTION  OF  GLANDULAR  EXTRACTS  UPON  THE  PUPIL. 

of  the  cat,  there  was  a  close  relation  when  adrenalin  was  instilled  into  the  eye. 
He  believes  that  in  the  frontal  lobes  there  is  an  inhibitory  mechanism  of  a 
s}Tnpathetic  nature.  Shima^  also  found  that  adrenalin  dilated  the  pupil  after 
transverse  section  of  the  spinal  cord,  as  low  as  the  exit  of  the  seventh  thoracic 
nerve.  Transverse  section  of  the  cervical  cord  also  permitted  adrenalin  to 
dilate  the  pupil.     Here  the  operations  were  upon  the  ciliospinal  fibres. 

Dr.  W.  H.  Schultz'^  has  shown  that  adrenalin  dilates  the  pupil  of  the  nor- 
mal eye  provided  the  intensity  of  the  light  stimuli  is  reduced.  He  used  two 
drops  every  two  minutes ;  and  in  several  animals  obtained  considerable  dilation. 

Our  experiments  were  made  upon  rabbits.  The  left  superior  cervical 
ganglion  was  excised  under  ether.  The  extracts  were  then  rubbed  up  with 
distilled  water  and  dropped  into  each  eye.  The  intensity  of  the  light  was 
regulated  so  as  to  be  about  the  same.  We  waited  twenty-four  hours  after  the 
excision  of  the  ganglion  before  any  observations  were  made.  The  rabbit  was 
placed  upon  a  table  and  permitted  to  run  about.  The  diameter  of  the  pupil 
was  measured  with  a  pair  of  compasses.  The  number  of  our  experiments  was 
thirty-two. 

Pituitary  extract  had  no  effect  upon  the  normal  eye.  On  the  eye  with  the 
superior  cervical  ganglion  removed,  it  dilated  the  pupil.  Pituitrin  also  dilated 
the  pupil  on  the  side  where  the  ganglion  was  excised. 

Parathyroid  nucleo-proteid  on  the  normal  eye  dilnted  the  pupil;  on  the 
excised  ganglion  side  it  at  first  contracted,  and  then  dilated  it. 

The  ovary,  thymus  and  mammary  gland  had  no  effect  upon  either  pupil. 

Parotid  and  testicular  extract  contracted  the  pupil  on  both  sides. 

lodothyrin  dilated  the  pupil  upon  the  side  of  the  excised  ganglion,  but  had 
no  effect  upon  the  normal  pupil.  The  dilatation  was  preceded  by  a  slight 
contraction.  The  amount  of  contractions  with  the  extracts  was  about  a  milli- 
meter, the  dilatations  about  two  millimeters. 

That  the  cervical  sympathetic  and  oculomotor  nerves  are  separately  or 
jointly  acted  upon,  by  the  active  principles  in  these  glands,  is  evident.  As  to 
the  exact  mechanism  of  this  act,  it  is  speculative.  It  is  quite  evident  that  the 
pupil  test  in  the  frog  or  mammal  for  the  presence  of  adrenalin  in  the  blood  is 
of  very  doubtful  value  in  the  presence  of  the  other  internal  secretions  which 
dilate  the  pupil. 

Appended  are  some  of  the  experiments  upon  the  pupil : 

Exp.  35. — Parathyroid  nucleoproteid  on  pupil.  Left  superior  cervical 
ganglion  extirpated : — Eabbit. 

L.  R.  L.  R. 

Normal.  Normal. 

P.M.  Millimeters.         Millimeters.  P.M.  Millimeters.  Millimeters. 

13.05  6  6  12.40  8  7 

Applied  to  both  eyes  12.45  6  7 

12.10  5  7  12.50  6  7 


ePfliigcr's  Archiv.,  Band  127,  p.  109. 

7  Proceedings  of  the  Society  for  Experimental  Biology  and  Medicine,   1908,  p.  23, 
vol.  vi. 


THE  ANTIDOTAL  EFFECTS  OF  ALCOHOL  UPON  PHENOL. 


495 


P.M. 
12.15 

L. 

Millimeters. 
5 

R. 

Normal. 
Millimeters. 
7 

P.M. 
12.55 

L. 

Millimeters. 
5 

R. 

Normal. 
Millimeters. 

7 

12.20 

5 

7 

1.00 

6 

7 

12.25 

7 

7 

1.10 

6 

7 

12.30 

7 

8 

1.20 

6 

7 

13.35 

8 

8 

Exp. 
Rabbit. 

P.M. 

2.45 

16. — Pituitary  on  pupil.    Extirpation  of  superior  cervical  ganglion : — 

L.                           R.                                                      L.                           R. 

Normal.                                                                         Normal. 
Millimeters.         Millimeters.             P.M.                Millimeters.         Millimeters. 
7                             9                      3.10                          7                             9 

Applied 

2.47 
2.50 

to  both 
8 
8 

eyes 

9 
9 

3.15 
3.17 

7 
Applied  to  both 
8 

9 

eyes 

9 

2.55 

8 

9 

3.19 

'    8 

9 

3.00 

8 

9 

3.29 

7 

9 

3.05 

7.5 

9 

3.34 

7 

9 

Exp. 
ganglion : 

P.M. 
2.35 

23.— lodothy 

—Rabbit. 
L. 

Millimeters. 

7 

rin    on   pupil. 

R. 

Normal. 
Millimeters. 
10 

Extirpat 

P.M. 

3.07 

ion   of    left    superior   cer^dcal 

L.                          R. 

Normal. 
Millimeters.        Millimeters. 
7                     10 

Applied 
2.36 

to  both 

7 

eyes 

10 

3.10 

7 
Applied  to  both 

10 
eyes 

2.40 

6 

10 

3.10.; 

30                 8 

10 

2.50 

7 

10 

3.11 

6 

10 

3.00 

7 

10 

3.15 

6.5 

10 

Applied 
3.00.30 

to  both 
8 

eyes 

10 

3.20 
3.24 

7 
7 

10 
10 

3.01 

8 

10 

3.25 

7 

10 

3.02 

7 

10 

3.30 

7 

10 

3.03 

6 

10 

THE  ANTIDOTAL  EFFECTS  OF  ALCOHOL  UPON  PHENOL. 


By  harry  J.  NOVACK,  M.D., 

PHILADELPHIA. 

Phenol  or  carbolic  acid  is  one  of  the  most  deadly  and  rapidly  acting 
poisons  known.  If  a  large  lethal  dose  be  swallowed  by  a  man,  he  may  drop 
dead  before  he  can  go  a  few  feet  from  the  spot  where  ho  stood  when  drinking 
the  drug,  or  he  may  live  a  few  hours.  With  the  suicide  it  is  exceptionally 
popular,  probably  on  account  of  the  ease  with  which  it  can  be  obtained.     Then 


496  THE  ANTIDOTAL  EFFECTS  OF  ALCOHOL  UPON  PHENOL. 

again,  in  many  households,  a  bottle  containing  carbolic  acid  can  be  found  near 
other  medicines  and  is  often  taken  by  mistake.  It  is,  therefore,  no  wonder 
that  so  much  stress  and  attention  should  be  directed  towards  this  one  poison, 
particularly  with  the  purpose  of  finding  a  thorough  antidote.  Within  recent 
years  a  number  of  antidotes  have  been  suggested,  but  none  have  become  so 
well  known  and  generally  used  as  alcohol. 

The  first  suggestion  of  the  use  of  alcohol  as  an  antidote  to  phenol  or 
carbolic  acid  was  made  by  Dr.  Seneca  D.  Powell,  of  iSTew  York  City.  He 
proved  that  as  a  result  of  some  great  antidotal  power  of  alcohol,  no  injury 
would  result  from  immersing  the  hands  in  pure  phenol,  provided  they  were 
immediately  afterwards  washed  in  absolute  alcohol.  From  this  and  other 
experiments  of  a  similar  nature,  he  concluded  that  alcohol  miglit  be  used 
internally  in  eases  of  phenol  poisoning;  but  this  has  proved  ineffective,  since 
strong  alcohol  cannot  be  used  internally  and  when  diluted  its  antidotal  power 
is  lost. 

Externally  however,  apart  from  its  use  in  accidental  phenol  burns,  the 
surgeon  often  applies  alcohol  to  neutralize  or  stop  the  corrosive  action  of  the 
phenol  with  which  he  has  swabbed  an  infected  wound,  or  touched  the  stump 
of  a  gangrenous  appendix.  In  fact,  it  is  claimed  to  be  so  perfect  an  antidote, 
that  the  wound  previously  white  from  the  corrosive  action  of  the  pure  phenol, 
will  return  to  its  normal  color  after  the  use  of  strong  alcohol.  How  it  acts  as 
an  antidote  to  phenol  is  still  a  subject  of  discussion  and  no  one  has  as  yet  satis- 
factorily explained  the  peculiar  phenomena  which  take  place  when  alcohol 
la  applied  to  the  tissues  affected  by  phenol.  Now  and  then  theories  are 
advanced,  one  endeavoring  to  prove  that  the  alcohol  acts  upon  the  tissues, 
while  another  suggests  that  it  affects  the  phenol  chemically  thus  rendering  it 
inert. 

The  adherents  of  the  chemical  theory  believe  that  the  result  of  the  reaction 
is  "a  new  phenol  benzine  or  aromatic  compound  having  the  chemical  and  thera- 
peutic properties  of  alcohol."  It  has  been  overlooked,  however,  that  this  new 
aromatic  compound,  or,  better  still,  solution  as  it  should  be  called,  also  has  the 
chemical  and  therapeutic  properties  of  phenol.  Although  dilution  decreases 
its  corrosiveness  externally,  it  still  does  not  in  the  least  lessen  the  result  of  a 
lethal  dose  when  taken  internally,  no  matter  with  how  much  alcohol  it  has  been 
diluted.  The  addition  of  a  small  quantity  of  alcohol  to  pure  phenol  Avill 
increase  its  corrosiveness  externally,  which  would  be  impossible  should  alcohol 
have  any  neutralizing  action.  This  is  due  to  the  more  rapid  absorption  of  the 
slightly  diluted  j)henol. 

Phenol  is  freely  soluble  in  alcohol  and,  when  the  two  are  mixed,  no 
chemical  change  can  in  any  way  be  detected.  They  are  merely  in  a  state  of 
mixture  or  simple  solution  and  are  as  easily  separable  as  a  solution  of  salt  in 
water. 

Experiment  No.  1. — Equal  quantities  of  phenol  and  alcohol  were  placed 
in  a  distilling  flask.  The  boiling  point  of  alcohol  being  much  lower  than  that 
of  phenol,  it  was  possible  to  distill  from  the  solution  all  of  the  alcohol  before 


THE  ANTIDOTAL  EFFECTS  OF  ALCOHOL  UPON  PHENOL.       497 

reaching  the  boiling  point  of  plienol.  Comparing  the  phenol  residue  in  the  flask 
with  some  of  the  unused  material,  not  the  slightest  change  could  be  determined. 

First. — No  two  chemically  united  substances  could  have  been  so  easily 
separated. 

Second. — It  is  almost  entirely  impossible  to  have  chemical  union  without 
the  presence  of  at  least  one  of  the  phenomena  that  accompanies  a  chemical 
reaction,  or  some  slight  alteration  in  either  one  or  all  of  the  factors  entering 
into  the  chemical  combination. 

When  the  application  of  phenol  to  the  tissues  is  followed  by  the  use  of 
alcohol,  noteworthy  changes  occur.  Paia  is  lessened,  corrosive  action  ceases 
and  all  visible  traces  of  the  phenol  disappear.  To  what  can  we  attribute  this 
great  antidotal  power  of  alcohol  ?  Some  believe  that  "the  alcohol  in  some  way 
affects  the  tissues,  thereby  lessening  the  destruction  that  would  otherwise 
follow."  It  is  a  knowTi  fact  that  after  the  cells  of  any  part  of  the  body  are 
destroyed  by  the  powerful  action  of  phenol,  neither  alcohol  nor  any  other  drug 
in  existence  can  have  much  effect.  It  would  also  be  ridiculous  to  believe  that 
the  dead  cells  have  been  repaired  because  the  color  of  the  tissue  returns  to 
normal  after  the  use  of  alcohol. 

Excluding  the  chemical  as  well  as  the  theory  that  alcohol  produces  its 
antidotal  action  upon  the  tissues,  there  still  remain  a  few  physical  phenomena 
that  are  worthy  of  consideration. 

ExrERiMEXT  No.  2. — (a)  A  piece  of  ordinary  newspaper  was  moistened 
in  the  centre  with  a  very  little  phenol,  and  allowed  to  be  absorbed.  Alcohol 
was  then  applied  to  one  side  and  gradually  minute  globules  of  phenol  collected 
on  the  other  side.  As  soon  as  the  alcohol  evaporated  the  phenol  was  reabsorbed. 
Alcohol  was  again  applied  to  one  side  and  the  result  was  that  the  phenol 
reappeared  upon  the  opposite  side  of  the  paper. 

{h)  Two  blisters  were  made  upon  the  flexor  surface  of  the  forearm. 
The  surfaces  of  both  blisters  were  repeatedly  painted  with  phenol.  Alcohol 
was  then  applied  to  the  first  and  after  withdrawing  the  fluid  by  inserting  the 
hypodermic  needle  at  a  point  not  touched  by  the  phenol,  it  was  found  to  con- 
tain phenol  that  was  easily  discernible  by  taste.  No  trace  of  the  phenol  was 
found  in  the  fluid  of  the  blister  upon  which  the  application  of  the  phenol  was 
not  followed  by  the  use  of  alcohol. 

There  is  no  doubt  that  the  alcohol  must  have  had  some  special  action  upon 
the  phenol  in  causing  its  appearance  in  the  fluid  of  the  blister.  When  a  drop 
of  alcohol  is  placed  on  a  glass  plate  near  a  drop  of  pure  phenol,  it  is  noticed 
that  the  latter  recedes  or  moves  away  from  the  alcohol  as  soon  as  the  two  have 
come  sufflciently  near,  though  not  necessarily  in  contact  with  each  other.  This 
peculiar  phenomenon  can  no  doubt  account  for  the  repulsion  of  the  phenol  to 
one  side  or  the  other  of  the  paper,  as  well  as  through  the  epidermis  of  the 
blister,  causing  its  presence  in  the  fluid. 

It  would  be  suSicient  to  state  from  the  above  phenomena  that  alcohol  has 
the  peculiar  property  of  repelling  phenol,  but  let  us  see  if  we  cannot  through 
molecular  study  get  some  enlightenment  as  to  the  origin  of  this  property. 

Evaporation  is  a  property  of  alcohol  and  phenol  as  well  as  of  all  other 
0 


498  THE  ANTIDOTAL  EFFECTS  OF  ALCOHOL  UPON  PHENOL. 

liquids  and  in  the  molecular  sense  of  the  term,  it  is  a  rapid  separation  of  the 
molecules  of  a  liquid  exposed  to  the  air,  being  dependent  upon  other  various 
conditions,  Not  all  liquids  evaporate  with  the  same  rapidity,  on  account  of, 
not  only  the  variations  in  size,  but  also  the  arrangement  of  the  molecules  in 
different  liquids.  The  molecules  of  alcohol  are  of  such  size  and  arrangement 
that  they  separate  more  readily  and  forcibly  than  do  those  of  phenol  and  from 
the  fact  that  the  drop  of  phenol  recoils  from  the  alcohol  even  before  visible 
contact  has  occurred,  it  stands  to  reason  that  what  has  been  given  off  from  the 
alcohol  to  so  affect  the  phenol,  cannot  be  other  than  an  infinite  number  of 
molecules. 

Although  both  the  alcohol  and  phenol  have  large  intermolecular  spaces, 
which  accounts  for  the  decrease  in  volume  when  equal  quantities  of  alcohol 
and  phenol  are  mixed,  still  the  molecidar  arrangement  of  the  phenol  is  such  as 
to  present  a  suitable  surface  upon  which  the  forcibly  evaporating  alcohol  mole- 
cules can  strike,  thus  producing  repulsion.  As  soon  as  a  sufficient  number 
of  molecules  have  been  absorbed  by  the  intermolecular  spaces  of  the  phenol, 
mixture  will  take  place  despite  the  fact  that  repulsion  is  the  primary  effect. 

Alcohol  has  the  same  effect  towards  any  other  liquid  whose  molecular 
size  and  arrangement  render  it  capable  of  receiving  the  rapidly  evaporating 
alcohol  molecules  directly  upon  its  surface  instead  of  entering  into  the  spaces  of 
that  liquid.  A  molecule  of  alcohol  in  striking  against  one  of  water,  not  only 
has  very  little  of  its  repellent  power  utilized,  but  is  easily  and  readily  absorbed 
by  the  intermolecular  space,  due  to  the  molecular  arrangement  of  the  water. 

The  lower  the  strength  of  the  alcohol,  the  slower  the  evaporation  and 
lessened  repellent  power,  hence  the  ineffectiveness  of  weak  alcohol  as  an  anti- 
dote to  phenol. 

Not  only  alcohol,  but  any  other  rapidly  evaporating  liquid  whose  molecules 
are  of  sufficient  size,  will  produce  the  same  effect  upon  phenol,  except  to  a 
variable  degree. 

Is  it  possible  that  alcohol  depends  upon  its  solvent  and  repellent  properties 
for  its  peculiar  antidotal  power?  This  seems  quite  evident  from  the  fact  that 
the  addition  of  water  to  either  the  alcohol  or  phenol,  by  affecting  these  proper- 
ties, greatly  disturbs  their  antidotal  relations. 

Experiment  No  3. — The  hand  was  immersed  in  pure  phenol  and  then 
immediately  afterwards  in  strong  alcohol.  With  the  exception  of  a  slight 
numbness,  no  injury  resulted.  The  alcohol  in  which  the  hand  was  washed,  was 
then  put  into  a  distilling  flask,  as  in  experiment  No.  1,  and  a  small  quantity 
of  phenol  obtained,  showing  that  the  alcohol  acted  as  a  solvent,  not  by  chang- 
ing the  phenol  chemically.  Anaesthesia  was  the  result  of  a  very  minute 
quantity  of  phenol  being  forced  into  the  pores  and  other  fissures  in  the  skin 
by  the  active  alcohol  molecules.  Phenol  being  a  very  corrosive  poison,  how 
are  we  to  account  for  the  fact  that  no  injury  results  to  the  hand  when  alcohol 
is  used  subsequently?  If  a  sensitive  photographic  plate  is  exposed  for  a  frac- 
tion of  a  second  in  a  light  that  naturally  requires  twenty  times  as  much,  no 
change  will  be  noticed  in  that  plate  when  developed;  but  this  woidd  not  prove 
the  plate  insensitive  to  light.     When  the  hand  is  exposed  for  a  few  seconds  to 


THE  ANTIDOTAL  EFFECTS  OP  ALCOHOL  UPON  PHENOL.       499 

the  action  of  pure  phenol  there  is  no  reason  why  injury  should  result,  if  the 
phenol  is  almost  completely  removed  by  the  alcohol  long  before  it  begins  to 
act.  Not  all  corrosive  poisons  act  upon  the  skin  within  the  same  time. 
Phenol  produces  no  change  until  it  is  allowed  to  act  for  almost  lifteen  or 
twenty  seconds,  depending  upon  the  tenderness  of  the  skin.  When  removed 
before  that  time,  by  as  thorough  a  solvent  as  alcohol,  no  injury  results  to  the 
hand. 

Experiment  No.  4.— Pure  phenol  was  applied  to  different  areas  of  the 
forearm  and  removed  by  washing  with  alcohol  after  being  allowed  to  act  first 
for  five,  then  ten,  and  finally  fifteen  seconds,  without  the  slightest  injury  result- 
ing. At  the  end  of  thirty  or  more  seconds,  the  effects  of  the  phenol  became 
noticeable.  At  the  end  of  one,  two  and  three  minutes,  the  inflammations 
produced  were  all  severe  and  alike,  repair  taking  place  in  all  within  the  same 
time. 

Using  water  instead  of  alcohol  to  remove  the  phenol,  the  results  obtained 
were  very  much  the  same  with  the  exception  that  at  the  end  of  thirty  seconds, 
one,  two  and  three  minutes,  the  inflammations  produced  were  similar  to  each 
other  as  well  as  to  those  produced  when  followed  by  alcohol  at  the  end  of  one, 
two  and  three  minutes.  At  the  end  of  thirty  seconds  the  water  is  incapable  of 
thoroughly  removing  the  phenol,  hence  a  severe  inflammation  results. 

Phenol,  as  well  as  any  other  coiTosive,  requires  a  definite  time  before  it 
can  produce  injurious  results,  and,  if  removed  at  any  time  before  that  limit, 
there  will  be  no  injury. 

After  the  phenol  is  allowed  to  act  upon  the  skin  for  a  minute,  it  coagulates 
the  albumin  of  the  tissue,  making  a  film  through  which  the  excess  of  the  cor- 
rosive cannot  pass  to  produce  more  injury  than  has  already  been  done. 

Water  does  not  affect  the  blanched  condition  since  it  is  unable  to  penetrate 
the  albuminous  film,  although  it  dissolves  out  the  phenol  superficially.  Alcohol, 
however,  by  its  power  of  diffusion  or  repulsion,  sends  the  small  amount  of 
phenol  in  the  coaguliun  deep  into  the  tissues  where  it  is  absorbed.  The  alcohol 
molecules  in  passing  through  this  film  like  so  many  fine  needles,  render  it  sieve- 
like, so  that  the  tissue  resumes  its  natural  color,  although  the  resulting  inflam- 
mation is  the  same  as  when  water  is  used,  except  when  the  alcohol  is  used  early. 

Experiment  No.  5. — The  mucous  membrane  of  the  lip  was  touched 
with  a  drop  of  pure  phenol.  Within  a  few  seconds  a  white  spot  appeared. 
Applying  strong  alcohol,  the  white  spot  gradually  disappeared.  The  explana- 
tion given  for  this  peculiar  phenomenon  is  that  "the  alcohol  in  some  way 
affects  the  tissues,  thereby  lessening  the  destruction  that  would  otherwise 
follow,  and  drawing  water  to  the  surface,  redissolves  the  coagulum."  The 
fallacy  of  this  statement  is  at  once  noticeable,  since  it  is  well  known  that  the 
water  which  the  alcohol  may  draw  to  the  surface  cannot  dissolve  coagulated 
albumin  unless  the  necessary  ferments  are  supplied  to  digest  it.  Just  as  in 
experiment  No.  2  the  phenol  was  repelled  to  one  side  or  the  other  of  the  paper 
and  even  through  the  epidermis  of  the  blister,  so  here  the  phenol  was  diffused 
by  the  alcohol  deep  into  the  mucous  membrane  where  it  was  absorbed  bv  the 
blood-vessels.     The  alcohol  instead  of  drawing  water  from  the  tissues,  repelled 


500  THE  ANTIDOTAL  EFFECTS  OF  ALCOHOL  UPON  PHENOL. 

from  the  surface  not  only  the  phenol,  but  forced  the  other  fluids  such  as  blood, 
Ij'inph,  etc.,  somewhat  away  from  the  surface.  No  doubt  this  may  be  the  cause 
of  the  peculiar  wrinkling  of  the  mucous  membrane  when  alcohol  is  applied  to 
it.  This  action  which  at  first  repelled  the  blood,  finally  gave  tone  to  the  blood- 
vessels so  that  the  blood  rushed  to  the  sui-face.  When  it  came  just  beneath  the 
thin  fihu  of  coagulated  albumin,  the  appearance  was  red.  Although  the 
albimiin  still  remained,  yet  it  was  not  as  solid  as  before,  for  the  alcohol  in 
passing  through,  rendered  it  more  or  less  sieve-like,  thus  showing  the  color  of 
the  tissues  below. 

The  mucous  membrane  of  the  lip  was  again  touched  with  a  drop  of  pure 
phenol  and  after  a  few  seconds,  water  was  used  instead  of  alcohol.  Within  a 
few  minutes  the  white  film  disappeared  almost  completely.  The  film  being 
very  thin,  it  was  possible  by  using  moderate  friction,  to  remove  the  phenol 
imbedded  in  this  superficial  film.  When  the  phenol  was  allowed  to  act  for  a 
minute  or  more,  the  film  became  too  thick  for  even  the  alcohol  to  penetrate  it. 
After  a  few  hours  both  spots  appeared  the  same,  not  only  being  equally  inflamed, 
but  healing  took  place  within  the  same  time. 

When  an  infected  wound  is  swabbed  with  pure  phenol,  it  becomes  covered 
with  a  film  of  albumin  which  gives  it  a  white  appearance,  just  as  the  mucous 
membrane  of  the  lip  in  the  last  experiment.  Corrosive  sublimate  combines 
chemically  with  the  albumin  of  the  cells,  forming  an  albuminate  of  mercury. 
Phenol,  however,  acts  like  heat  and,  after  coagulating  the  albumin  of  the  tis- 
sues, still  remains  as  pure  phenol  on  the  surface.  When  strong  alcohol  is 
applied,  the  wound  returns  to  its  original  color  and  to  all  appearances  the 
phenol  has  been  completely  antidoted.  The  following  is  what  really  occurs. 
The  coating  of  albumin  is  not  entirely  impervious  and  when  the  wound  is 
swabbed  over  with  strong  alcohol,  the  small  amount  of  phenol  imbedded  in 
this  film,  is  driven  through  the  fissures  and  crevices  to  the  deeper  structures 
below,  thus  diffusing  it  so  that  it  can  be  absorbed  instead  of  further  affecting 
■the  tissues.  Some  of  the  phenol  on  the  surface  mixes  with  the  alcohol  and  is 
made  so  thin  and  weak  that  it  easily  passes  through  this  film  made  pervious  by 
the  first  impulse  of  the  alcohol.  Should  the  amount  of  phenol  be  large,  the 
urine  will  reveal  the  presence  of  carbolates.  The  return  of  the  wound  to  its 
original  color  is  the  same  as  in  experiment  No.  5,  in  which  the  mucous  mem- 
brane of  the  lip  returns  to  its  normal  color. 

The  internal  use  of  alcohol  as  an  antidote  to  phenol  has  not  only  proved 
ineffective  but  even  dangerous.  Although  alcohol  acts  the  same  internally  as  it 
does  externally,  still  the  result  is  harmful  when  left  in  the  stomach  together 
with  the  phenol. 

All  dogs  used  in  the  following  experiments  were  first  placed  under  the 
influence  of  ether,  and  their  stomachs  washed  by  means  of  the  stomach  pump. 

Experiment  No.  6. —  (a)  Two  drachms  of  pure  alcohol  were  given  to 
one  dog.  Within  a  few  minutes  toxic  symptoms  began  and  continued  for 
several  hours  until  death  occurred. 

When  the  stomach  was  examined  it  was  found  to  contain  a  good  deal  of 
the  phenol  used,  absorption  having  been  prevented  by  the  formation  of  an 


THE  ANTIDOTAL  EFFECTS  OF  ALCOHOL  UPON  PHENOL.  501 

albuminous  film.  Death  was  principally  the  result  of  the  shock  produced  by 
the  local  action  of  the  poison  and  but  slight  absorption. 

(6)  To  a  second  dog  of  about  the  same  weight  as  the  first,  two  draclmis 
of  pure  phenol  were  given.  A  few  minutes  later  alcohol  was  administered  and 
immediately  all  toxic  s}7nptoms  increased,  death  resulting  within  the  hour. 

The  stomach  was  foimd  empty  and  not  as  white  as  in  the  first  dog.  The 
urine  and  blood  showed  very  much  the  presence  of  the  poison,  since  death  was 
hastened  by  the  increased  absorption  brought  about  by  the  alcohol. 

(c)  A  solution  of  two  drachms  of  phenol  in  alcohol  were  given  to  a 
third  dog.  Poisoning  symptoms  rapidly  began  and  continued  until  death, 
which  resulted  v/ithin  the  hour.  The  stomach  was  found  empty  and  to  all 
appearances  normal.     The  urine  and  blood  were  saturated  with  the  poison. 

(d)  A  small  quantity  of  phenol  was  given  to  a  fourth  dog  and  later 
followed  by  alcohol.  Signs  of  poisoning  arose  but  were  not  very  severe.  The 
urine  was  obtained  and  allowing  it  to  cool,  changed  to  a  very  dark  color, 
indicating  the  presence  of  carbolates.  The  quantity  of  phenol  given  was  not 
sufficient  to  produce  death,  and,  although  forced  more  rapidly  into  the  system 
by  the  alcohol,  it  was  finally  eliminated  by  the  kidneys. 

In  every  case  where  alcohol  was  used,  either  following  or  together  with  the 
phenol,  the  stomach  was  found  empty  and  with  very  little  or  no  change  in  the 
color  of  the  mucous  membrane. 

When  a  large  amount  of  phenol  has  been  taken  and  alcohol  is  given  while 
the  poison  is  still  ia  a  free  state,  death  will  be  much  hastened,  just  as  in  the 
second  dog.  The  alcohol  in  this  case  acts  like  an  oil  in  phosphorous  poisoning, 
by  increasing  absorption.  The  alcohol  mixes  with  the  free  phenol  in  the 
stomach  and,  acting  like  pure  alcohol  except  to  a  less  degree,  forces  the  phenol 
already  im.bedded  in  the  mucous  coat  of  the  stomach  into  the  circulation, 
following  which  the  remainder  of  the  contents  are  absorbed,  death  rapidly 
ensuing.  Should  the  free  acid  in  the  stomach  be  first  removed  and  tlien  fol- 
lowed by  alcohol,  the  result  would  depend  upon  the  quantity  of  phenol  already 
imbedded  in  the  mucous  coat  of  the  stomach.  This  quantity  when  large,  upon 
diffusion  and  rapid  absorption,  would  result  in  death ;  but,  if  not  enough  to  be 
dangerous  to  the  system  when  absorbed,  alcohol  would  be  of  great  benefit  by 
hastening  the  elimination  of  the  poison  in  a  diluted  state,  as  in  the  case  of  the 
fourth  dog.     Even  then  there  is  great  danger  to  the  kidneys. 

The  importance,  therefore,  of  first  removing  whatever  poison  there  is  in 
the  stomach  before  using  alcohol  cannot  be  too  strongly  urged.  This  is  best 
accomplished  by  lavage.  Some  believe  lavage  to  be  contraindicatcd  on  account 
of  the  corrosive  action  of  the  phenol  upon  the  stomach  and  the  danger  of  per- 
foration; but  it  must  not  be  forgotten  that  particularly  phenol,  of  all  corrosive 
poisons,  limits  its  destructive  progress  and,  therefore,  does  not  weaken  the 
stomach  to  such  an  extent  as  to  make  the  passage  of  a  stomach  tube  dangerous. 

Many  solutions  can  be  used  for  lavage  in  phenol  poisoning,  but  by  far 
the  best  results  are  obtained  from  a  solution  of  the  two  most  well  known  and 
best  antidotes  for  this  poison,  namely,  albumin  and  magnesium  sulphate.  To 
every  eight  or  ten  ounces  of  water,  a  few  grains  of  sodium  chloride  are  added 


502  THE  ANTIDOTAL  EFFECTS  OF  ALCOHOL  UPON  PHENOL. 

and  the  white  of  one  egg  dissolved,  then  enough  magnesium  sulphate  is  added 
to  saturate  the  solution.  A  clear  solution  results  and  when  a  drop  of  phenol 
is  added  to  it  in  a  test  tube,  a  uniform  white  precipitate  will  immediately  occur. 
Care  should  be  taken  not  to  add  too  much  albimiin  in  making  this  solution,  as 
lavage  will  become  diflicult  due  to  the  clogging  of  the  stomach  tube  by  the 
albumin  coagulated  by  the  phenol  in  the  stomach. 

The  phenol  exerts  its  energy  upon  the  albumin  in  this  solution  more 
thoroughly  and  rapidly  than  upon  albumin  alone.  It  combines  feebly  with 
the  magnesium  sulphate  chemically,  is  mildly  astringent  and  does  not  force 
the  poison  through  the  albuminous  film  into  the  system,  as  does  alcohol.  This 
solution  is  of  not  much  benefit  when  left  in  the  stomach  together  with  a  poison- 
ous amount  of  phenol,  as  will  be  shown  later,  but  for  lavage  it  cannot  be 
excelled.  Although  the  albmnin  is  coagulated  by  the  phenol,  still  it  does  not 
combine  with  it  chemically,  as  does  bichloride  of  mercury.  The  albumin  in 
this  solution  acts  mechanically  and  is  a  means  of  bringing  up  the  free  phenol. 

Experiment  No.  7. — Lethal  doses  of  from  two  to  four  drachms  of  pure 
phenol  were  given  to  each  of  five  dogs.  Just  as  soon  as  poisoning  signs  arose, 
lavage  was  made  with  the  magnesium-sulphate-albumin  mixture  until  the  solu- 
tion came  away  clear  and  no  shreds  of  coagulated  albumin  were  visible.  In  this 
way  all  of  the  free  phenol  was  removed  from  the  stomach.  This  was  then 
followed  by  lavage  with  twenty  per  cent,  alcohol.  The  result  was  recovery 
in  all. 

Most  of  the  phenol  having  been  removed  by  tlie  first  solution,  it  became 
safe  to  use  the  alcohol  as  lavage.  By  its  repellent  and  solvent  properties  it 
has  the  advantage  of  clearing  the  mucous  membrane  of  the  stomach,  besides 
acting  as  a  stimulant.  Stimulation  by  strychnine,  atropine  and  digitalin  was 
resorted  to  as  required. 

Experiment  Xo.  8.— Two  drachms  of  pure  phenol  were  given  to  each  of 
two  dogs,  followed  l)y  a  few  ounces  of  tlie  magnesium-sulpliate-albumin  mixture 
which  was  left  in  the  stomach.  Within  a  few  hours  both  dogs  died,  despite 
all  means  of  stimulation  by  external  heat,  strychnine,  atropine  and  digitalin. 
This  proves  that  it  is  the  lavage  aud  not  the  antagonism  that  is  of  greatest 
value. 

The  tincture  of  iodine  has  been  recently  claimed  as  a  good  antidote  in 
cases  of  phenol  poisoning.  Some  of  the  experiments  were  repeated,  using  the 
tincture  of  iodine  instead  of  alcohol.  The  results  obtained  were  the  same  as 
when  alcohol  was  used.  This  is  due  to  the  fact  that  the  antidotal  action  of  the 
tincture  is  entirely  dependent  upon  the  alcohol  which  it  contains  and  not  to 
any  chemical  antagonism.  It  is  claimed  that  the  phenol  combines  chemically 
with  the  iodine,  forming  a  phenol  iodide.  A  phenol  iodide  will  not  be  formed 
by  the  mere  mixture  of  the  two.  A  "para-phenol  iodide"  does  exist,  which 
besides  being  difiicult  to  make,  is  a  very  corrosive  poison. 

Conclusions. — 1.  The  peculiar  phenomena  by  reason  of  which  alcohol  has 
been  acclaimed  an  antidote  to  phenol  are  the  result  of  its  solvent  and  repellent 
properties  and  not  of  any  chemical  antagonism. 


CREMATION,  THE  BEST  METIIOD  OF  DISPOSAL  OF  THE  DEAD.  503 

2.  Phenol  or  carbolic  acid,  though  it  is  a  powerful  corrosive,  limits  its 
destructive  progress  by  the  formation  of  an  albuminous  coagulum. 

3.  Alcohol  is  of  great  value  externally  when  used  early,  but  late,  the 
destruction  of  tissue  is.  not  prevented,  although  the  appearance  is  better. 

4.  On  account  of  the  repellent  and  solvent  properties  of  alcohol,  it  is 
dangerous  to  be  left  in  the  stomach  together  with  the  phenol. 

5.  The  advised  treatment  is  first  lavage  with  some  solution  as  the  mag- 
nesium-sulphate-albumin mixture,  followed  by  lavage  with  a  solution  of  alcohol 
as  a  clearing  agent. 

1122  North  Fortieth  Street,  Philadelphia,  Pa. 


Editorial 


CREMATION,  THE  BEST  METHOD  OF  DISPOSAL  OF  THE  DEAD. 

The  question  of  how  to  dispose  of  the  dead  is  indeed  a  grave  question. 
It  deserves  thoughtful  consideration  and  in  the  case  of  the  inhabitants  of  our 
large  cities  it  becomes  an  anxious  and  a  pressing  matter  which  can  only  be 
solved  by  scientific  principles.  It  is  a  fundamental  question  of  civilization. 
The  method  of  disposing  of  the  dead  in  such  a  manner  as  best  to  combine 
reverence  for  the  body  with  due  care  for  the  living  and  their  health,  is  one  so 
full  of  interest,  that  no  one  traveling  in  lands  where  other  methods  are  in 
vogue  can  fail  to  express  some  curiosity  on  the  subject. 

Nothing  can  be  more  admirable  from  a  scientific  point  of  view  than  the 
newly  proposed  method  of  disposing  of  the  dead  by  cremation.  There  is  no 
scientific  or  religious  reason  for  objecting  to  cremation,  as  God  who  raises  the 
dead  from  their  graves  can  also  join  them  together  from  the  ashes  which  have 
been  scattered  to  the  winds  or  preserved  in  urns.  From  a  scientific  point  of 
view  the  best  method  is  that  which  is  in  strict  accordance  with  Nature's  fixed 
intentions  and  which  shall  not  be  delayed  by  artificial  means  to  the  obvious 
detriment  of  our  plainest  sanitary  necessities.  We  should  approach  this  sub- 
ject and  its  investigation  by  the  broad  scientific  and  sanitary  road. 

History  tells  us  that  the  burial  customs  of  ancient  nations  differed  widely. 
Man  throughout  all  historic  periods  has  disposed  of  his  dead  kin  after  some 
fashion  or  other.  He  has  either  hidden  the  body  in  a  cave  and  closed  the 
opening  to  prevent  the  tenants  from  wild  beasts,  or  to  embalm  and  preserve  as 
much  as  may  be  so  preservable — a  delay  of  Nature's  certain  work,  or  the  body 
was  buried  in  the  soil  in  wood,  stone  or  metal.  Each  one  of  these  modes  of  dis- 
posal is  another  means  or  contrivance  of  delay  but  never  to  prevent  the 
inevitable  change.  In  cremation,  the  body  is  burned  and  so  restored  at  once 
to  its  original  elements,  in  which  case  Nature's  work  is  hastened. 

The  obstacles  to  cremation  are  numerous,  and  among  the  chief  are  super- 
stition, customs  and  sentiment  of  a  very  promiscuous  kind.  The  question  to  be 
solved  is,  which  form  of  disposal  of  the  body  is  best  for  tlie  survivor.     It  must 


504  CREIVIATIOISI,  THE  BEST  METHOD  OF  DISPOSAL  OF  THE  BEAD. 

only  be  regarded  from  the  point  of  view  in  the  interest  of  the  survivor  as  we 
know  that  the  dead  has  no  interest  in  the  matter. 

It  is  a  well-known  fact  that  with  the  progress  and  onward  rush  of  civiliza- 
tion, it  is  the  tendency  of  the  population  to  increase  and  condense,  and  thus  live 
in  crowded  cities.  There  is  no  necessity  to  prove,  the  fact  is  too  potent,  that 
burial  in  the  soil  is  full  of  danger  to  the  living.  Every  piece  of  ground  used 
as  a  burial  ground  will  some  day  be  utilized  for  the  purpose  of  building  dwell- 
ings, or  for  food  production.  No  available  progress  can  be  made  in  moulding 
public  taste  and  opinion  upon  this  subject,  until  we  scientific  men  are  prepared 
to  offer  good  reasons  for  our  declarations.  The  chief  appeal  must  be  the  most 
impoi-tant  law  of  nature,  namely  self-protection. 

Cremation  insures  the  purity  of  the  atmosphere  and  springs.  By  means 
of  the  modern  and  scientific  method  of  cremation,  the  human  body  can  within 
a  short  time  be  reduced  to  a  few  pounds  of  white,  odorless  ashes. 

Cremation  is  now  a  necessity,  a  sanitary  precaution  against  the  propaga- 
tion of  disease  among  a  population  which  is  increasing  and  becoming  large  in 
relation  to  the  area  it  occupies. 

There  is  a  general  rule  that  what  is  good  lives  and  vrhat  is  bad  dies.  It  is 
so  with  the  human  body.  When  it  reaches  the  stage  in  which  it  is  diseased 
to  such  an  extent  that  there  is  an  inharmonious  working  of  the  bodily  organs 
or  an  inactivity  of  the  vital  processes,  death  results.  It  is  then  that  the  stages 
of  decomposition  set  in  with  its  attendant  putrescence.  This  is  Nature's 
method  of  reducing  the  body  to  ashes.  Nature  does  nothing  without  an  ample 
meaning;   nothing  without  an  object  desirable  in  the  interest  of  the  body. 

The  processes  of  decomposition  affecting  an  animal  body  is  one  that  has 
a  disagreeable,  injurious,  often  fatal,  influence  on  the  living  body  if  sufficiently 
exposed  to  it.  Thousands  of  human  lives  have  been  cut  short  by  the  slowly 
decaying  and  often  diseased  animal  matter.  Every  dead  body,  whether  it 
be  an  animal  or  a  man,  must  enter  sooner  or  later  by  the  process  of  decom- 
position into  the  vegetable  kingdom.  Then  why  not  hasten  this  inevitable 
change  and  thus  avert  the  disaster  which  it  causes  yearly.  Why  should  we 
permit  it  to  make  mischief  during  its  change  ?  We  must  change  the  slow  and 
disagreeable  process  of  decomposition  and  rid  the  earth  of  the  decaying  remains 
of  diseased  humanity  which  pollute  the  earth,  the  air  and  the  water.  It  has 
been  calculated  that  the  injury  inflicted  upon  the  population  is  in  proportion 
to  the  density  of  the  population  and  the  extent  of  the  cemeteries. 

It  cannot  be  denied  that  cremation  has  advantages,  instead  of  the  old 
process  of  putrefaction  occupying  a  term  of  a  number  of  years  and,  at  the  same 
time,  disseminating  iimumerable  germs  of  fatal  diseases,  only  to  be  propagated 
in  whatever  way  they  find  a  favorable  soil.  There  are  also  physical  changes 
which  are  too  repulsive  for  the  mind  to  dwell  upon.  However,  the  chief  object 
of  cremation  is  to  convert  the  entire  mass  of  putrefied  matter  as  rapidly  as 
possible  into  a  harmless  dust  and,  at  the  same  time,  destroy  all  the  pathogenic 
organisms.  It  destroys  all  corrupting  matters,  renders  all  the  infectious 
matter   inert,    and    restores    valuable    matter    in    the    form    of    gases    to    the 


ANTIFERiIE>;T  SERUM  IN  THE  TREATMENT  OF  SUPPURATION.       505 

atmosphere  where  they  at  once  enter  into  new  combinations  with  healthy  living 
organisms  in  obedience  to  the  laws  of  Nature. 

By  the  act  of  interment  or  "paying  that  last  tribute  of  respect  to  the 
dead"  we  literally  sow  broadcast  innumerable  seeds  of  pestilence,  germs  which 
long  retain,  their  vitality.  Many  of  them  are  destined,  at  some  future  time,  to 
resume  activity  and  thus  bring  about  premature  deaths,  or  else  ruined  health 
and  untold  misery  to  thousands. 

The  earth  worm  in  some  cases  plays  an  important  role  in  bringing  up 
buried  infectious  material  by  its  ceaseless  activity  which  thus  endangers  the 
lives  of  the  individuals  in  that  vicinity. 

There  are  many  cases  and  scores  of  instances  in  countries,  villages  and 
cities  both  at  home  and  abroad  that  the  graveyards,  which  are  found  in  the 
midst  of  the  dense  population  and  dwellings,  are  so  packed  with  putrefied  bodies 
that  it  becomes  impossible  to  dig  a  grave  without  disturbing  human  remains. 
The  soil  being  so  saturated  with  foul  fluids,  and  the  emanations  so  noxious,  as  to 
make  the  churchyard  a  focus  of  disease. 

Graveyards,  v/herever  situated,  are  in  their  nature  transitory.  Even 
remote  cemeteries  far  out  in  the  country  succumb  to  the  march  of  improvement. 
Beautiful  as  they  sometimes  seem,  and  harmless  as  the  advocate  of  inhumation 
would  have  us  to  believe  them  to  be,  the  putrid  tenants  of  the  graves  contain 
the  germs  of  infectious  diseases. 

Plagues,  caused  by  excavation  of  the  ground  where  a  few  hundred  years 
previous  the  victims  of  pestilence  had  been  buried,  have  been  recorded.  It  has 
been  finally  resolved  from  investigations,  that  the  inhumation  of  human  or 
animal  bodies  dead  from  infectious  diseases  result  in  constantly  loading  the 
atmosphere  and  polluting  the  waters  with  not  only  the  germs  that  arise  from 
the  process  of  putrefaction,  but  with  the  specific  germs  of  the  diseases  from 
which  death  resulted.  The  air  becomes  vitiated  and  the  springs  and  wells  in 
the  vicinity  become  polluted. 

Another  charge  that  can  be  brought  against  cemeteries  is  that  enonnous 
sums  of  money  are  invested  annually  for  their  maintenance.  Sums  entirely 
disproportionate  to  the  sums  they  yield.  Every  year  many  acres  of  fertile 
land  are  devoted  to  the  burial  of  the  dead  that  might  otherwise  be  restored  to 
better  uses  than  the  mere  storing  of  decaying  bodies. 


/Vlatcria  Jledica  and  Therapeutics 


ANTIFERMENT  SERUM  IN  THE  TREAT-  cavity,    the   Suppuration    will    generally 

MENT  OF  SUPPURATION.  cease  within  twenty-four  hours,  and  in 

Dr.  A.  Fuchs  has  employed  leukofer-  from  one  to  two  days  healthy  granulation 

mantin  in  11  cases  of  his  gynecological  will  be  former] .     The  results  Avere  not  so 

practice,  with  the  best  results.     If  the  good    in    puerperal    mastitis,    since   the 

serum  is  brought  intimately  in  contact  abscesses   here    are    frequently    dissorai- 

with    the    interior   of    the    suppurating  nated  and  require  free  incision. 


506 


APPENDICITIS. 


ARTERIOSCLEROSIS,  GASTRIC  SYMPTOMS  OF. 


In  every  inflammation  leading  to  sup- 
puration^ the  polynuclear  leucocytes  play 
an  important  role,  in  that  they  furnish  a 
proteolytic  ferment  which  digests  the 
tissue  proteids.  In  normal  blood  serum 
there  is  found  an  antibody  against  the 
ferment,  which  is  able  to  paralyze  its 
action.  A  horse  serum  has  now  been 
placed  on  the  market  under  the  name  of 
leukofermantin,  which  contains  this  anti- 
body in  sufficient  amounts  for  therapeutic 
purposes.  It  will  inhibit  the  excessive 
breaking  down  of  the  tissue,  and  thus 
hasten  the  process  of  absorption  and 
healing.      (Zentralbl.    f.    Gynek.,    1909, 

No.  9.)  , 

APPENDICITIS,  TEEATMENT  OE. 

Dr.  Beverly  Eobinson  outlines  the  fol- 
lowing treatment  for  appendicitis:  1, 
Eest  in  bed;  2,  the  ice-bag  or  hot  water 
bag;  3,  laxative  enemas;  4,  codeine 
every  hour,  by  the  mouth,  in  small  doses; 
5,  in  rare  instances  only,  morphine  hyper- 
dermically,  and  this  only  for  excessive 
pain,  not  otherwise  relieved.  Whenever 
the  stomach  tolerates  it,  10  grains  of 
salicin  in  cachets  every  two  to  iowv  hours. 
This  gives  a  practical,  rational,  effective 
treatment  of  appendicitis.  During  the 
acute  stage  only  liquid  food  in  small 
quantities  should  be  pemiitted.  When- 
ever an  abscess  is  well  defined,  it  should 
be  opened  and  drained.  Prompt  opera- 
tion is  the  only  hope  when  perforation 
occurs.  "A  dose  of  castor  oil  and  blue 
mass,  taken  in  time,  for  adults  and 
children,  and  sweets  and  alcohol  cut  off 
for  a  while  from  daily  use,  would  save 
many  a  patient  from  operation  and  from 
abdominal  pain  and  distress.  (New  York 
Medical  Journal,  May,  1909.) 


AHTERIOSCIEROSIS,  TREATMENT  OE  THE 
GASTRIC  SYMPTOMS  OF. 
Dr.  H.  L.  Akin,  of  Omaha,  discusses 
the   frequency   of   gastric   symptoms   in 


cases  of  arteriosclerosis,  and  gives  the 
histories  of  some  personal  cases.  He 
emphasizes  particularly  the  importance 
of  examining  the  vascular  system  thor- 
oughly. The  diet  should  be  restricted  to 
plain,  nutritious  and  digestible  food,  the 
evening  meal  very  strictly  limited,  so  as 
to  leave  no  chance  for  gas  formation,  and 
careful  attention  paid  to  such  hygienic 
aids  as  are  suitable  to  the  case — bathing, 
fresh  air,  suitable  exercise,  attention  to 
the  bowels,  relief  from  work,  etc.  He 
states  that  the  vasodilators  are  the  fore- 
most drugs — diuretin,  a  saturated  solu- 
tion of  sodium,  nitrite,  and  nitroglycerin. 
Diuretin,  or  theobromine  sodium  salicy- 
late, is  the  most  effective  and  most  used, 
being  employed  in  doses  of  10  to  15 
grammes  three  times  a  day.  So  prompt 
and  satisfactory  is  its  action  in  cases  of 
this  kind  that  its  use  has  been  recom- 
mended as  a  means  of  diagnosis  in  doubt- 
ful cases.  Its  effect  depends  on  its  pow- 
erful action  in  overcoming  the  vessel 
spasm  and  dilating  the  arterioles  so  tiiat 
they  allow  a  greater  flow  of  blood  to  the 
sclerosed  areas. 

Of  diuretin  it  is  also  suggested  by 
Buch  that  it  may  neutralize  the  effect  of 
some  toxic  agent  which  tends  to  irritate 
the  vasomotor  centres  and  cause  contrac- 
tion. "Whatever  the  exact  mode  of  action, 
its  effects  are  very  satisfactory,  and  its 
use  may  be  continued  for  one  or  two 
weeks  or  even  longer  without  harm. 
Following  this  the  effect  may  be  con- 
tinued by  the  use  of  tincture  of  stro- 
phantlms,  5  to  8  drops  three  times  a  day, 
which  seems  to  have  a  similar  action  to 
the  diuretin,  so  much  so  that  it  is  used  in 
place  of  the  latter  in  some  cases  in  which 
expense  is  of  great  consideration. 

As  in  all  arteriosclerotic  conditions, 
the  iodides  have  an  important  place. 
Potassium  or  sodium  iodide  in  doses  of 
5  to  10  grains  may  be  continued  over  a 


DISLOCATION  OF  THE  SHOULDER. 


MENINGEAL  COMPLICATIONS.      507 


long  period,  but  it  is  asserted  that  the 
good  they  accomplish  is  not  due  so  much 
to  their  so-called  alterative  effects  as  it  is 
either  to  a  dilating  effect  on  the  vessels 
involved  or  to  a  lessening  of  the  blood 
densit3^  (Journal  of  American  Medical 
Association,  June  5,  1909.) 


DISLOCATION  OF  THE  SHOULDER, 
EEDUCING  A. 
Dr.  G.  Schichhold  relates  the  following 
simple  method  of  reducing  dislocation  of 
the  shoulder:  The  forearm  is  held  be- 
tween the  physician's  thighs  as  he  stands 
in  front  of  the  seated  patient.  The  arm 
is  held  firm  by  the  adductor  muscles  and 
strong  pressure  can  thus  be  brought  to 
bear  as  the  physician  pulls  back  while 
holding  the  shoulder  with  his  hands. 
The  downward  pressure  thus  exerted 
overcomes  the  action  of  the  antagonist 
muscles  and  stretches  the  capsule  and 
ligaments  until  reduction  is  easily  done. 
Dr.  Schichhold  has  applied  this  method 
in  many  cases  during  the  last  forty  years 
with  satisfactory  results.  The  chief  ad- 
vantage of  this  technique  is  that  he  can 
regulate,  hjjnself,  the  force  of  the  trac- 
tion exerted  to  the  exact  amount  required 
for  reduction,  as  he  grasps  the  neck  of 
the  humerus  with  one  hand  and  with  the 
other  presses  the  head  into  place,  both 
hands  being  free  for  the  manipulation  of 
the  joint.  The  only  assistance  required 
is  some  one  to  hold  the  patient  firm  in  the 
chair,  one  arm  around  the  neck  and  the 
other  in  the  axilla.  The  technic  allows 
rapid  reduction  of  even  old  dislocations 
without  anajsthesia,  assistance  or  ap- 
paratus. (Medizinische  klinik.,  "Berlin, 
April  11, 1909.) 


MEmNGEAL,  SINTJS  AND  LABYRINTHINE 
COMPLICATIONS,  TREATMENT  OF. 
Dr.  S.  MacCuen  Smith  states  that  the 
operative  procedure  consists  in  eliminat- 


ing the  focus  of  the  disease  by  removing 
all  the  necrotic  bone,  including  a  com- 
plete exenteration  of  the  mastoid  cells, 
thus  exposing  the  affected  dura.  When 
necessary,  the  membrane  should  be  in- 
cised to  provide  for  the  escape  of  any 
fluids,  just  as  is  done  in  the  serous  forms 
of  meningitis. 

The  author  believes  that  a  pyemic 
state  does  not  necessarily  mean  a  sinus 
thrombosis.  He  cites  two  cases  of  meta- 
static abscesses  of  the  liver  which  were 
traced  directly  to  a  suppurative  process 
in  the  organ  of  hearing  in  which,  on 
autopsy,  the  sinus  was  not  involved  in 
any  way.  The  consensus  of  opinion 
favors  ligation  of  the  internal  jugular 
vein  when  the  sinus  contains  pus,  a  dis- 
integrated clot  or  more  especially  when  a 
thrombus  is  felt  along  the  course  of  the 
vessel. 

The  mode  of  infection  in  labyrinthine 
suppuration  is  through  the  fenestra 
rotunda,  the  fenestra  ovalis,  the  promon- 
tory or  horizontal  semi-circular  canal. 
This  invasion  may  also  occur  by  way  of 
the  aqueductus  vestibuli,  the  aqueductus 
cochlea3  and  the  posterior  or  superior 
canal.  If  during  the  radical  mastoid 
operation,  necrosis  is  observed  to  involve, 
or  pus  is  escaping  from,  one  of  the  afore- 
mentioned localities,  the  surgeon,  espe- 
cially in  the  absence  of  definite  labyrin- 
thine s}Tiiptonis,  will  find  it  hard  to 
decide  whether  or  not  operative  inter- 
ference is  absolutely  indicated.  Most  of 
these  cases  spontaneously  recover  with 
the  good  drainage  provided  by  the  radical 
operation  and  the  removal  of  the  granula- 
tion tissue  from  tlie  infected  window, 
but  one  should  be  careful  not  to  disturb 
the  protective  adhesions  that  limit  the 
fooiis  of  the  disease  to  the  labyrintli.  If 
the  fistulous  opening  is  merely  enlarged, 
the  patient  will  generally  recover.  (The 
Therapeutic  Gazette,  March  15,  1909.) 


508 


MENINGITIS,  TREATItlENT  OF. 


MENINGITIS,  TREATMENT  OF,  BY 
UROTROPIN. 
Dr.  S.  J.  Crowe  reported  a  case  with 
cerebrospinal  fistula  in  which  a  fatal  out- 
come was  looked  for,  and  in  which,  at  Dr. 
Cushing's  suggestion,  urotropin  in  large 
doses  was  given,  in  the  hope  of  its  cere- 
brospinal excretion.     The  patient  recov- 
ered.    This  led  to  further  investigation 
by  the  writer  and  it  was  found  that  the 
drug  may  possibly  be  absorbed  as  readily 
by  the   rectum   as   when   given  by  the 
mouth.     It  has  been  the  custom  in  the 
Johns   Hopkins   Hospital  to   administer 
urotropin  promptly  to  all  patients  with 
lesions  which  are  not  infrequently  fol- 
lowed by  meningeal  infection;    and  the 
complete  absence  of  such  complication  in 
quite  an  extensive  series  of  cases  seems  to 
fairly  well  establish  the  prophylactic  im- 
portance of  the  drug.     This  series   in- 
cluded a  number  of  compound  fractures 
of  the  skull,  gunshot  wounds  of  the  head, 
and  cerebrospinal   fistulas,  the  patients 
receiving  30  to  60  grains  urotropin  daily. 
It  is  also  used  prior  to  ventricular  or 
lumbar  puncture,  when  local  conditions 
make  possible  the  inoculation  of  the  men- 
inges with  organisms  from  the  affected 
skin ;  and,  too,  urotropin  should  be  given 
before  a  first  catheterization  or  one  done 
when  urethral  infection  is  present.     Pos- 
sibly, too,  the  drug  may  be  wisely  used  in 
cases  of  extracranial  infection  when  ex- 
tension to  the  meninges  is  feared,  as  in 
infected  scalp  wounds,  otitis  media,  sup- 
puration of  the  cranial  sinuses.     Its  use 
may  be  desirable  also  in  elaborate  spinal 
or  cerebral  operations.     The  author  sum- 
marizes:— 

1.  Urotropin,  given  by  mouth,  invari- 
ably appears  in  the  cerebrospinal  fluid. 
This  fact  has  been  demonstrated  by  a 
large  number  of  observations  on  man, 
and  is  also  true  of  dogs  and  rabbits. 

2.  The  largest  amount  of  urotropin  is 


PHLEGMONS  OF  THE  HAND. 

present  in  the  cerebrospinal  fluid  from 
thirty  to  sixty  minutes  after  ingestion  of 
the  drug. 

3.  After  therapeutic  doses  a  sufficient 
amount  of  urotropin  appears  in  the  cere- 
brospinal fluid  to  exercise  a  decided 
inhibitory  effect  on  the  growth  of  organ- 
isms inoculated  into  this  fluid  after 
removal  from  the  body. 

4.  Following  a  subdural  inoculation  of 
dogs  and  rabbits  with  streptococci,  60  to 
80  grains  of  urotropin  a  day,  given  under 
conditions  which  insure  absorption,  will 
markedly  defer,  and  in  some  cases  pre- 
vent, the  onset  of  a  fatal  meningitis. 

5.  The  prompt  administration  of  uro- 
tropin is  advised  in  all  clinical  cases  in 
which  meningitis  is  a  possible  complica- 
tion, or  even  when  meningeal  infection 
has  actually  accurred.  (Jolms  Hopkins 
Hospital  Bulletin,  April,  1909.) 


PHLEGMONS  OF  THE  HAND  WITH  EOT 
AIK  BATHS,  TREATMENT  OF. 

Dr.  H.  Iselin  outlines  a  very  successful 
treatment  of  such  an  affection.  Small 
incisions  are  made  on  the  palmar  and 
lateral  surfaces  to  evaciuite  pus,  without 
injuring  tendons  or  nerves;  cavities  are 
irrigated  with  salt  solution,  and  very 
lightly  packed  with  iodoform  gauze;  on 
the  very  day  of  operation  the  hot  air 
treatment  is  instituted,  at  first  daily  for 
two  hours,  later  only  once  each  day. 
The  dressings  are  renewed  and  the  af- 
fected member  placed  in  the  dry  hot  air 
bath  at  a  temperature  of  from  90  degrees 
to  110  degrees  C.  Care  should  be  taken 
to  keep  the  skin  in  good  condition. 

By  means  of  this  treatment  the  pain 
is  much  reduced  and  healing  accelerated. 
The  necrosis  of  tendon  sheaths  is  almost 
eliminated,  occurring  only  once  in  a 
woman  with  streptococcus  infection,  in 
whom  a  single  tendon  was  lost.  The  re- 
sults have  far  surpassed  those  obtained 


PLACENTA  PREVIA,  TREATMENT  OF. 


SUBACUTE  ALCOHOLISM.   509 


by  means  of  Bier's  passive  hyperjeinia 
and  hospital  supervision  is  not  essential. 
(Miienchener  Medizinische  Woch,  April 
20, 1909.) 


PLACENTA  PRa:VIA,  TREATMENT  OF. 
Dr.  B.  Krouig  summarizes  the  details 
of  twenty  cases  of  placenta  prsevia  at  the 
Freiburg  clinic  in  which  the  women  were 
under  the  most  favorable  conditions  in 
regard  to  the  medical  supervision  in  a 
clinic,  asepsis,  etc.,  from  the  start.  In 
every  instance  during  delivery  haemor- 
rhage was  arrested  by  version.  He  states 
that  control  of  hasmorrhage  hj  the  metre- 
urynter cannot  be  relied  upon  owing  to 
the  fact  that  hasmorrhage  is  from  the 
isthmus  as  a  rule  and  the  metreurynter 
stretches  the  isthmus  still  farther.  Four 
of  the  twenty  patients  bled  to  death  and 
another  succumbed  to  sepsis,  and  yet  the 
conditions  were  exceptionally  favorable 
for  all.  Those  who  survived  suffered  long 
from  severe  anemia.  The  more  advanced 
the  pregnancy  the  greater  the  tendency  to 
haemorrhage.  The  conclusions  from  this 
series  of  cases  are  that  the  results  of 
treatment  of  placenta  prasvia  are  so  dis- 
appointing by  the  present  methods  that 
it  is  incumbent  on  us  to  seek  for  im- 
proved methods  of  treatment.  He  has 
been  looking  over  the  records  of  34  cases 
of  placenta  prasvia  received  at  the  clinic 
since  1904,  in  which  the  date  of  the  first 
haemorrhage  is  mentioned;  in  every  in- 
stance a  warning  hsmorrhage  had  oc- 
curred during  the  last  few  days  or  weeks 
before  the  child-birth.  The  physician 
summoned  merely  ordered  the  patients  to 
bed  and  the  hjEmorrhage  stopped  with  the 
bed  rest.  These  warning  hemorrhages 
recurred  three  or  more  times  before  labor 
came  on,  and  the  physician  would  have 
had  ample  time  to  send  the  patient  to  the 
clinic  if  the  warning  of  these  premonitory 
haemorrhages  had  been  heeded.     The  ob- 


stetrician is  able  to  save  the  mother  with 
contracted  pelvis  by  perforation  during 
delivery  in  the  home,  but  with  placenta 
pra3via  both  mother  and  child  succumb  in 
15  to  20  per  cent,  of  the  deliveries  in 
private  houses.  Even  in  the  clinics  the 
mortality  is  still  from  5  to  8  per  cent,  at 
the  best.  (Zentralblatt  fiir  Gyniikologie, 
Leipsic,  April  3,  1909.) 


SUBACUTE  ALCOHOLISM,  TREATMENT  OF. 
Dr.  Eobin  reports  the  treatment  of  a 
case  of  alcoholism  in  a  patient  with  good 
results.  The  patient  was  a  man  aged 
42  years,  house  painter,  who  entered  the 
hospital  with  slight  attacks  of  lead  colic, 
which  gradually  disappeared  and  with 
subacute  alcoholic  poisoning,  with  tre- 
mors, excitement  and  hallucinations.  The 
best  remedy  in  such  cases,  according  to 
the  author  is  paraldehyde.  This  may  be 
taken  in  solution,  4  grains  in  GO  cubic 
centimeters  of  water.  Of  this,  one-fourth 
should  be  taken  in  a  little  water  at  inter- 
vals of  half  an  hour.  This  treatment 
should  be  renewed  a  few  days  later.  At 
the  hospital  the  following  potion  is  em- 
ployed : — 

I^   Potassium  bromide,  G  Gm. 

Morphine  hydrochlorate,  0.05  Gm. 
Cherry  laurel  water,  10  Gm. 
Syrup  of  ether,  30  Gm. 
Hydrolate  of  valerian,  110  Gm. 

Five  tablespoonfuls  in  twenty-four 
hours.  Under  this  treatment  the  excite- 
ment rapidly  disappears.  Injection  of 
two-tenths  of  a  milligram  of  scopolamine 
hydrobromide  are  exceedingly  useful  for 
tlie  tremors.  Six  of  these  injections  were 
within  eight  days  and  the  tremor  disap- 
peared. Alcoholics  bear  these  injections 
well.  Other  patients  should  not  get  more 
than  one-tenth  milligram  at  first  and  the 
dose  may  be  increased  gradually  to  eight- 
tenths  of  a  milligram,  but  never  above  one 


510      TRAUMATIC  INJURIES  OF  THE  EXTREMITIES. 


VARICOSE  VEINS. 


milligram.  The  remedy  is  very  toxic  and 
rapidly  produces  vertigo,  somnolence  and 
clouding  of  the  intellect,  which  indicate 
that  the  limit  of  tolerance  has  been 
reached.     (Quinzaine  Thera.,  April  10, 

1909.)  

TRAUMATIC  INJURIES  OF  THE  EXTREMI- 
TIES; THEIR  TREATMENT. 
Dr.  Walter  T.  Dannreuther,  of  Xew 
York,  advocates  conservatism  whenever 
at  all  possible  in  the  treatment  of  trauma- 
tisms of  the  extremities,  even  when  we 
have  compound  and  comminuted  frac- 
tures which  are  soiled  as  well.  He  gives 
three  illustrative  cases  in  which  the  part 
was  saved  to  the  patient  by  the  use  of 
conservatism.  The  essential  prerequis- 
ites are  a  good  constitution,  age  under 
sixty,  the  integrity  of  at  least  one-third 
of  the  circmnference  of  the  limb,  ad- 
equate blood-supply  to  the  injured  area, 
and  a  good  nurse.  Perfect  asepsis  and 
antisepsis,  immediate  restoration  of  the 
parts  to  their  normal  position  relations  as 
far  as  possible,  free  drainage,  and  con- 
stant wet  dressings  are  the  methods  used 
to  obtain  cure.  Glycerin  is  of  value  to 
keep  the  dressings  wet  and  promote 
drainage  and  hasten  sloughing.  (Med. 
Eecord,  May  1,  1909.) 


VARICOSE   VEINS    OF   THE   LEG,    TREAT- 
MENT OF. 
Dr.  J.  E.  Jennings  describes  a  very 
practical  and  advantageous  method  of  re- 
moving the  entire  vein.     IJis  method  is 


as  follows:  The  foot  is  placed  on  a 
sand-bag  with  the  heel  elevated  about 
eight  inches.  A  sterilized  Esmarch  band- 
age is  lightly  tied  as  high  up  on  the 
tliigh  as  possible.  The  internal  saphe- 
nous is  found  as  low  down  as  possible, 
preferably  where  it  crosses  in  front  of  the 
internal  malleolus  and  cut  down  upon 
through  a  small  longitudinal  incision. 
Through  this  the  vein  is  lifted  up, 
clamped  and  cut,  and  into  the  lumen  of 
the  proximal  end  of  the  vein  a  twister  is 
inserted  and  passed  up  inside  the  vein 
as  far  as  it  will  go.  This  will  be  some- 
what below  the  knee,  where  it  is  felt 
through  the  skin  and  cut  down  upon.  A 
clamp  is  put  on  the  vein  above  the  end 
of  the  tractor  and  the  vein  cut,  a  ligature 
just  below  this  is  passed  through  the 
walls  of  the  vein  and  the  hole  in  the  end 
of  the  tractor  and  tied  around  the  vein 
and  instrument.  Then  the  end  of  the 
vein  is  twisted  and  pulled  back,  so  as  to 
inraginate  into  its  own  lumen  through 
which  by  torsion  and  traction  it  is  re- 
moved. The  process  is  then  repeated 
above,  passing  the  tractor  from  below 
upward,  as  it  does  not  then  engage  in 
branch  veins.  The  twisting  of  the  vein 
in  its  removal  is  a  great  help  in  some 
cases,  and  tlic  case  with  which  veins  are 
removed  will  vary.  The  ha}morrhage  is 
not  marked,  especially  when  the  vein  is 
twisted  out,  and  is  easily  controlled  if 
present  by  a  light  roller  from  the  toes  up. 
(Long  Isl.  Med.  Jour.,  Feb.,  1909.) 


5ool<  Reviews 


The  Emmanuel  MovEirsNT  in  a  New  I-Znoland  Town.  A  Systemic  Account  of  Experiments 
and  Reflections  Desifmed  to  Determine  the  Proper  Relationship  between  the  Mmister  and 
the  Doctor  in  the  Liglit  of  Modern  Needs.  By  Lyman  P.  Powell,  Rector  of  St.  Johns 
Church,  Northampton,  Mass.,  Author  of  "Christian  Science:  The  Faith  and  Its  founder,^^ 
and  "The  Art  of  Natural  Sleep";  and  Editor  of  "Historic  Towns  of  the  United  States. 
Illustrated.  New  York  and  London:  G.  P.  Putnam's  Sona;  The  Knickerbocker  Press, 
1909. 


BOOK  REVIEWS.  511 

In  this  volume  are  brought  together  all  the  author's  experiences  and  accomplishments  in 
healing  the  sick  by  means  of  the  Emmanuel  methods.  Tlie  cases  which  he  has  treated  were  a 
wide  range  of  the  so-called  nervous  disorders,  and  also  alcoholics. 

The  book  appeals  to  those  interested  in  this  movement  to  spread  and  also  put  the  methods 
in  practice.  It  gives  one  a  good  idea  of  the  aim  of  the  Emmanuel  movement,  and  the  good 
that  can  be  brought  about  by  the  adoption  of  its  principles. 

The  book  is  bound  nicely,  type  is  large,  and  is  well  worth  reading. 

New  atstd  Non-Official  Remedies,  1909.  Containing  Descriptions  of  the  Articles  which  have 
been  Accepted  by  the  Council  on  Pharmacy  and  Chemistry  of  the  American  Medical  Asso- 
ciation, Prior  to  January  1,  1909.  Chicago:  Press  of  the  American  Medical  Association, 
103  Dearborn  Avenue,  1909. 

This  small  book,  which  we  commend,  will  prove  valuable  to  the  physician  by  keeping  him 
in  touch  with  the  latest  materia  medica.  The  medicinal  substances  contained  therein  have 
been  examined  and  accepted  by  the  Council  of  Pharmacy  and  Chemistry  of  the  American 
Medical  Association. 

A  description,  dose,  action,  and  uses  of  each  drug  is  given.  The  book  will  undoubtedly 
prove  its  merits. 

Aknttal  REroRT  OF  THE  Pennsti.vania  State  COLLEGE  FOR  THE  Yeae  1907-1908.  From  July 
1,  1907,  to  June  30,  190S.  Part  I.  Departments  of  Instruction.  Part  II,  Agricultural 
Experiment  Station.     Harrisburg,  Pa.:    Harrisburg  Publishing  Co.,  State  Printer,  1908. 

This  report  gives  all  the  information  concerning  the  condition  of  State  College.  Through- 
out this  volume  are  the  departmental  reports,  outlining  the  achievements,  hopes  and  needs 
of  the  respective  departments.  These  reports  contain  matters  of  great  interest  to  the  people 
of  the  Commonwealth,  and  give  one  a  thorough  understanding  of  the  courses  and  work  accom- 
plished by  this  institution.     It  is  well  worth  a  perusal. 

Vaccine  and  Serum  Therapy.  Including  also  a  Study  of  Infections,  Theories  of  Immunity, 
Opsonins  and  the  Opsonic  Index.  By  Edwin  Henry  Schorer,  B.S.,  M.D..  Assistant  Pro- 
fessor of  Parasitology  and  Hygiene,  University  of  Missouri ;  formerly  Assistant  Rocke- 
feller Institute  for  iledical  Research,  New  York  City.  Illustrated.  St.  Louis:  C.  V. 
Mosby  Co.,  1909. 

This  small  volume  of  131  pages  is  excellently  arranged,  and  is  divided  into  eight  chapters: 
I.  Infections;  II,  Immunity;  III,  Opsonic  Index;  IV,  Criticisms  and  Modifications  of 
Wright's  Opsonic  Index  Determinations;  V,  Opsonic  Index  in  Health  and  Disease;  VI, 
Nature  of  Opsonins;    VII,  Vaccine  Therapy;    VIII,  Servmi  Therapy. 

As  the  preface  states,  "In  this  work  an  attempt  has  been  made  to  state  concisely  and 
accurately  the  present  knowledge  concerning  vaccines  and  immune  sera.  An  efTort  has  been 
made  to  establish  theoretical  and  experimental  evidence  as  well  as  clinical  application  to  the 
specific  treatment  of  bacterial  diseases."  The  author  has  well  succeeded.  Vaccine  and  serum 
therapy  is  a  subject  of  growing  importance  to  the  phj^sician,  and  the  literature  bearing  on 
it  is  none  too  great,  especially  in  quality.  The  subjects  covered  are  based  Tipon  the  latest 
investigations,  and  in  order  to  make  the  book  of  especial  value  the  author  has  devoted  con- 
siderable space  to  opsonins,  the  opsonic  index,  and  the  importance  of  opsonins  in  health  and 
disease.  He  also  describes  concisely  the  course  of  infection,  the  theories  of  immunity  and 
the  various  sera.  In  order  that  the  text  be  eminently  practical,  the  writer  has  described  the 
mechanical  technique.  The  entire  book  is  written  in  such  a  style  as  to  make  it  engaging 
reading,  while  it  also  imparts  instruction  in  every  line.  Ail  the  chapters  are  good,  and  noth- 
ing of  importance  seems  to  have  been  left  unsaid. 

Physiological  and  Medical  Observations  Among  the  Indians  of  Southwestern  United 
States  and  Northern  Mexico.  Bj  Ales  Hrdlicka.  Washington:  Government  Printing 
Office,  1908. 

This  volume  is  the  thirty-fourth  bulletin  of  the  Bureau  of  American  Ethnology,  and 
contains  considerable  data  concerning  the  physiological  nature,  medical  questions  and  notes 
on  conditions  which  determine  the  welfare  of  the  Indians.  The  work  is  arranged  by  subjects 
and  not  by  tribes.  All  the  information  contained  in  this  bulletin  is  the  result  of  personal 
observation  and  extended  researches  in  the  region  between  latitude  38°  and  18°  west  of  the 
Rio  Orande  and  the  Mexican  Central  Railway,  and  east  of  the  Rio  Colorado  and  the  Gulf  of 
California. 

Besides  the  numerous  illustrations,  there  is  an  appendix  which  contains:  A,  Native 
Foods;    B,  Tables  of  Detail  Measurements  and  Observations;    C,  Bibliography. 


512  BOOK  REVIEWS. 

The  text  is  well-arranged,  well-written,  facts  clearly  stated  and  interesting,  and  meets 
the  requirements  for  which  it  is  placed  before  the  profession. 

Tuberculosis  a  Preventable  and  Curable  Disease.  Alodern  Methods  for  the  Solution  of 
the  Tuberculosis  Problem.  By  S.  Adolphus  Knopf,  M.D.,  Professor  of  Phthisio-therapy 
at  the  New  York  Post-Graduate  Medical  School  and  Hospital;  Associate  Dii'ector  of  the 
Clinic  for  Pulmonary  Diseases  of  the  Health  Department;  Attending  Physician  to  the 
Eiverside  Sanatorium  for  Consumptives  of  the  City  of  New  York,  etc.  New  York: 
Moffat,  Yard  &  Company,  1909. 

This  work  is  intended  to  afTord  a  more  intimate  knowledge  and  comprehension  of  this 
dreadful  disease,  tuberculosis.  It  is  not  only  a  book  for  the  physician  and  sanitarian,  but 
also  for  the  consumptive  himself  and  those  living  with  him;  a  book  for  the  statesman,  legis- 
lator, educators  and  teachers.  It  discusses  the  most  simple  and  practicable  means  of  pre- 
venting the  spread  of  the  disease,  the  various  methods  of  combating  it  when  it  is  present,  etc. 

The  book  contains  twelve  chapters:  I,  What  a  Tuberculosis  Patient  Should  Know  Con- 
cerning His  Disease;  II,  What  Those  Living  with  Patients  Should  Know  Concerning  the 
Disease;  III,  The  Duties  of  the  Physician  Towards  His  Patient,  Towards  the  Family  of  the 
Patient  and  the  Community  He  Lives  in;  IV,  How  the  Sanatorium  Treatment  May,  if 
Necessary,  be  Adapted  to  and  Imitated  in  the  Home  of  the  Consumptive,  Well-to-do  or 
Poor;  V,  What  Hygienists  and  Sanitarians  May  do  Towards  the  Prevention  of  Tuberculosis; 
VI,  Tlie  Duty  of  the  Modern  Municipal — City  or  To^^■n — Health  Avithorities;  VII,  The  Duties 
of  the  City  Fathers,  Legislators  and  Statesmen  in  the  Combat  of  Tuberculosis;  VIII,  Wliat 
Employers,  Factory  Owners,  Storekeepers  and  People  Having  Servants  can  do  to  Diminish 
Tuberculosis  Among  the  Men  and  Women  Working  for  Them;  IX,  The  Duties  of  Educators, 
Professors  of  Colleges  and  Teachers  in  Public  and  Private  Schools  in  the  Combat  of  Tuber- 
culosis; X,  The  Duties  of  Philanthropists,  Charitable  Individuals  and  Charity  Organizations; 
XI,  The  Duty  of  the  People  at  Large  in  the  Combat  of  Tuberculosis  as  a  Disease  of  the 
Masses;    XII,  Prospect  of  the  Ultimate  Eradication  of  Tuberculosis. 

The  author  is  so  clear  and  explicit  in  his  details  that  any  one  should  be  able  to  employ 
the  methods  outlined  by  him.  The  book  cannot  fail  to  prove  of  great  interest  and  benefit,  as 
the  author  is  well-known  as  an  authority  on  this  subject.  He  has  devised  a  window  tent 
which  is  within  reach  of  the  poor  consumptive  who  cannot  afford  the  more  elaborate  ones. 
The  ground  is  covered  well  and  the  work  deserves  to  be  read. 

Hand-Book  of  Diseases  of  the  Rectum.  By  Louis  J.  Hirschman,  M.D..  Detroit,  Mich., 
LT.  S.  A.,  Fellow  American  Proctologic  Society;  Lecturer  on  Rectal  Surgery  and  Clinical 
Professor  of  Proctology,  Detroit  College  of  Medicine;  Attending  Proctologist,  Harper 
Hospital;  Consulting  Gynecologist,  Detroit  German  Polyclinic;  Collaborator  on  Proc- 
tology, "Physician  and  Surgeon";  Editor  "Harper  Hospital  Bulletin";  Chairman  Sec- 
tion on  Surgery,  Michigan  State  Medical  Society;  ex-President  Alumni  Association, 
Detroit  College  of  Medicine,  etc.,  etc.  With  One  Himdred  and  Forty-seven  Illustrations, 
mostly  Original,  Including  Two-colored  Plates.  St.  Louis:  C.  V.  Mosby  Medical  Book 
&  Publishing  Co.,  1909. 

This  book  has  been  written  with  the  main  end  in  view  of  giving  those  assistance  in  the 
field  of  proctology  or  ano-roctal  diseases  wlio  have  had  deficient  training  in  this  field  during 
their  early  college  career,  and  it  will  therefore  be  of  invaluable  service  to  those  who  wish  to 
pursue  this  line  of  work.  The  subject  has  been  treated  from  the  standpoint  of  a  specialist, 
and  every  topic  is  concise,  outlining  and  emphasizing  the  importance  of  early  examination. 

The  book  is  composed  of  374  pages,  and  is  divided  into  seventeen  chapters:  I,  Anatomy; 
II,  Symptoms  which  Should  Call  Attention  to  the  Rectum;  III,  Examination  of  the  Patient; 
IV,  Constipation  and  Obstipation;  V,  Faecal  Impaction;  VI,  Pruritus  Ani;  VII,  Anal 
Fissure  and  Ulcer;  VIII,  Abscess  of  the  Ano-Rectal  Region;  IX,  Fistula  in  Ano;  X, 
Haemorrhoids;  XI,  Rectal  Polypi,  Hypertrophied  Anal  Papillae,  Cryptitis;  XII,  Proctitis 
and  Sigmoiditis;  XTII,  Dysentery;  XIV,  Prolapse  of  the  Rectum  in  Children;  XV,  The 
Technique  of  the  LTse  of  Local  Anaesthesia  in  the  Treatment  of  Ano-Rectal  Diseases;  XVI, 
The  Limitations  of  Office  Treatment  and  Indications  for  Other  Measures;  XVII,  The  Faeces 
and  Their  Examination. 

In  no  other  work  can  there  be  found  such  a  store  of  practical  knowledge.  The  treat- 
ment is  particularly  full,  and  it  deals  with  conditions  not  only  amenable  to  non-operative 
treatment,  but  also  those  demanding  operative  procedures.  The  work  is  authoritative,  and 
is  arranged  systematically,  thus  covering  the  whole  field  of  proctology  with  accuracy  and 
clearness. 


ONTHLY      CYCLOPiEDI 

AND 

EDicAL   Bulletin 


Published  the  Last  of  Each  Month 


Monthly  Cyclopedia  Section 


Vol.  II.  PHILADELPHIA,  SEPTEMBER,  1909.  No.  9. 


Original  Articles 


Department  in  charge  oj  J.  MADISON  TAYLOR,  A.M.,  M.D. 


THE  MILK  QUESTION  FROM  THE  STANDPOINT  OF  THE  PEDIATRICIAN. 

Br  JAMES  H.  McKEE,  M.D., 

Professor  of  Pediatrics  in  the  Philadelphia  Polyclinic;    Clinical  Professor  of  Pediatrics 

in  the  Medical  Department  of  the  Temple  University;    Visiting  Pediatrician 

to  the  Philadelphia  General  Hospital. 

PHILADELPHIA. 

Viewed  from  any  standpoint,  the  milk  question  is  an  enormous  and 
important  one;  but  from  the  viewpoint  of  the  pediatrician  it  is  fundamental 
and  well-nigh  dominant.  It  is  impossible  to  survey  the  whole  ground  in  a 
discussion  like  the  present,  so  only  a  few  promontories  in  the  landscape 
will  be  pointed  out,  and  even  these  accorded  somewhat  terse  descriptions. 
For  the  nonce,  the  writer  must  act  as  a  somewhat  "bromidic"  guide  who  has 
endeavored  to  con  well  his  pediatric  Baedecker. 

1.  "Lording  it  over  his  fellows,"  as  Washington  Irving  would  have  said, 
stands  one  great  truth — one  at  which  no  student  of  biology  is  surprised. 
Figuratively  we  may  style  it  Mount  Species.  Succinctly  stated,  the  truth  is 
that  the  milk  of  every  species  is  the  proper  food  for  the  young  of  that 
species.  It  is  chemically  and  biologically  superior  to  any  other  food  that 
can  be  administered  to  the  infant  progeny  of  a  given  animal.  Many  times 
these  words  are  spoken,  more  or  less  glibly,  but  as  yet  their  full  significance 
has  not  been  realized  by  civilized  peoples. 

Aside  from  the  congenitally  deformed,  the  congenitally  diseased,  the 

babies  injured  at  birth  and  the  babies  infected  at  birth  or  soon  after  it, 

very  few  breast-fed  infants  die.     That,  on  the  other  hand,  the  death  rate 

among  the  artificial-fed  is  enormous,  need  scarcely  be  stated  to  this  audi- 

3  (513 


514      illLK   QUESTION    FKOM   THE   STANDPOINT    OF   THE    PEDIATRICIAN. 

ence.     Gastro-enteric   diseases   loom   above   all   others    as   causes   of   death 
during  the  first  and  second  years  of  life. 

Of  Chapiu's  teaching  concerning  this  specificity,  .some  doggerel  has 
been  perpetrated: — 

"Says  he  if  babes  would  surely  be 
The  finest  of  their  ilk, 
The  proper  food  to  feed,  per  se, 
Is  good  old  mother's  milk. 

Nor  think  he  wanders  far  afield. 

Like  unto  famed  Ulysses; 
His   reasoning   no    palm    shall    yield, 

His  argument  is  species.'' 

Civilized  man  has  readjusted  himself  to  many  changed  conditions  of 
life;  indeed,  he  has  profited  by  not  a  few  of  them.  If  the  great  truth 
stated  above  is  once  fully  appreciated,  this  problem  of  maternal  feeding 
will  be  answered  also.  Good  mothers  have  many  splendid  attributes.  Some 
of  them  are  really  equipped  for  the  "profession  of  maternity.''  But  the 
truly  good  mother  of  the  young  infant  should  possess  one  essential  attribute 
— the  a])ility  to  nurse  her  baby. 

2.  But  let  us  descend,  as  it  were,  from  the  heights  of  ideal  nutrition 
to  the  broken  and  dangerous  ground  of  artificial  feeding.  Here,  despite 
many  a  rough  boulder  and  deadly  morass,  there  are  still  some  well-beaten 
and  fairly  safe  paths.  Two  of  them,  carefully  traversed,  will  usually  convey 
the  infant  through  the  most  dangerous  journey  of  his  life.  Their  sign- 
boards read:     1.  Cleanliness — i.e.,  original  integrity.    2.  Proper  modification. 

Xature  clearly  indicates  that  the  food  of  the  young  animal  should  be 
practically  free  from  bacteria.  As  it  is  found  in  the  milk  ducts  it  is  clean. 
And  yet,  as  you  all  know  too  well,  milk  is  a  splendid  culture  medium  for 
micro-organisraal  life.  Had  we  not  learned  this  fact  from  the  bacteriologist 
directly,  had  we  not  acquired  it  practically  through  many  a  sad  experience, 
we  might  have  expected  to  find  it  so  from  the  rather  close  relationship  of 
its  chem.ical  constituents  to  those  of  the  blood  and  lymph.  Theoretically, 
it  would  certainly  seem  best  that  the  milk  of  another  species,  if  fed  to  the 
human  infant,  should  not  be  exposed  to  such  contamination.  And  practi- 
cally, in  the  island  of  Cuba,  suckling  the  infant  directly  from  the  goat  is 
reputed  to  yield  excellent  results.  The  writer  has  talked  with  two  American 
fathers  who  have  pursued  this  direct  method,  and  both  have  been  enthu- 
siastic in  its  praise.  For  some  time  it  has  been  the  writer's  intention  to 
carry  out  some  experiments  of  this  nature. 

3.  But  for  practical  purposes,  as  we  all  know,  there  is  but  one  animal 
that  can  supply  the  enormous  demand  for  food  of  those  cheated  of  their 
birthright. 

"But  breasts  go  dry,  alack!    alack! 

We  know  not  always  how. 
Then  pediatric  thoughts  hark  back 
To  the  UEemotionnl  cow." 


MILK   QUESTION   FROAi  THE   STAI^DPOINT   OF   THE   PEDIATRICIAN.      515 

Let  us  pause  right  here  and  look  squarely  at  two  incontestable,  though 
possibly  antipodal,  facts:  1.  Ordinarily  market  milk  is  a  filthy  product,  con- 
cerning which  the  public  mind  should  be  illumined.  As  has  been  graphically 
stated,  its  bacteriologie  count  may  be  higher  than  the  bacteriologic  count  of 
sewage.  2.  Milk  has  been  sent  from  New  Jersey  to  Paiis,  from  Wisconsin  to 
Paris,  and  from  both  starting  pomts  to  Paris  and  back  without  becoming 
sour  in  the  journeys  (Chapin).  Indeed,  we  read  that  these  milks  upon 
their  arrivals  in  the  French  capital  were  cleaner  than  the  milks  then  being 
vended  in  that  city,  and  yet  the  only  methods  pursued  in  the  securance  of 
these  splendid  products  were  those  of  scrupulous  cleanliness. 

Such  milks  as  the  latter,  from  the  pediatrician's  standpoint,  approach 
the  ideal  foods  for  the  hand-fed  baby.  His  is  the  responsibility,  mark  you, 
for  the  lives  and  health  of  the  helpless  ones  entrusted  to  his  care.  I  need 
not  trespass  upon  your  time  to  explain  what  certified  milks  and  certification 
mean,  but  milk  produced  as  these  milks  are  produced  is  what  the  pediatrician 
wants.  When  the  public  once  appreciates  the  differences  between  clean,  fresh 
milk  and  ordinary  market  milk,  the  former  is  the  kind  that  will  be  demanded 
for  baby  feeding.  It  is  a  glowing  tribute  to  many  a  poor  mother,  when  such 
differences  are  explained,  to  hear  her  ask:  "Where  can  I  get  the  milk?'* 
What  witless  parsimony  to  quibble  about  56  cents  more  per  week  for  the 
superior  article!  Occasionally  the  quibbler  is  found  smoking  a  2o-cent 
cigar,  and  he  may  be  still  dopy  and  irritable  as  a  result  of  the  expensive 
supper  that  has  been  tendered  some  business  friend  the  night  before.  "Six- 
teen cents  a  quart  for  milk,  forsooth  1" 

4.  Pasteurization  is  sometimes  necessary  during  the  warmer  days  of 
the  year.  Like  peptonization,  however,,  it  had  best  be  regarded  as  a  tem- 
porary expedient.  We  believe  that  it  is  most  effective  when  applied  at  home, 
the  milk  being  pasteurized  in  the  bottles  that  are  used  for  feeding  the  baby. 
That  it  is  more  dangerous  to  handle  milk  subsequent  to  this  process  than 
it  is  to  handle  milk  not  so  treated,  has  been  well  proved  by  Evans  and  Cope. 
The  well-known  Freeman  apparatus  serves  us  well  for  home  use.  The 
writer  does  not  wish  to  criticize  some  noble  charities,  for  in  properly  equipped 
plants  the  milk  may  be  pasteurized  in  the  same  vessels  in  which  it  is  to  be 
dispensed.  Such  a  milk  is  much  better  for  dispensing  among  the  needy 
than  the  article  that  they  would  probably  secure  from  the  corner  store.  Of 
commercial  pasteurization  as  commonly  employed,  however,  the  designation, 
commercial  fraud,  is  neither  harsh  nor  unjust.  When  we  call  the  attention 
of  the  producer  or  his  agent  to  the  fact  that  Pasteur's  principles  arc  not 
followed  in  this  process,  we  are  either  informed  that  we  are  talking  about 
the  old  way,  or  else  we  are  assured  that  this  is  not  pasteurization — that  it 
is  the  "shocking  process."  I  am  grateful  for  that  term;  it  is  truly  a  shock- 
ing process,  for  the  lay  purchaser  rests  under  the  delupion  that  he  is  receiving 
a  pasteurized  milk.  Is  he  not  told  so?  Again,  the  milk  is  robbed  of  that 
most  important  evidence  of  its  age — souring.  And  still,  again,  in  some 
recent  experiments  at  the  Kockefeller  Institute,  animals  were  inoculated  with 
tuberculosis  from  two  specimens  of  th'Ia  so-called  p.'vsteurized  milk. 


516        illLK   QUESTION   FROM   THE   STANDPOINT   OF   THE   PEDIATRICIAN. 

Whether  or  not  the  commercial  processes  that  respect  the  teachings 
of  Pasteur  and  Freeman  and  Eosenau  shall  stand  the  tests  of  time  and 
experience,  remains  to  be  determined;  but  until  such  determinations  shall 
have  been  made  a  personal  preference  must  be  expressed  for  fresh,  clean 
milk. 

5.  With  respect  to  these  high  grade,  clean  milks  of  fairly  definite  com- 
position, the  physician  has  two  very  great  responsibilities.  Unless  he  assumes 
them,  justice  is  not  done  to  the  producer  nor  the  consumer.  He  must  teach 
his  patients  that  the  increased  cost  of  the  good  milli  really  represents  good 
economy.  This  despite  the  fact  that  some  driver  or  other  agent  is  paid  a 
bonus  for  securing  customers  with  the  lure  that  his  "cheaper  milk  is  just 
as  good."  lie  must  also  teach  his  patients  that  these  milks  are  readily 
contaminated;  that  they  should  be  accorded  little  handling  and  exposure, 
and  that  they  should  be  kept  on  ice. 

6.  But  to  enable  the  baby  to  traverse  this  country  successfully  it  is 
also  necessary,  at  least  in  most  instances,  to  follow  the  second  route  indi- 
cated— that  of  modification.  Methods  multiply  and  fashions  change,  but 
the  writer  still  believes  that  the  idea  born  of  Arthur  Y.  Meigs,  of  this  city, 
and  the  method  expounded  by  Eotch,  of  Boston,  have  stood  the  test  of  time. 
He  proclaims  himself  an  advocate  of  the  percentage  method  of  feeding. 
He  does  not  prescribe  milk  formula  without  thinking  in  the  terms  of  pro- 
teids,  fats,  and  carbohydrates.  He  realizes  fully  that  he  is  not  dealing 
with  the  same  proteids,  fats,  carbohydrates,  ferments  and  salts  that  are 
found  in  human  milk.  Nevertheless,  they  are  milk  constituents  and,  clin- 
ically, he  finds  them  far  superior  to  the  more  or  less  bizarre  products  of 
commercial  brains.  He  understands  fully  that  his  percentages  may  not  be 
quite  accurate.  Very  well,  if  they  are  unsuited  to  the  individual  baby,  that 
baby  proclaims  the  fact  to  observant  eyes  and  ears.  In  the  main,  the  baby 
is  the  best  laboratory  for  the  individual  milk  or  milk-mixture.  Percentage 
feeding,  properly  understood,  is  never  the  rule  of  thumb  feeding;  it  is 
intensely  individualistic.  An  able  critic  has  said  that  we  sliould  remember 
that  we  are  feeding  individual  babies  and  not  test-tubes.  No  more  powerful 
argument  than  this  was  ever  placed  in  the  mouth  of  the  percentage  advocate. 
Percentage  feeding  always  considers  the  individual  bab}^ 

But  what  of  the  calorimetrie  method?  The  writer  is  not  oblivious  to 
the  enormous  amount  of  painstaking  work  that  this  method  represents. 
He  uses  the  calorimetrie  method,  but  he  uses  it  as  a  check  upon  his  per- 
centage method  rather  than  as  a  guide  to  his  percentages.  In  the  literature 
a  number  of  criticisms  of  the  calorimetrie  method  have  been  advanced,  but 
the  two  that  have  most  appealed  to  the  writer  have  been:  1.  That  the 
method  strives  to  prescribe  so  many  calories  of  energy  for  so  much  baby — 
this  rather  precluding  individualism.  2.  That  the  same  number  of  calories 
may  be  yielded  by  several  different  combinations  of  proteids,  fats,  and  carbo- 
hydrates, and  yet  one  such  formula  may  agree  perfectly  well  with  a  given 
baby,  while  another  disturbs  him  most  markedly. 

The  writer  believes  that  he  has  formulated  the  simplest  method  for 


MILK   QUESTION   FROM  THE   STANDPOINT   OF   THE   PEDIATRICIAN.         517 

obtainmg  percentage  milk-formula  in  existence.     In  devising  it  he  strove 
to  follow  the  top-milk  methods  of  Holt  and  Chapin  and  others: — 

"Nor  need  one  rack  the  weary  brain, 

Kor  search  for  method  far; 
The  good  percentage  end  we  gain 

From  three  levels  of  the  jar." 

He  has  expressed  the  whole  matter  in  two  rules: — 

Eule  1.  Knowing  the  ratio  of  the  desired  fat  percentage  to  the  desired 
proteid  percentage,  invert  that  ratio  and  make  a  fraction  of  it.  That  frac- 
tion represents  the  level  of  the  quart  milk  jar  from  which  the  top  milk 
is  withdrawn.  (Examples:  If  the  desired  fat  percentage  is  3  per  cent., 
and  the  desired  proteid  percentage  is  1  per  cent.,  the  inverted  ratio  is  1:3. 
The  milk  is  secured  from  the  upper  third  of  the  jar.  If  the  ratio  is  2:1, 
the  milk  is  withdrawn  from  the  upper  half  of  the  jar.) 

Eule  2.  Make  the  desired  amount  of  proteid,  expressed  in  a  percentage, 
the  numerator  of  a  fraction.  Make  the  percentage  of  proteid  present  in  the 
milk  the  denominator  of  the  fraction.  Multiply  the  total  amount  of  food 
to  be  given  in  the  twenty-four  hours  by  this  fraction,  and  the  result  equals 
the  amount  of  top  milk  to  be  used  in  the  mixture.  The  remainder  of  the 
mixture  is  the  diluent. 

With  the  aforementioned  authorities,  he  finds  that  most  babies,  not 
previously  disturbed,  can  be  successfully  fed  from  modifications  of  the  milk 
from  the  upper  third  of  the  jar,  the  upper  half  of  the  jar,  and  the  whole 
milk. 

When  a  more  mobile  method  of  feeding  is  needed,  the  so-called  Bauer's 
formulje — better,  the  Baner  modification  of  Thompson  Westcott's  formulae 
— still  help  the  writer  over  many  a  rough  place  in  the  road.  As  many  of 
you  probably  know,  Westcott  has  accepted  the  Baner  modification,  and  has 
applied  it  practically  in  his  ingenious  "little  wheel.^' 

But  in  this  percentage  feeding,  as  in  other  methods  of  feeding  that  are 
to  bring  success,  it  must  be  remembered  that  no  problem  of  nutrition  is 
solely  a  matter  of  food.  One  must  enter  into  and  adjust  every  hygienic 
detail  of  the  infantile  existence.  Suit  the  food  to  the  baby,  but  bring  the 
baby  up  to  its  food  also. 

7.  Despite  several  clarion-like  denials  from  inhabitants  near  the  great 
lakes,  the  writer  still  finds  that  the  casein  of  the  cows'  milk  sometimes  dis- 
turbs the  human  baby.  Probably  the  best  clinical  evidence  of  this  is  found 
in  the  fact  that  babies  who  are  disturbed  by  whole  milk,  may  still  take 
whey-cream  mixtures  and  thrive  upon  them.  That  fat  is  often  the  disturb- 
ing agent,  however,  there  is  no  gainsaying.  Among  Americans  who  called 
attention  to  this  fact  some  years  since,  we  may  mention  Jacoby  and  West- 
cott and  Edsall.  While  expressing  himself  as  truly  grateful  for  every 
particle  of  laboratory  work  that  enables  us  to  detect  the  various  undigested 
milk  constituents  in  the  stools  of  babies,  the  writer  still  finds  the  following 
clinical  table  of  value: — 


518        MILK  QUESTION   FROM  THE   STANDPOINT   OF   THE   PEDIATRICIAN. 


SYMPTOMS  THAT  GOVERN  US  IN  THE  PERCENTAGE  FEEDING  OF  THE 
INDIVIDUAL   BABY. 


Symptoms. 

Proteid. 

Fat. 

Carbohydrate. 

of 
Excess. 

Intestinal     colic.       The 
baby   is  often  relieved   by 
the    passage    of    gas    from 
the  bowel. 

The  stools  are  often 
green,    and   there   may   be 
constipation    or    diarrhoea. 
In  the  former  case,   there 
may     be     a     putrefactive 
odor.     Curds  may  also  be 
present,     but     these     are 
hard   to  tell    from   masses 
of  fat  or  soap. 

Ycmitlng,  when  present, 
is    liable    to    appear    soon 
after     feeding,     and     the 
vomitus  contains  curds. 

These   babies    may    gain 
rapidly   in   weight   despite 
their  discomfort. 

Vomiting     often     occurs 
hours    after    feeding,    and 
usually    the    odor    of    bu- 
tyric  acid   is   very  appar- 
ent. 

The  stools  are  often 
loose,    and    are    also    sour 
(butyric   acid).     They  are 
frequently      very      yellow 
(gelbfarbung-Biedert's    fat 
diarrhcEa). 

They   also  contain   fatty 
masses.       On     the     other 
hand,    there   may  be   con- 
stipation,  v/hon   the  stools 
are     peculiarly      light     In 
color  and  dry. 

Colic,    when    present,    la 
usually  gastric  (Westcott). 

Tomiting  may  be  very 
frequent  and  the  vomitus 
very  sour.  (This  is  due  to 
lactic  acid,  however.) 

The  stools  are  acid,  and 
often  excoriate  the  but- 
tocks. They  are  often 
green. 

Frctftilncss  is  liable  to 
be  present  most  of  the 
time. 

Rickets  (?).  In  reality, 
this  may  result  because 
the  excess  of  carbohy- 
drate is  used  to  atone 
for  the  deficiencies  of 
other  organic  elements. 

Scurvy. 

Deficiency  In 

Hunger. 

Failure  to  gain  weight. 

Pvicketa 

Scurvy. 

Rickets 

Hunger    and    failure    to 
gain  weight. 

Not  definitely  known; 
but  it  seems  rational  to 
use  an  amount  of  milk 
sugar  equivalent  to  that 
which  nature  has  placed 
in  mother's  milk. 

In  certain  states  (dia- 
betes, etc.)  disaster  re- 
sults when  we  give  too 
little  carbohydrate. 

With  but  two  mo(iificatioDS,  this  table  has  been  in  use  for  teaching 
purposes  for  nine  years.  In  the  original  table  he  spoke  more  positively  of 
the  occurrence  of  curds  in  the  stools  than  it  is  now  possible  to  do.  In  the 
original  table  he  did  not  mention  the  dry  type  of  fatty  stools  so  graphically 
described  by  Brenneman  and  Walls.  Concerning  this  fat  constipation,  how- 
ever, the  writer  must  hasten  to  say  that,  while  he  has  seen  it  several  times, 
he  does  not  view  it  as  a  usual  symptom  with  fat  excess  in  the  food.  He 
finds  the  Bicdert  symptoms-complex  far  more  frequently  (Biedert's  fat  diar- 
rhoaa).  As  Jacoby  has  shown,  some  babies  fail  to  do  well  until  fat  is  added 
to  their  food.  The  writer  rarely  gives  more  than  3  per  cent,  of  fat,  and 
almost  never  more  than  S""/^  per  cent. 

8.  Anent  of  fat  disturbances,  one  must  give  more  than  a  passing  men- 
tion to  the  wonderfully  successful,  if  somewhat  revolutionary,  method  of  but- 
termilk-feeding. He  never  thinks  of  it  and  of  the  babies  he  has  seen  saved 
by  it,  that  he  does  not  feel  grateful  to  his  colleagues,  Drs.  Fife  and  Car- 
penter, who  employed  this  method  so  successfully  at  the  Philadelphia  Hos- 
pital. The  wonderful  potency  of  buttermilk  is  not  dependent  alone  upon 
its  low  fat  content;  it  is  not  dependent  solely  upon  the  fact  that  it  is 
usually  prescribed  in  sterile  form;  but  also,  and  probably  chiefly,  upon  the 
fact  that  the  proteid  (the  tissue  builder)  is  given  in  relatively  large  amounts 
in  a  readily  digestible  and  assimilable  form.  The  producer  who  will  supply 
us  with  a  reliable  buttermilk  will  find  a  large  sale  for  his  article,  and  will 
secure  a  good  price. 


THE  THEFvAPEUTIC  ACTION  OF  IODINE  AND  MERCUllY.  519 

9.  The  casein  of  cows'  milk  often  requires  some  modification.  Fol- 
lowing Chapin's  methods  rather  closely,  the  writer  finds  himself  using 
carbohydrate  diluents  more  and  more  frequently.  The  carbohydrate  is  used 
in  small  quantity,  however,  and  is  not  ordinarily  intended  to  replace  the 
fats  or  the  proteids  of  the  milk. 

In  the  case  of  premature  or  very  weak  babies,  ordinary  percentage 
methods  are  abetted  by  peptonization.  We  thus  give  the  baby  a  sterilized 
food,  and  at  the  same  time  spare  him  the  energy  that  he  would  otherwise 
have  expended  in  digestion.  If  the  processes  of  sterilization  and  prediges- 
tion  are  thoroughly  understood,  neither  will  be  pursued  for  a  length  of  time. 
After  he  is  well  started  on  life's  journey,  the  little  subject  is  carefully  tried 
upon  appropriate  certified  milk  formulae  until  he  is  finally  able  to  digest 
them  and  thrive  upon  them. 

10.  In  the  treatment  of  babies  affected  with  the  infectious  diarrhoeas 
of  the  summer  season,  milk  has  no  place.  Whether  we  are  dealing  with  a 
milk  infection  or  not,  and  usually  we  are,  milk  will  still  furnish  a  splendid 
culture  medium  for  the  bacteria  still  inhabiting  the  disturbed  gastro-intes- 
tinal  tract.  The  writer  makes  it  a  working  nile  to  avoid  aU  milk  for  at 
least  one  week  after  such  an  attack. 

Thus  we  have  made  a  hasty  survey  of  a  large  and  wonderfully  inter- 
esting territory.  Some  of  it  is  still  unknown  country,  and  work  remains 
to  be  done,  not  by  the  overzealous  adventurer,  but  by  the  scientific  explorer. 
Anyone  of  the  points  of  interest  we  have  noted  on  the  way  would  have 
furnished  sufficient  material  for  a  whole  evening's  discourse.  Let  us  for 
a  moment  proceed  back  to  the  starting  point  and  permit  our  e3'es  to  rest 
upon  the  mountain — upon  one  of  Nature's  inmiutable  laws — for  there  rests 
the  promised  land  of  the  race. 


THE  THERAPEUTIC  ACTION  OF  IODINE  AND  MERCURY  IN  DISEASES 
OTHER  THAN  SYPHILIS. 

By  n.  A.  ROBBINS,  M.D., 
Professor  of  Dermatology  and  Syphilology  in  the  Howard  University,  Washington,  D.  C. 

WASniNGTON,   D.    O. 

The  recent  rehabilitation  of  mercury  in  the  treatment  of  tuberculosis 
coincides  suggestively  witli  tlie  fact,  that  for  many  years  I  have  noticed  tlie 
curative  effects  of  mercury  and  iodine  in  diseases  in  cases  in  which  there 
was  no  suspicion  whatever  of  syphilis — as  already  emphasized  in  a  paper  T 
read  January  13,  1908,  before  the  Therapeutic  Society  of  the  District  of 
Columbia  on  tliis  subject.  As  to  iodine,  Coindet,  of  Geneva,  was  the  first 
to  employ  and  recommend  the  use  of  this  valuable  agent.  His  success  fully 
answered  his  expectations,  and  in  a  paper  communicated,  July  25,  1820,  to 
tbe  Society  of  Natural  Sciences  at  Geneva,  he  made  known  his  invalual)lo 
discovery.     Ue  remarked   that   "the   efficiency   of   Ihe   remedy   in   goi^or." 


520  THE  THERAPEUTIC  ACTION  OF  IODINE  AND  MERCURY. 

naturally  led  to  its  emplo^iiient  in  other  tumefactions,  especially  the  scrofu- 
lous." The  favorable  reports  made  of  it  rapidly  diffused  its  reputation 
throughout  the  medical  world.  The  names  of  Brera,  Lugol,  and  Manson 
are  also  favorably  connected  with  the  early  history  of  iodine,  especially  in 
connection  with  "scrofula,'^  which  we  now  know  signifies  tuberculosis. 

In  the  Journal  of  the  American  Medical  Association,  November  17,  1900, 
there  appeared  an  exceedingly  interesting  article  by  Alfred  C.  Croftan  (then 
living  at  Pasadena,  California),  entitled  ^'Iodine  Used  Hypodermically  in 
the  Treatment  of  Pulmonary  Tuberculosis,"  in  which  he  reviewed  the  work 
done  by  Coindet,  and  Rilliet,  and  Binz,  Niemeyer,  Kaemmerer,  See,  and 
Stille.  Croftan  then  (nine  years  ago)  stated,  "In  the  light  of  our  theoretic 
beliefs  the  administration  of  iodine  should  act  curatively  in  pulmonary  tuber- 
culosis; the  virus  of  tuberculosis,  entering  the  blood  at  first  in  minute 
quantities,  produces  certain  slight  reactive  phenomena  from  the  cells  that  it 
is  selectively  attracted  to;  this  reaction  may  or  may  not  become  subjectively 
and  objectively  perceptible;  that  will  depend  on  its  intensity,  the  character 
of  the  reactive  symptoms  with  the  rather  crude  clinical  means  at  our  dis- 
posal, and  the  uncertain  evidence  of  our  senses." 

Croftan  made  use  of  iodipin  in  the  form  of  a  10-per-cent.  preparation. 
The  injections  were  made  into  the  subcutaneous  tissues  between  the  skin 
and  the  muscle,  and  preferably  in  the  gluteal  and  interscapular  regions. 
"jSTo  discomfort  of  any  kind  was  ever  caused,  no  inflammatory  reaction 
observed  at  the  site  of  the  injections,  though  some  patients  received  daily 
injections  for  a  period  of  three  or  four  months. 

"Beginning  -Rath  one  drop  of  iodipin  which,  to  give  the  necessary  bulk 
for  hypodermic  administration,  was  dissolved  in  half  a  drachm  or  so  of 
sterilized  oil,  the  injections  were  gradually  increased,  one  drop  being  added 
to  the  dose  each  day.  .  .  .  The  results  obtained  so  far  by  this  plan  of 
treatment  have  been  uniformly  good;  in  a  few  cases  amelioration  of  symp- 
toms was  marked  from  the  beginning;  appetite  improved,  the  cough,  the 
night  sweats,  grew  less  severe;  the  patient  gained  in  weight  and  improved 
in  spirits.  The  physical  signs  were  modified  and  seemed  to  show  that  the 
process  was  at  least  being  held  in  check  and  rendered  latent;  in  3  out  of 
my  27  cases  a  recurrence  of  symptoms  occurred  at  the  expiration  of  three 
and  five  months,  respectively;  these  patients  underwent  a  second  course 
of  treatment  with  good  result.  It  is  altogether  too  early  to  make  any  state- 
ments in  regard  to  a  cure." 

More  than  twenty  years  ago  I  re]")orted  the  case  of  a  man  who  was 
far  advanced  in  pulmonary  tuberculosis.  He  became  interested  in  daguer- 
reotyping,  and  passed  hours  every  day  in  the  dark-room,  inhaling  the 
fumes  of  the  iodides.  In  a  few  months  he  had  entirely  regained  his  health. 
I  also  met  recently  Mr.  Samuel  Push  Seibert,  who  had  been  one  of  the  first 
disciples  of  Daguerre.  Mr.  Seibert  referred  to  many  such  cases,  and  explained 
that  they  were  obliged  not  only  to  inhale  the  fumes  of  iodine,  but  also 
of  mercury.  He  furthermore  gave  me  an  abstract  of  an  article  which 
appeared  in  the  rMIadelpJiia  Eecnrd,  January  26,  1908,  alluding  to  Benjamin 


THE  THEBAPEDTIC  ACTION  OF  IODINE  AND  MERCURY.  521 

Loclunan,  the  oldest  photographer  in  Allentown  (aet.  82),  in  the  following 
terms : — 

"Mr.  Lochman  relates  an  interesting  experience  he  had  ia  connection 
with  the  developing  of  daguerreotypes.  As  a  young  man  he  was  a  con- 
sumptive and  had  frequent  haemorrhages.  It  was  his  physical  weakness, 
indeed,  that  induced  him  to  take  up  daguerreotyping  as  a  calling,  which 
would  not  overtax  his  strength.  In  developing  the  plates  iodine,  in  con- 
nection with  other  chemicals,  was  used,  and  the  constant  inhaling  of  its 
fumes,  he  claims,  is  what  healed  his  lungs  and  made  him  well  and  strong. 
.  Not  many  years  ago  Mr.  Lochman  received  a  letter  from  a  scientist 
who  was  impressed  with  the  fact  that  many  men  who  were  weak  and  frail 
when  they  started  in  that  business,  rapidly  became  stronger,  and  that  vital 
statistics  showed  that  the  great  majority  became  old  men. 

"Numerous  cases  of  dropsy  owe  their  cure  to  potassium  iodide,  including 
ascites  due  to  splenic  or  hepatic  induration,  and  hydrothorax  depending 
upon  cardiac  obstruction.  It  has  cured  acute  hydrocephalus  from  granular 
meningitis,  but  chiefly  when  mercury  had  been  previously  administered, 
and  chronic  hydrocephalus  under  similar  circumstances.  In  these  intractable 
diseases  it  should  never  be  neglected;  and  in  regard  to  tubercular  or  granular 
meningitis,  which  so  rarely  recovers  under  any  treatment,  the  use  of  mer- 
cury, followed  by  iodide  of  potassium,  cannot  be  too  strongly  recommended. 
In  not  a  few  cases  also  presenting  signs  of  tumor  of  the  brain,  whether 
syphilis  or  not,  the  symptoms  have  been  greatly  mitigated,  and  sometimes 
quite  removed  by  this  medicine.  Seguin  insisted  on  the  necessity  of  admin- 
istering very  large  doses  in  all  such  cases.'^^ 

It  would  take  up  too  much  space  to  quote  authorities  on  the  curative 
action  of  iodine  in  some  forms  of  rheumatism;  also  in  lead  poisoning,  which 
has  so  well  been  described  by  Orfila  and  Melseus  and  William  Budd. 

Foumier,  of  Paris,  states  that  mercury  and  potassium  iodide  are  not 
reagents  of  syphilis  only — ^that  is,  an  affection  favorably  affected  by  them 
is  not  necessarily  syphilitic.  At  a  meeting  of  the  Societe  Frangaise  de  Der- 
matologie  et  Syphilographie,  he  (Fournier)  reported  a  case  in  which  a  patient 
had  consulted  him  for  enormous  ulcers  of  the  hand  and  arm,  resembling  in 
all  points  tuberculous  lesions.  Not  only  did  the  patient  deny  having  had 
syphilis,  but  no  sign  of  the  latter  could  be  discovered.  Moreover,  the 
patient  was  suffering  from  pulmonary  tuberculosis,  and  the  cutaneous 
lesions  dated  from  many  years  back.  In  order,  however,  to  insure  his 
results,  a  subcutaneous  injection  of  calomel  was  administered.  This  gave 
rise  to  a  stomatitis,  but  also  caused  great  improvement  in  the  local  condition 
of  the  patient.  A  second  and  a  third  injection  were  given  with  so  much 
success  that  only  some  slight  thickening  of  the  skin  remained  in  the  region 
where  the  ulcers  had  existed.  Fournier  thinks  that,  after  all,  the  question 
should  be  asked  whether  calomel  did  not  have  a  curative  action  in  some 
Tarieties  of  tuberculosis. 


^  Medical  Record,  zzi,  60. 


522  SEASONAL  INFLUENCE  ON  SUICIDE. 

Angagneur,  of  Lyons,  has  reported  the  case  of  an  18-year-old  boy  suf- 
fering from  tuberculous  lesions  of  the  legs,  and  who  had  a  toe  amputated 
for  tuberculosis,  which  had  lasted  for  about  ten  years.  The  administration 
of  potassium  iodide  caused  very  great  improvement,  as  it  did  in  another 
patient  suffering  from  suniiar  lesions.  Jacquet  also  reported  a  case  in 
which  a  recently  delivered  young  woman  suffered  first  from  puerperal  infec- 
tion, followed  by  acute  osteomyelitis  of  the  left  thigh.  The  administration 
of  Gibert's  syrup  caused  almost  immediate  recovery. 

In  the  United  States  Naval  Bulletin,  April,  1908,  Surgeon  Barton  Lisle 
Wright,  of  the  United  States  navy  (as  stated  by  Sajous  in  the  October,  1908, 
number  of  this  journal),  writes: — 

"1.  We  have  shown  the  almost  immediate  improvement  in  the  gen- 
eral condition  of  the  patient  following  the  administration  of  mercury:  the 
slowing  of  the  pulse,  the  reduction  of  temperature,  and  the  gain  in  weight. 

"2.  We  have  conclusively  demonstrated  that  it  will  cure  extremely 
advanced  tubercular  ulceration  of  the  larjoix  and  pharynx  in  a  remarkably 
short  period  of  time. 

"3.  We  have  shown  that  it  produces  marked  improvement  in  advanced 
pulmonary  lesions,  and  that  it  also  has  a  decided  beneficial  action  in  tuber- 
culous glands." 

Saboraud  states  that  the  only  two  known  cases  of  human  glanders 
which  had  recovered  had  been  taken  for  syphilis,  and,  consequently,  were 
treated  with  mercury.  One  was  reported  in  the  Vracli,  St.  Petersburg,  by 
Dr.  M.  K.  Kondrovski,  entitled  "Glanders  in  a  Man,  Treated  with  Mer- 
curial Inunction,"  1891,  xi,  717.  The  other  was  reported  by  Dr.  T.  K. 
Gralevoski,  published  in  the  same  journal,  1893,  with  the  same  title. 


SEASONAL  INFLUENCE  ON  SUICIDE.  ♦     , 

Br  W.  F.  R.  PHILLIPS,  M.D., 
Ex-President  American  Climatological  Association, 

WASHINGTON,    D.    C. 

If  the  vital  statistics  of  countries  within  the  temperate  zones  be  exam- 
ined with  reference  to  deaths  by  suicide,  it  will  be  found  that  there  is  a 
regular  annual  rise  and  fall  in  the  number  of  deaths  so  recorded,  and  that 
the  greatest  number  coincides  with  the  warmest  part  of  the  year,  and  the 
smallest  number  with  the  coldest  part  of  the  year.  So  uniform  and  so 
universal  is  this  fact  that  I  shall  not  burden  you  with  any  statistics  of  my 
own  collecting,  and  with  but  few  of  those  of  others.  The  following  table 
taken  from  a  paper  read  by  Dr.  Ogle  before  the  Eoyal  Statistical  Society 
in  1886,  shows  the  general  trend  of  all  statistics  of  suicidal  deaths : — 


*  Bead    before    the    American    Climatological    Association,    June    5,    1909,    Fort 
Monroe,  Va. 


SEASONAL  INFLUENCE  ON  SUICIDE.  523 

Distribution  of  Suicides  in  London  by  Montlis  of  Equal  Length, 
per  10,000  Suicides,  1865-84. 

January 732  [  July 906 

February 714      August 891 

March 840      September 766 

April 933      October 772 

May 1003      November 726 

June 1002  j  December 697 

The  amplitude  of  variation  in  incidence,  shown  by  this  table,  is  suffi- 
ciently near  enough  to  accuracy  to  be  said  to  be  true  of  all  countries,  slight 
differences  in  the  maximum  and  minimum  times  of  occurrence  excepted. 

Thus  Morselli  found  that  the  month  of  the  greatest  number  of  suicides 
varied  somewhat  in  different  countries  and  with  different  nationalities. 
According  to  him  May  is  the  month  of  maximum  suicides  in  Ireland,  Saxony, 
Austria,  Sweden  and  the  ISTetherlands ;  June,  in  France,  Italy,  Norway, 
Belgium  and  Denmark,  and  July,  in  Switzerland,  Bavaria,  Wiirttemberg 
and  Baden;  and,  according  to  Leffingwell,  the  suicides  of  the  Japanese 
Empire  will  be  found  to  recur  in  each  session  of  the  year  in  almost  the 
same  proportion  as  in  Western  Europe.  Dexter,  in  his  studies  of  suicides 
in  the  cities  of  New  York  and  Denver,  found  the  same  general  agreement. 
Midwinter,  without  exception,  is  the  period  of  fewest  self-inflicted  deaths. 

Here  then  we  see  presented  a  vital  phenomenon,  with  a  regular  rise 
to  a  maximum  at  one  part  of  the  year,  and  an  equally  regular  decline  to  a 
minimum  at  another  part  of  the  year,  and  the  two  parts  of  the  year  related 
to  each  other  in  extreme  meteorological  antithesis. 

When  two  or  more  apparently  independent  series  of  events  are  observed 
running  either  in  direct  or  inverse  parallelism  as  to  time,  quantity,  occur- 
rence, or  other  forms  of  manifestation,  it  is  but  natural  that  we  should 
associate  them  in  a  causal  relation,  one  to  the  other.  With  the  discovery 
of  the  statistical  facts  as  to  the  periods  of  maximum  and  minimum  incidence 
of  suicide,  came  also  the  idea  of  seasonal  and  meteorological  influences. 

Morselli  attributes  the  seasonal  influence  chiefly  to  the  physiological 
effects  of  high  and  low  temperature.  **To  estimate  justly  the  influence  of 
the  annual  temperature  on  suicide,"  says  he,  "it  suffices  to  observe  the  dif- 
ference between  the  intermediate  and  the  extreme  seasons;  in  general, 
autumn  and  winter  on  one  hand,  spring  and  summer  on  the  other,  form 
two  very  distinct  periods  in  the  year  which  denote  that  the  filling  and 
rising  of  the  temperature  produces  the  most  marked  disturbance  on  the 
psychological  activities  of  man,"  and  he  gives  as  the  result  of  hii  studies  a 
general  law  as  to  the  monthly  distribution  of  suicides,  which  is  as  follows: 
"The  number  of  voluntary  deaths  goes  on  regularly  increasing  from  the 
beginning  of  the  year  to  June,  in  which  month  it  commonly  reaches  its 
maximum,  and  hence  falls  also  with  regularity  to  the  end  of  the  year,  the 
minimum  falling  generally  in  the  month  of  December." 

Strahan  accounts  for  the  seasonal  variation  in  suicide  in  this  wise: 
"There  is  an  annual  rhythmic  rise  and  fall  which  affects  all  animate  nature. 
With  the  approach  of  spring  and  the  increase  of  temperature,  there  is  a 


524  SEASONAL  INFLUENCE  ON  SUICIDE. 

general  wakening  from  the  period  of  comparative  rest  in  which  the  pre- 
ceding cold  season  has  been  passed.  With  this  awakening  every  function 
is  quickened,  and  the  procreative,  which  is  the  highest  of  all  functions,  is 
excited  to  most  vigorous  action.  During  this  period  of  spring  and  early 
summer  the  organism  is  working  at  its  highest  tension,  and  every  function 
of  mind  and  body  is  more  active  than  at  any  other  period  of  the  year.  It 
is  not  surprising,  then,  that  at  this  portion  of  the  yearly  cycle  we  should 
meet  with  the  most  breakdowns  of  the  machine. 

*1n  this  annual  quickening  of  the  functions  of  the  organism  we  do  not 
find  the  true  cause  of  suicide,  any  more  than  we  find  a  true  cause  of  crime, 
immorality  or  madness.  It  merely  acts  as  an  exciting  cause  of  those  pre- 
disposed. The  normal  or  healthy  person  passes  through  this  natural 
rhythmic  vital  disturbance  without  injury;  it  is  only  the  abnormal  to 
whom  it  acts  as  an  incentive  to  unnatural  acts.  To  the  healthy  individual 
the  heightened  vital  activity  of  spring  no  more  suggests  suicide  than  it  does 
madness ;  to  the  abnormal  it  suggests  that  to  which  he  is  already  predisposed. 
Thus,  while  one  gives  way  to  crime  or  the  indulgence  of  the  passions,  an- 
other will  become  insane  or  commit  suicide.  It  is  a  disturbing  agent  of 
great  power,  and  acts  in  overthrowing  the  unstable  exactly  as  accidental 
disturbances  of  equal  power  may  act  at  any  period.*' 

Too  much  emphasis  cannot  be  laid  upon  Strahan's  position  that  the 
annual  seasonal  variation  in  temperature,  or  even  extending  the  idea  to 
include  the  general  meteorological  conditions,  is  not  the  all-sufficient  cause 
of  self-destruction.  The  seasonal  meteorological  changes  are  always  but 
secondary  to  some  more  potent  endogenous  activities.  Nor  should  it  be 
understood  that  all  suicides  are  equally  affected;  many  unquestionably  are 
no  more  influenced  by  meteorological  changes  than  thpy  are  by  the  rise  and 
fall  of  the  tides,  or  the  changes  in  the  styles  of  ladies'  hats.  We  must  dis- 
tinguish in  the  causes  that  prompt  to  self-murder.  Strahan  has  given  what 
seems  to  be  an  excellent  working,  if  not  accurate  psychological,  classification 
of  suicides  into  rational  suicides,  and  irrational  or  true  suicides.  Rational 
suicides  proceed  from  religious  belief,  as  with  the  Brahmins,  from  grief  and 
affection  for  dead  friends,  from  a  desire  for  notoriety,  and  from  motives  that 
others  may  gain  by  the  death  as  beneficiaries  of  insurance,  etc.  (and  we 
may  add  those  who  seek  by  death  to  escape  disgrace  or  punishment).  Irra- 
tional or  true  suicides  are  those  where  the  individuals  who  leave  life  do  so 
because  they  are  disgusted  with  and  tired  of  living,  or  have  an  instinctive 
craving  for  or  a  love  of  death.  The  true  suicides,  he  subdivides  into  three 
classes : — 

'Tirst,  that  in  which  there  is  mental  aberration. 

"Second,  that  in  which  the  act  depends  upon  irrestible  impulse  and 
in  which  there  is  no  mental  aberration,  and 

**Third,  that  in  which  certain  predisposition  makes  it  possible  for  a 
slight  shock,  trial  or  irritation  to  awaken  the  unnatural  impulse." 

It  is  difficult  to  conceive  how  rational  suicides  could  be  influenced  by 
meteorological  environment,  since  they  are  based  solely  upon  reasoned  out 


SEASONAL  INFLUENCE  ON  SUICIDE.  525 

objects  and  ends  to  be  accomplished.  The  true  suicides,  however,  may  and 
m.ust  be  so  affected,  otherwise  we  could  not  have  this  great  and  universal 
rhythm  in  deaths  from  self-destruction.  Unfortunately  our  statistics  are 
not  so  gathered  as  to  enable  us  to  make  the  scientific  analysis  needed  to 
establish  or  overthrow  our  hypotheses  or  suppositions.  In  order  to  get  more 
light  on  the  subject  of  suicide  and  the  suicidal  impulse,  thought  or  desire, 
we  must  call  into  consideration  other  acts  and  occurrences  to  aid  us.  Apart 
from  the  obviously  insane  among  whom  suicide  is  so  common,  it  would  seem 
that  we  are  justified  in  regarding  the  impulse  to  self-murder  as  closely  allied 
in  psychological  development  to  the  impulse  to  homicide,  to  assault  or  to 
any  of  the  other  acts  denoting  temporary  loss  or  surrender  of  seK-control. 
Now  all  these  acts  show  a  wonderful  uniformity  in  seasonal  occurrence  with 
that  of  suicide.  Thus  murders,  assault  and  battery,  rapes,  crimes  against  the 
person,  and  illegitimacies  show  the  same  seasonal  maxima  and  minima  as 
shown  by  suicide.  These  are  admittedly  things  due  more  largely  to  loss  of 
control  of  temper,  v,dll  or  appetite  than  to  premeditation.  This  loss  of  con- 
trol of  self  may  come  from  over  or  undue,  and  explosive,  development  of 
impulse  or  from  an  inverse  weakening  of  the  powers  of  the  ordinary  will. 
While  the  end  result  is  the  same,  the  predisposing  and  inciting  factors  in 
any  two  cases  may  be  very  different  and  even  opposite.  Thus,  in  one  ease, 
rise  in  atmospheric  temperature,  lessening  the  body  energy  to  be  expended 
as  heat,  leaves  it  to  manifest  itself  as  muscular  power,  and  this  new  sense 
of  physical  prowess  results  in  the  quick  resentment  of  a  fancied  or  real 
wrong  that,  previously,  a  lesser  sense  of  prowess  would  have  passed  by,  self 
pride  being  soothed  with  the  idea  that  prudence  was  the  better  part  of  valor. 
On  the  other  hand,  another  case  under  like  temperature  conditions  but  dif- 
ferent endogenous  conditions,  responds  not  with  physical  force,  but  with 
nervous  irritability  that  manifests  itself  solely  in  impotent  rage  or  hysteria. 
If  we  be  right  in  the  motive  of  our  true  suicides,  that  of  disgust  or 
ennui  of  life,  or  a  love  for  death,  we  should  naturally  expect  to  find  in 
such  persons  evidences  of  deficiency  of  self-control,  and  such  seems  to  be 
the  consensus  of  investigators  who  have  had  much  experience  with  suicides 
and  attempted  suicides,  either  personally  or  statistically.  Morselli  sums 
up  his  conception  of  the  subject  thus:  "Suicide  is  an  effect  of  the  struggle 
for  existence  and  human  selection,  which  works  according  to  the  laws  of 
evolution  among  civilized  people,"  and  his  general  conclusion  seems  to  be 
that  suicide  is  merely  a  mode  of  confession  of  defeat  in  the  struggle  for 
those  inherent  demands  of  life,  sustenance  and  sexuality.  It  is  therefore 
only  the  physically  and  neurologically  unstable  that  succumb,  that  furnish 
the  true  suicides.  What  then  has  seasonal  influence  to  do  with  such? 
The  general  effect  of  temperature  upon  protoplasm  is  well  known;  within 
certain  limits  and  conditions  growth,  development  and  activities  are  in 
proportion,  not  accurately  measurable  but  yet  unquestionable,  to  the  degree 
of  temperature,  and  this  increased  functioning  is,  as  already  referred  to, 
considered  by  many  as  the  only  etiological  effect  of  season  upon  suicide — 


526  iSEASO^AL  LN'PLUENCE  ON  SUICIDE. 

simply  exciting  the  machine  to  work  beyond  its  mechanical  strength,  with 
the  consequent  breakdown. 

Many  of  the  seasonal  suicides  may  l)e  so  accounted  for,  but  this  explana- 
tion is  not  satisfying  enough;  it  is  too  physiologically  broad  and  indefinite. 
I  am  not  able  to  offer  substitutes  that  shall  be  based  upon  better  founda- 
tions than  those  quoted,  namely,  hypotheses;  but  still,  even  at  the  risk 
of  only  engaging  in  speculating,  I  shall  intrude  upon  your  attention  two 
suppositions  that  have  for  some  time  been  in  mind  and  regarding  the  ten- 
ability  of  which  it  may  be  possible  at  some  future  time  to  investigate  experi- 
mentally, at  least  as  far  as  the  limitations  imposed  by  the  nature  of  the 
subject  will  admit. 

The  first  is  based  upon  the  idea  of  a  cumulative  irritability  of  the 
nervous  system  generally,  resulting  from  extensive  and  more  or  less  con- 
tinuous low-grade  irritation  of  the  skin,  and  the  second  upon  a  possible 
effect  of  the  annual  variation  in  the  quality  and  quantity  of  the  average 
daily  dietary.  Both  these  conceptions  are  essentially  the  effects  of  seasonal 
changes,  and  both  are  more  largely  the  result  of  temperature  rise  and  fall 
than  of  any  other  single  meteorological  or  seasonal  element.  Again,  both 
may  act  together  or  separately  to  accomplish  the  same  result;  that  is,  con- 
ceivably they  may.  Ph3^siologically  these  two  conceptions,  or  permit  me 
to  call  them  hypotheses,  are  closely  associated,  both  being  dependent  for 
their  ultimate  manifestations  upon  their  effects  upon  the  central  nervous 
system,  which  they  reach  through  the  media  of  the  different  afferent 
nerves  of  the  skin  and  the  viscera,  respectively. 

Taking  the  first  hypothesis,  that  of  skin  irritation,  it  is  unnecessary 
to  more  than  remind  you  that  the  skin,  as  a  whole,  is  the  largest  sense- 
bearing  organ  of  the  body,  and  comes  more  in  contact  with  the  variations 
of  environment  than  any  other  part  of  the  organism.  It  is  never  at  any 
time  free  from  irritation  or  stimulus  of  some  sort,  though  the  effect  pro- 
duced ma3%  and  ordinarily  most  frequently  does  not,  reach  that  degree  or 
quality  that  produces  conscious  sensation  or  attracts  special  attention.  But 
this  low-grade  irritation  by  that  peculiar  property  of  nervous  matter,  cumu- 
lativeness,  produces  effects,  often  of  explosive  character,  Jnst  as  certainly 
as  though  it  were  consciously  perceived.  Illustrations  will  suggest  them- 
selves. In  the  normal  individual  there  is  simply  the  appreciation  of  the 
ordinary  feelings  of  comfort,  well-being,  exhilaration,  or,  on  the  other  hand, 
the  various  negative  phases  of  these  sensations,  together  with  the  more  or 
less  general  recognition  of  their  causes  and  of  an  effort  to  either  remove 
their  operations  or  to  patiently  endure  them,  as  the  case  may  require. 
But  in  the  abnormal  may  it  not  be  different,  and  that  often  altogether 
so?  Let  us  consider  onr  own  skin  sensations  under  certain  conditions,  such 
as  a  moderately  high  temperature,  somewhere  close  to  80  degrees,  and 
with  an  average  relative  humidity  of  65  per  cent.  Under  such  conditions 
we  feel  comfortable  enough  if  at  rest,  or  with  but  little  or  gentle  exercise. 
However,  let  the  temperature  rise,  say,  but  two  or  three  degrees,  and  then 
mark  the  change:    perspiration  begins  to  become  sensible,  the  skin  more 


SEASONAL  INFLUENCE  ON  SUICIDE.  527 

sensitive,  and  clothing,  before  perfectly  unnoticed,  begins  to  stick,  and  to 
bind,  and  to  pinch,  and  to  irritate,  and  the  even  tempered,  urbane  member 
of  the  Cliniatological  Association  of  but  the  moment  before,  loses  his  char- 
acteristic placidity  and  amiability  just  in  degree  as  the  temperature  mounts 
higher  and  higher,  and  his  skin  becomes  moister  and  moister  and  more  and 
more  appreciative  of  the  fact  of  the  irritativeness  of  its  clothing  envelope, 
which  in  itself  has  not  changed  one  particle  from  its  previous  irritative 
potentiality.  N"o-w  is  there  anything  statistical  to  support  tlie  idea  that 
such  cutaneous  sensations,  either  conscious  or  subconscious,  have  any  influ- 
ence on  suicides?  Yes.  Dexter  found  in  studying  the  suicides  of  New  York 
and  Denver,  that  they  were  more  excessive  upon  warm,  dear,  humid  and 
windy  days,  and  particularly  was  there  striking  coincidence  between  high 
suicide  rates  and  days  with  high  humidity  and  high  wind  movement.  High 
humidity  impedes  evaporation  and  keeps  the  skin  moist,  and  consequently 
more  sensitive  to  all  irritants;  and  the  wind  by  its  thousands  of  molecular 
impacts  against  the  skin  becomes  of  itself  a  mechanical  irritant  in  direct 
proportion  to  its  velocity,  and  it  may  be  that  it  also  produces  irritation 
otherwise.  During  the  winter  and  early  spring  the  low  temperature  keeps 
the  skin  relatively  anamic,  dry,  inactive,  and  insensitive  to  much  of  its 
immediate  surrounding  irritation,  or,  in  other  words,  lowers  the  conductivity 
of  the  skin  for  stimuli.  As  the  temperature  rises  with  the  progress  of 
spring  and  advent  of  summer,  so  the  skin  becomes  gradually  more  and  more 
hyperseraic  and  more  and  more  sensitive  to  its  surroundings,  and  capable  of 
sending  inwardly  myriads  of  impressions,  mostly  subconscious,  which  make  for 
good  or  bad  feeling,  for  satisfaction  or  for  dissatisfaction,  and  which  later 
may  in  the  abnonnal,  the  individual  with  the  germ  of  the  true  suicide  in  his 
make  up,  be  the  determining  straw  that  tips  the  scales  of  life  to  the  side 
of  oblivion.  As  the  warm  season  advances  more  and  more  unstable  systems 
will  mature  and,  so  to  speak,  fall  off  like  ripened  fruit,  until  the  crop  is 
exhausted.  But  the  cycle  of  another  year  brings  others  to  maturation,  and 
so  year  after  year  our  crop  of  suicides  is  harvested  with  an  all  too  appalling 
regularity  and  certainty.  If  this  hypothesis  have  any  truth  in  it,  it  sug- 
gests then  something  definite  in  the  way  of  rational  prevention  in  indi- 
viduals of  suspected  inclinations  to  suicide,  and  that  is  careful  and  intelli- 
gent attention  to  the  hygiene  of  the  skin,  and  especially  during  the  seasons 
and  weathers  that  throw  most  work  upon  it. 

Taking  up  the  second  hypothesis,  that  of  limitation  of  the  variety  of 
the  food  supply  and  considering  the  temperate  zone  as  a  whole,  and  the 
average  of  all  classes  and  conditions  of  its  population,  there  is  little  need 
to  dwell  upon  the  obvious  fact  that  we  are  dependent  upon  agriculture  for 
our  foods,  and  that  these  foods  are  in  the  ultimate  the  result  of  the  spring 
and  summer  sunshine,  rain  and  heat.  While  the  staple  cereals  and  pota- 
toes form  the  major  part  of  our  food,  yet  it  is  essential  for  the  pres- 
ervation of  health  that  we  have  for  a  minimum  of  the  year  a  certain 
quantity  of  fresh  vegetables  and  fruits.  Now  these  vegetables  and  fruits  do 
not  begin  to  mature  till  near  the  summer  solstice,  and  then  continue  till 


528  PREVENTIVE   MEDICINE   IN  A  NEGLECTED  DIRECTION. 

frost.  From  midsummer  to  midwinter  fresh,  or  relatively  fresh  vegetables 
and  fruits  are  plentiful  and  cheap,  and  form  a  large  and  important  part 
of  the  dietary  of  the  average  individual.  But  from  midwinter  on  to  mid- 
summer they  are  no  longer  in  such  abundance  and  cheapness,  and  in  the 
greater  number  of  households  have  disappeared  from  the  table  or,  if  present, 
are  there  by  their  dried  or  otherwise  imperfectly  preserved  representatives. 
Even  the  meats  partake  of  the  same  seasonal  fluctuation,  either  actually  or 
relatively.  During  the  summer  and  early  autumn,  fresh  meat  in  the  shape 
of  fowls  and  eggs  are  either  themselves  sufficiently  plentiful  and  cheap  to 
appear  at  least  weekly  upon  the  average  table,  or  to  so  lower  the  price  of 
beef  and  mutton  as  to  place  these  within  the  reach  of  the  average  housekeeper. 
But  as  autumn  passes  and  winter  and  spring  comes,  so  passes  the  fresh 
and  so  comes  the  salt  and  preserved  meats,  and  well  on  into  early  summer 
they  persist.  Were  we  to  chart  graphically  our  daily  foodstuffs  according 
to  quality  and  quantity  as  to  freshness  and  variet}^,  we  would  find  striking, 
if  not  significant,  contrast  between  these  curves  and  those  representing  our 
annual  suicides.  ISTo  one  can  question  the  profound  metabolic  effects  that 
variety  or  want  of  variety  in  food  causes.  Thus  in  a  fluctuation  clearly 
seasonal  in  its  causation  we  may  have  by  its  influence  upon  an  unstable 
system  another  source  of  increment  in  our  seasonal  suicides. 

Perhaps  all  this  may  be  carrying  seasonal  influences  to  extremes,  but 
in  climatological  effects  we  are  not  dealing  with  simple  phenomena  and  im- 
mediate effects.  What,  after  all,  we  are  considering  is  the  working  of  that 
wonderful  complex  of  effects  embodied  in  the  theory  of  evolution  that  every- 
where confronts  us:  the  struggle  for  existence  and  the  effort  at  adaptation 
to  environment. 

References. 
MORSELLI:   "Suicide,"  London,  1S99. 
Dexter  :   "Weather  Influences,"  New  York,  1904. 

Leffingwell:  "Illegitimacy  and  the  Influence  of  Seasons  upon  Conduct,"  London,  1802. 
Stbauan:   "Suicide  and  Insanity,"  London. 


PREVENTIVE  MEDICINE  IN  A  NEGLECTED  DIRECTION. 

By  BERTHA  C.  DOWNING,  M.D., 

Sometime  Superintendent  of  the  School   Department  of  the   Vineland,   N.   J..   Training 
School   for  Feeble-minded;    Fellow  of  the  American   Academy  of  Medicine. 

LEXINGTON,    MASS. 

Thebe  are  hundreds  of  thousands  of  atypical  children  in  this  country 
to-day  and  we  are  only  beginning  to  -awaken  to  the  vastness  of  the  problems 
they  make  for.  They  are  in  the  families  of  the  rich  as  well  as  the  poor. 
Just  here  are  the  roots  of  insanit}^,  feeble-mindedness,  epilepsy,  criminality 
and  much  disease — notably  tuberculosis.  The  death  rate  among  the  feeble- 
minded, due  to  this  cause,  is  three  times  greater  than  among  normal  people, 
and  late  statistics  say,  for  New  York  State,  it  is  on  the  increase,  and  so  it 


PREVENTi\Ti]  SIEDICINE   IN  A  NEGLECTED  DIllECTION.  529 

will  be  until  we  have  scientific  studies  of  the  feeble-minded.  We  know  that 
this  disease  is  largely  to  be  found  at  the  two  intellectual  extremes  of 
himianity — the  idiot  and  the  genius. 

Who  is  to  blame  for  all  the  woe  these  children  are  making  for,  the 
medical  profession  or  the  educators?  Is  it  one  or  both?  Had  they  worked 
more  together,  long  before  this  we  would  have  had  types  of  childhood  and 
what  they  stand  for  in  health  and  disease.  Just  here  great  strides  might  be 
made  along  the  line  of  preventive  medicine. 

G.  Stanley  Hall  defines  a  type  as  follows :  "A  norm  to  which  every  indi- 
vidual in  a  really  homogeneous  group  tends  to  approach  or  to  vary  from, 
and  in  a  pure  race  the  average  persons  should  be  more  frequent  and  around 
them  others  should  be  grouped  closely  as  well  as  symmetrically.  Any  indi- 
vidual, although  far  from  a  miscellaneous  average,  may  represent  a  type  and 
illustrate  some  tendency  away  from  the  average  in  some  new  direction,  or 
may  be  a  sport  leading  to  a  new  type. 

Our  best  teachers  of  the  feeble-minded  recog-nize  types  among  these 
children,  and  that  no  amount  of  education  will  change  one  type  into  another. 

The  Mongolian  type,  so  called,  are  as  much  alike  as  peas  in  a  pod; 
much  more  so  than  brothers  and  sisters  in  one  family.  Although  they  do  not 
have  the  same  degree  of  intelligence,  it  is  of  a  like  kind.  Their  sense  of 
direction  is  abnormally  strong.     They  average  40  among  1,000  feeble-minded. 

With  few  exceptions  they  are  hght  complexioned.  In  all  cases  they  have 
a  characteristic  hand.  I  would  add  an  additional  fact  concerning  the  hand. 
Out  of  100  cases  the  forefinger  is  longer  than  the  third  in  89  cases,  and  in 
no  case  was  it  shorter. 

In  public  school  children  I  found  but  20  in  1000.  These  children  were 
of  a  high  moral  type.  This  long  forefinger  is  found  among  college  women 
and  in  men  of  high  morals.  There  have  been  a  few  scientific  studies  on  the 
hand.  The  old  masters  must  have  had  knowledge  of  the  hand  which  we 
of  to-day  have  not.  Pictures  of  "The  Christ"  are  given  this  long  fore- 
finger; Judas  has  a  very  short  one.    The  artists  gave  it  to  all  the  j\radonnas. 

Among  all  children  there  are  traits,  or  groups  of  traits,  so  marked  as  to 
color  the  entire  character  of  the  child,  to  be  known  to  all  who  know  it — so 
marked  as  to  bear  on  the  child's  future  career. 

It  would  seem  that  we  have  seven  true  types  and  six  links  (2500  cases 
studied)  sufficiently  well  drawn  to  be  of  real  worth  to  the  physician  and  the 
educator,  but  much  more  work  should  be  done  along  these  lines.  I  do  know 
that  one  of  these  types  responds  to  certain  drugs  and  diseases  in  its  own  way. 

We  know  that  the  normally  nervous  child  makes  for  our  best  citizens, 
and  Dr.  Sachs  has  shown  that  no  amount  of  school  work  seems  to  harm 
him.  N'ot  so  the  abnormally  nervous  child  (not  feeble-minded;  these  are 
seldom  nervous  in  the  ordinary  sense  of  the  word). 

These  abnormally  nervous  children  are  very  talkative,  as  a  rule — asking 
a  great  many  questions.    They  are  easily  excited  or  confused. 

Phobias  and  imperative  ideas  may  occur. 

Ofttime  such  children  are  very  responsive  to  emotional  states.     Motor 

4 


530  PREVENTIVE  MEDICINE  IN   A  NEGLECTED   DIIIECTION. 

abnormalities  are  numerous;  abstraction  and  inattention  often  found.  Idio- 
syncrasies toward  animals.  Idios5mcrasies  of  food.  A  little  pain  causes  a 
peculiar  tremor.  Nausea  and  pain  go  hand  in  hand.  Hysterical  symptoms. 
Do  we  have  a  hysterical  type?  It  seems  so,  but  more  cases  must  be  studied. 
Many  show  manifestations  in  the  uro-genital  sphere.  The  nervous 
children  described  above  show  fatigue  with  school  work  that  a  night's  rest 
does  not  repair. 

Take  1000  cases  of  insane  and  follow  back  to  childhood  to  their  school- 
days. You  wiU  find  idiosyncrasies  like  those  Just  described.  The  physician 
and  the  educator  have  a  duty  to  these  abnormallij  nervous  children  which 
they  are  neglecting.  There  are  very  many  in  our  schools,  but  few  recognize 
that  these  children  are  the  roots  of  degeneracy.  The  special  classes  for  the 
so-called  'T)ackward"  is  not  spending  of  the  taxpayers'  money  for  the  greatest 
good  to  the  greatest  number.  Special  care  of  these  nervous  children, 
would  be  economy  for  the  taxpayer.  The  public  is  bound  to  pay  the 
bills  for  degeneracy.  By  giving  a  faulty  education  or  better  training  to  the 
so-called  "l^ackward,"  most  of  wbom  are  feehle-minded,  doctoring  branches 
and  making  more  in  the  future,  for  surely  they  go  out  into  the  world  better 
equipped  for  harm.  Take  care  of  these  children  who  might  be  said  to  be 
two  steps  back  biologically  of  the  feeble-minded  child.  Recognize  the  fact 
that  men  and  women  are  yet  in  the  making,  and  by  physical  and  mental 
training  based  on  child-study,  as  we  find  it  in  some  of  our  universities,  aid 
in  developing  more  balanced  individuals  and  thus  cut  down  degeneracy  and 
disease. 

Bosma,  in  his  book  "Nervous  Kinder,'"  says  "Wrong  education  is  a  most 
powerful  factor  in  the  causation  of  psychogenic  troubles.  If  through  wrong 
education  moods  are  not  suppressed,  good  habits  not  established,  training 
of  will  power  neglected  before  the  age  of  puberty,  and  the  imagination 
allowed  to  run  riot,  we  are  in  great  danger  of  cultivating  the  neurasthenic 
soil  on  which  all  sorts  of  psychogenic  affections  may  grow. 

Weed  out  and  put  into  institutions  the  idiots.  Give  home  schools  to 
the  feeble-minded  child.  He  is  not  being  handled  educationally,  as  he  should 
be.  Henderson  shows  he  could  be  made  self-supporting.  This  problem  of 
the  feeble-minded  is  not  so  hopeless  as  most  of  the  superintendents  of 
institutions  for  such  would  have  us  think.  They  never  taught  one  of  these 
children,  so  how  can  they  know,  and  few  have  had  a  scientific  education. 
Educate  the  children,  normal  and  abnormal,  and  according  to  their 
needs  the  physician  and  the  educator  should  work  together  to  this  end. 

Let  the  physical  needs  of  children  be  considered  first  in  our  educational 
system. 

The  following  is  translated  from  a  lecture  given  by  Professor  Mosso: 
"To  Paul  Flechsig  is  due  the  credit  of  having  shown  that  our  cerebral  nerve 
fibers  are  not  complete  at  birth,  and  that  the  white  nerve  paths  come  from 
the  medulla,  extending  from  the  periphery  toward  the  center. 

*ln  man  the  brain  develops  later  than  in  other  animals.  For  this  fact 
that  the  brain  develops  so  slowly,  I  am  able  to  discover  no  other  reason  than 


PREVENTIVE  MEDICINE   IN   A  NEGLECTED   DIRECTION.  531 

this,  that  at  birth  the  organs  which  effect  movements  over  which  the  brain 
later  exercises  its  authority,  are  not  yet  developed. 

"The  brain  of  man  slowly  develops  up  to  forty  years.  Kaes  found  that 
up  to  the  fortieth  year  there  are  found  in  the  cerebral  convolutions  new 
plexuses  of  nerve  fibers,  which  are  lacking  in  younger  brains. 

'Excitation  of  the  senses  and  impulses  to  movement  hasten  the  devel- 
opment of  the  nerves  in  question. 

"The  experiments  of  Ambrau  and  Held  has  shown  that  if  one  eye  of 
a  new-bom  kitten  is  opened  to  the  light,  the  other  remaining  closed,  the 
optic  fibers  of  the  eye  remaining  open  to  the  stimulation  of  light  are  more 
quickly  surrounded  by  myeline  than  those  of  the  other.  Another  important 
fact  is,  that  the  motor  fibers  are  completed  earlier  than  the  sensory. 

''These  facts  must  apply  to  pedagogy  (I  would  substitute  for  the  word 
pedagogy  the  department  of  education),  only  that  science  can  show  how 
injurious  is  precocious  instruction  for  the  development  of  the  child. 

"If  we  wish  to  hasten  the  maturity  of  the  brain,  we  must  decide  whether 
the  formation  of  the  myeline  can  better  be  hastened  by  stimulation  of  the 
senses  and  intellectual,  or  better  by  muscular  exercises.^' 

The  latter  way  seems  to  Angelo  Mosso  the  more  natural. 

We  must,  therefore,  to  begin  with,  consolidate  the  motor  nerve  paths 
which  develop  first,  and  after  that  seek  to  develop  the  portion  of  the  brain 
concerned  with  intellectual  work. 

Diagnosis  of  morbid  conditions  of  childhood  involve  something  more 
than  mere  search  for  evidence  of  disease.  During  the  period  of  plasticity 
numerous  influences  prevail  in  all  ranks  of  life  to  alter  normal  growth  and 
organic  development  by  which  the  foundations  of  constitutional  weakness 
are  often  laid.    These  are,  in  a  great  measure,  preventable,  at  least  in  part. 

We  must  know  more  of  normal  growth  and  the  phenomena  of  develop- 
ment. The  facts  are  at  hand,  but  we  pass  them  by.  Normal  processes  are 
profoundly  modified  by  peculiarities  of  temperament,  inherited  or  acquired. 

What  are  we  teaching  our  medical  students  of  the  child?  Should  he 
not  have  all  the  known  scientific  facts  of  childhood,  mental  as  well  as  physical — 
in  health  and  disease — all,  too,  that  anthropology  can  give  us  of  the  history  of 
the  child? 

A  few  who  are  making  for  the  best  in  educational  matters  have  this 
knowledge. 

Where  is  the  medical  school  that  will  have  a  chair  of  child  study  ?  The 
child  is  father  of  the  man. 

Gradually  we  are  awakening  to  an  appreciation  of  the  fact  that  the 
same  general  methods  of  investigation  that  are  applicable  in  the  study  of 
all  biological  sciences,  may  be  successfully  adopted  in  attacking  the  prob- 
lems of  mental  diseases  and  mental  deficiency. 

Where  is  the  university  that  will  have  a  department  for  the  solution  of 
these  problems? 

"The  presence  of  such  would  show  that  the  leaders  of  men  were  as 


532  PREVENTIVE  MEDICINE   IN  A  IS^EGLECTED   DIRECTION. 

much  interested  in  endeavoring  to  increase  the  public  sanity  as  they  are  in 
the  results  of  exploration  in  the  uttermost  parts  of  the  earth." 
Let  us  have  preventive  medicine  and  preventive  morals. 
We  will  not  get  far  on  the  road  until  Ave  have  scientific  studies  of  the 
feeble-minded,  not  just  psychologists  in  institutions  for  such.  The  physi- 
cians in  those  institutions  need  psychology.  There  is  a  great  need  for  a 
scientific  department  as  well  as  an  educational  department  there,  to  tell  us, 
why  do  some  diseases  make  for  idiocy  and  not  others  ?  Why  are  a  sufficiently 
large  number  immune  from  some  of  the  contagious  diseases  to  make  the  fact 
a  remarkable  one  ?  Why  do  three  times  as  many  die  of  tuberculosis  as  among 
normal  people?  Why  is  eczema  contagious  among  the  feeble-minded? 
Are  food  instincts  of  special  idiots  of  interest  to  the  evolutionist?  Why  are 
rudimentary  organs  in  low  grade  feeble-minded  larger  than  in  normal 
children?  The  teeth  furnish  interest  to  the  anthropologist.  The  study  of 
speech  would  soon  have  us  using  speech-therapeutics  in  our  clinics  not  only 
for  the  abnormal,  but  for  the  normal.  If  speech  training  were  to  be  intro- 
duced into  the  lower  grades  of  our  schools,  many  a  "backward"  child  would 
be  saved  to  future  usefulness.  The  speech  center  and  the  leg,  arm,  and 
finger  centers  are  adjacent  to  that  of  music.  Finger  g}Tnna sties  and  music 
are  given  to  assist  in  developing  the  right  co-ordinations  and  to  develop  the 
motor  area  of  the  brain.  "Music  is  the  language  of  the  unconscious  in  us, 
the  expressions  of  our  forebears  were  more  than  play"  (G.  Stanley  Hall). 
I  have  known  cases  where  music  has  been  the  basis  of  developing  the  mathe- 
matical concept  in  "backward  children."  Music  trains  hearing;  mental  ability 
and  hearing  are  correlated. 

Make  a  study  of  Plato's  fourteen  boys  in  his  twenty-seven  dialogues,  and 
get  interested  in  types,  and  so  know  the  soils  disease  grows  in;  get  at  tbe 
root  of  these  matters. 

The  following  show  some  of  the  conclusions  drawn  after  investigations 
on  abnormally  nervous  chiklren  in  Chicago,  in  which  Dr.  John  Dewey  was 
interested : — 

Nutrition  and  feeding  have  a  direct  bearing  on  both  physical  and  mental 
states.  Preference  in  foods  frequently  results  in  the  preferred  food  being 
better  digested.  By  regulating  the  diet  as  to  quantity  and  quality  to  suit 
individual  preference  and  needs,  better  digestion  was  obtained.  A  close 
relation  exists  between  pulse  deviation  and  non-elimination.  A  close  rela- 
tion exists  between  deviation  and  supra-normal  and  subnormal  effort. 

There  is  close  relation  between  baths  and  sleep.  Young  nervous  cliildren 
require  hot  baths  at  least  once  a  day  to  help  reduce  the  nervous  condition. 
Emotional  tone  greatly  affects  mental  effort  and  physical  activity  substan- 
tiating this  relationship;  there  were  found  some  very  interesting  points. 
Emotional  tone  is  greatly  affected  by  the  amount  of  sleep  per  day.  Nervous 
children,  because  of  their  greater  activity,  require  more  carbohydrates. 

In  addition  the  investigation  brought  to  light  facts  valuable  in  tracing 
the  mental  deviation  back  to  physical  causes. 


THE   PHILADELPHIA    WATER    SUPPLY.  533 

Stomach  incligestion  produces  acerbity  of  disposition:  over-sensitiveness, 
fretfulness,  irritability. 

Obstruction  of  the  small  intestine  produced  variability,  erratic  conduct, 
and  similar  manifestations.  Obstruction  of  the  large  intestine  produced 
stupidity,  languor,  accompanied  by  heavy  headaches,  particularly  over  the 
eyes.    Melancholia,  moodiness  and  moroseness  were  also  an  accompaniment. 

The  above  will  illustrate  what  might  be  accomplished  were  we  to  have 
scientific  departments  in  our  institutions  for  the  feeble-minded. 


Editorial 


THE  PHILADELPHIA  WATER  SUPPLY. 

"Philadelphia  water  is  as  good  as  is  fur-  "There  is  not  a  filter  bed  in  the  entire 

nished  to  any  city,  and  entirely  satisfac-  system  that  is  furnishing  pure  water — there 
toxj."  —Eesolutions  of  Councils,  September  16,  never  has  been  pure  filtered  water  in  this 
1909.  city." — Interview  President  Municipal  Improve- 

ment Co.,  North  American,  September  22,  1909. 

The  controversy  regarding  the  Philadelphia  water  supply  has  assumed 
such  shape  as  to  make  it  of  the  deepest  interest  to  its  physicians  and  people. 
The  resolution  of  the  City  Councils  quoted  above  would  indicate  that  Philadel- 
phia possesses  the  most  modem,  best  equipped  and  scientifically  operated  fil- 
tration system  in  the  world.  If  this  statement  is  not  true  it  is  calculated  to 
do  great  damage,  for,  reassured  by  evidence,  authoritative  and  apparently 
trustworthy  that  they  have  pure  water,  the  people  may  in  the  security  of  that 
assurance  consume  it  for  a  beverage  and  for  cooking  purposes  with  lesser  pre- 
caution as  to  deleterious  results  on  account  of  the  confidence  thus  inspired. 

In  controversion  to  the  resolution  of  the  Councils,  it  is  claimed  by  the 
President  of  the  Municipal  Improvement  Co.  that  Philadelphia's  great  filtra- 
tion plant  is  rendered  virtually  useless  through  incompetence  of  the  men  who 
handle  it;  that  analyses  of  raw  water  taken  from  the  Delaware  and  Schuylkill 
Rivers,  from  the  affluent  wells  and  from  the  distributing  reservoirs,  analyses 
soon  to  be  made  public,  will  show  how  this  incompetence  is  affecting  the 
water  being  dealt  out  to  the  public  and  what  dangers  its  use  involves.  Need  it 
be  urged  that  the  health  of  the  community  is  mainly  dependent  upon  the  purity 
of  the  total  amount  of  water  it  consumes,  and  that  we  are  dealing  therefore 
with  the  most  important  of  the  many  factors  which  affect  the  death  rate  of 
our  city? 

Which  of  these  claims  is  right?  Whom  shall  we  believe?  How  shall  this 
important  question  be  settled?  Is  it  not  one  which  belongs  essentially  to  the 
domain  of  the  physician,  who  alone  in  the  community  is  conversant  with  its  many 
scientific  phases,  especially  those  concerned  with  the  preservation  of  health? 
His  daily  training  as  a  diagnostician  endows  him  with  discernment  as  keen 
ag  his  voice  is  far  reaching,  and  were  he  in  the  present  issue  to  study  the  ques- 


534  THE    PHILADELPHIA    WATER    SUPPLY. 

tion  in  detail  and  express  an  unbiased  opinion,  the  public  would  be  strongly 
influenced  by  his  advice  in  whichever  direction  it  would  tend.  Do  the  contend- 
ing parties  have  confidence  enough  in  the  justice  of  their  cause  and  the  com- 
pleteness of  their  proof  to  place  its  decision  with  the  profession  best  equipped 
to  render  a  just  and  impartial  verdict? 

We  repeat  again,  that  hoth  of  the  two  statements  quoted  at  the  beginning 
of  this  article,  so  absolutely  antagonistic,  cannot  he  true;  that  no  more 
important  question,  than  that  as  to  vjhich  is  true,  is  to-day  before  the  medical 
profession  and  the  people  of  Philadelphia.  On  one  side  is  the  boast  of  the  city 
government  as  to  the  purity  of  the  water  which  it  is  giving  to  its  citizens;  on 
the  other  is  the  official  statement  of  a  corporation  whose  engineers,  chemists 
and  bacteriologists  it  is  claimed  are  second  to  none  in  America,  that  the 
supply  is  absolutely  unfit  for  use  and  that  the  water  given  the  people  of 
Philadelphia  is  better  before  being  filtered  than  after. 

It  will  not  do  for  any  medical  journal  or  any  medical  man  to  remain 
inactive  and  silent  under  such  conditions.  It  is  a  vital  matter,  a  matter  con- 
nected in  every  manner  with  the  well-being  of  Philadelphia  and  its  people  that 
the  truth  or  the  falsity  of  these  respective  claims  be  established.  If  the  water 
the  people  of  Philadelphia  are  receiving  is  what  it  is  claimed  to  be  by  the  resolu- 
tion of  the  Philadelphia  Councils,  its  physicians  and  people  should  know  it  that 
they  may  rest  secure  in  that  knowledge  and  not  be  harassed  by  tormenting 
fears  and  anxieties,  and  on  the  other  hand,  if  it  is  as  vile  and  disease-laden 
as  is  claimed  by  the  President  of  the  Municipal  Improvement  Co.,  that  fact 
too  should  be  known  at  once  that  the  city  may  rise  in  its  power  and  take  im- 
mediate action  toward  the  correction  of  such  a  fearful  condition. 

The  Monthly  Cyclopedia  and  Medical  Bulletin  calls  upon  all  of  its 
medical  friends  and  its  friends  associated  with  collateral  science  to  assist  in 
the  quick  solution  of  this  problem.  It  calls  upon  the  physicians  of  Philadel- 
phia to  take  up  this  matter  at  their  society  meetings,  in  their  laboratories  and 
Clinics  and  after  making  investigation  to  make  public  the  results  of  that  inves- 
tigation; it  calls  on  the  daily  papers  of  Philadelphia  to  make  quickly  pnblic 
whatever  facts  these  investigations  may  develop. 

If  we  have  the  best  water  in  the  world,  let  us  so  establish  that  fact  that 
we  may  pride  ourselves  in  the  knowledge  and  make  it  known  far  and  wide  to 
the  benefit  of  the  city  and  its  material  interest  beyond  the  reach  of  criticism, 
question  or  doubt,  and  if,  unfortunately,  the  reverse  should  prove  the  fact,  then 
let  the  city  show  to  the  world  by  the  quickness  of  its  action  that  Philadelphia, 
if  slow,  is  nevertheless  never  slow  when  established  facts  that  threaten  the 
integrity,  the  health  and  prosperity  of  its  people  confront  it. 

In  earnest  appeal  to  all  medical  and  collateral  interests  and  in  the  full 
confidence  that  the  President  of  the  ]\Iunicipal  Improvement  Co.'s  state- 
ment, if  a  slander,  shall  be  quickly  refuted,  and,  if  the  truth,  shall  by  the  power 
of  the  medical  profession  of  Philadelphia  and  the  patriotism  of  her  people 
soon  cease  to  be  a  fact,  this  editorial  is  written. 

C.  E.  DE  M.  Sajous. 


ABDOMINAL    OPERATIONS. 


ABDOMINAL   PHENOMENA. 


536 


Q^clope^dla  of  Current  I^iterature 


ABDOMINAL  OPERATIONS,  EARLY  RISING 
ATTER. 

The  writer  does  not  believe  in  keeping 
patients  upon  whom  laparatomy  has  been 
performed  several  weeks  in  bed.  On  the 
contrary  if  there  are  no  indications  of 
fever  he  is  inclined  to  let  them  get  up 
after  a  few  days,  dependent  greatly  on 
the  patient's  own  desire.  But  when  there 
is  fever  the  patients  are  kept  in  bed,  as 
he  believes  that  early  rising  may  do  harm 
in  such  cases.  The  objections  usually 
urged,  dangers  of  secondary  haemorrhage, 
breaking  open  of  the  wound,  and  embol- 
ism, he  considers  theoretical  rather  than 
practical.  Hartog  (Berliner  klinische 
Wochenschrift,  March  15,  1909). 

ABDOMINAL      OPERATIONS,      ERUPTIONS 
AFTER. 

In  an  attempt  to  discover  the  cause 
of  the  skin  eruptions  seen  so  often  after 
abdominal  operations,  the  author  found 
that  these  occurred  most  often  in  patients 
who  were  given  an  enema  of  soap  suds 
made  from  common  yellow  soap,  but  if 
castile  soap  were  substituted  no  eruption 
followed.  This  was  corroborated  by  the 
fact  that  in  exchanging  the  yellow  for 
the  castile  soap  in  other  patients  who  had 
these  eruptions  it  was  found  tliat  the 
yellow  soap  produced  rashes,  whereas  the 
castile  soap  did  not.  It  was  then  found 
that  the  cheap  and  common  yellow  soap 
contained  a  considerable  quantity  of 
resin,  and  to  this  tlie  writer  believes  the 
cause  of  many  of  the  rashes  seen  after 
abdominal   section   must   be   attributed. 


F.  J.  Shepherd  (Journal  of  Cutaneous 
Diseases,  July,  1909) . 

ABDOMINAL    PHENOMENA   WITH   INCIP. 
lENT  PNEUMONIA. 

Two  cases  have  been  encountered  by 
the  writer  in  which  the  syndrome  decep- 
tively simulated  appendicitis  but  in  a  few 
days  the  abdominal  symptoms  subsided  as 
severe  pneimionia  became  installed.  In 
one  of  the  cases  there  was  an  interval  of 
nine  days  before  the  symptoms  of  pneu- 
monia became  manifest.  In  both  these 
cases  and  in  13  of  31  reported  by  Ben- 
necke  the  pneumonia  terminated  in  an 
abscess  or  other  serious  complication. 

The  necessity  for  differentiating  these 
cases  of  "pneumogenic  abdominal  shock" 
from  actual  appendicitis  is  beyond  ques- 
tion, as  a  useless  appendicectomy  would 
weaken  the  pneumonia  patient.  The 
most  important  points  in  differentiation 
are:  (1)  the  expression  of  the  face, 
which  is  not  so  distressed  as  in  appen- 
dicitis; (2)  the  tongue,  which  is  gen- 
erally moist  and  not  much  coated;  (3) 
the  rapid  breathing;  (4)  the  rigidity  of 
the  abdominal  wall,  which  is  never  so 
circumscribed  as  in  beginning  appen- 
dicitis ;  the  abdomen  is  only  superficially 
tender,  deep  pressure  is  not  particularly 
painful;  (5)  careful  objective  examina- 
tion of  the  chest,  regardless  of  the 
assumed  appendicitis.  Differentiation 
may  be  rendered  much  more  diflBcult  by 
drugs  previously  given.  In  the  writer's 
first  case  the  patient  was  subject  to  lead 
colic  and  opium  was  given  at  first,  which 


536 


ABORTION,    TREATMENT   OF. 


ADENOIDS    IN    INFANCY. 


masked  the  diagnosis  for  a  time.  It  is 
probable  that  the  pain  caused  by  the 
inflammation  in  the  lung  is  reflected  into 
the  abdomen.  The  irritation  may  even 
be  transmitted  through  the  sympathetic 
nervous  system  to  the  splanchnic  nerves, 
inducing  tj-mpanites.  B.  Glaserfeld 
(Berliner  klinische  Wochenschrift,  Aug. 
2,  1909). 

ABORTION,  TREATMENT  01. 

In  th«  course  of  a  clinical  lecture  the 
author  remarks  that  the  main  task  in 
treatment  of  abortion  during  the  first 
seven  months  is  to  arrest  the  hajmorrhage, 
but  later  the  task  is  to  ensure  the  com- 
plete emptying  of  the  uterus.  He  warns 
that  the  curette  should  never  be  used  with 
a  vesicular  mole  as  it  is  impossible  to 
know  the  extent  of  the  destruction  of 
the  uterus  wall.  After  the  uterus  has 
been  cleared  with  the  finger,  he  rinses  it 
out  with  two  or  three  liters  of  70  per 
cent,  alcohol  in  every  case  of  abortion. 
Franz  (Deutsche  medizinische  Wochen- 
Bchrift,  July  1,  1909). 

ACHYLIA  QASTEICA. 

The  various  causes  that  result  in 
achylia  gastrica  probably  dijffer  in  nature : 
(a)  Those  that  accompany  pernicious 
anaemia  apparently  result  from  a  definite 
atrophy  of  glandular  parenchyma  of  the 
stomach,  (b)  Others  seem  to  follow  gas- 
tritis, (c)  Others  appear  to  be  second- 
ary to  general  infection,  possibly  from 
gastritis,  as  is  seen  after  typhoid  fever, 
syphilis,  etc.  (d)  There  remains  a 
large  group  in  which  from  unknown 
causes,  the  secretion  becomes  more  and 
more  depressed  until  complete  achylia 
is  established.  It  has  been  suggested 
that  the  trouble  in  the  beginning  is 
functional,  and  that  subsequently  gland 


structure  disappears,  siniilar  to  atrophy 
from  lack  of  use  in  other  regions.  In 
attempting  to  follow  the  course  of  cases 
apparently  about  to  become  complete 
achylia  gastrica,  there  is  confessedly  a 
source  of  possible  error  through  misinter- 
pretation. A  case  which  shows  a  trace 
of  combined  chlorides  or  a  faint  biuret 
reaction  may  go  on  to  complete  loss  of 
secretion ;  but,  on  the  other  hand,  secre- 
tion may  be  found  restored  if  the  case 
is  studied  long  enough.  Nevertheless, 
these  patients  should  be  studied  in  rela- 
tion to  achylia  gastrica,  because  in  them 
only  are  we  able  to  discover  achylia  gas- 
trica in  its  process  of  development. 

The  author  reports  132  cases,  of  which 
number  62  were  males,  70  females.  Ages 
were  from  twenty-one  to  seventy-two 
years;  but  only  five  patients  were  under 
thirty  and  only  one  beyond  seventy. 
There  were  29  patients  between  the  ages 
of  thirty  and  forty;  37  patients  between 
forty  and  fifty;  28  between  fifty  and 
sixty;  and  25  between  sixty  and  sixty- 
nine.  C.  G.  Stockton  (American  Jour- 
nal Medical  Sciences,  August,  1909). 

ADENOLDg  IN  IKEASOY. 

The  writer  criticizes  the  neglect  of 
adenoids  in  early  infancy  as  they  inter- 
fere with  the  proper  development  of  the 
child  by  reflex  action,  by  the  irritation 
they  produce  and  the  obstruction  they 
cause.  The  post-nasal  pharynx  at  birth 
is  a  space  only  one-quarter  inch  high  by 
one-third  inch  wide,  eo  that  a  very  slight 
adenoid  hypertrophy  at  this  period  will 
cause  obstruction.  At  the  end  of  the 
first  year  it  is  nearly  doubled  in  size.  It 
often  produces  symptoms  in  the  first  days 
of  life  and  the  mistake  is  sometimes  made 
of  diagnosing  specific  disease.  The 
inuflBes  are  specially  marked  while  the 
child  is  nursing  and  result  from  an  ade- 
noid which  produces  irritation,  and  if 


BUTTERMILK  IN  INFANT  FEEDING. 


ECZEAIA,  TREATMENT  OF.        537 


large  enough  to  obstruct  the   pharynx, 
there  is  mouth  breathing.    Other  causes 
may  produco  mouth  breathing  but  ade- 
noids do  so  most  frequently  during  the 
first  year  of  life.    A  third  indication  of 
the  condition  is  the  appearance  of  recur- 
rent colds  which  during  the  first  year  are 
usually  caused  by    adenoids.      Another 
most  characteristic  sign  is  a  persistent 
cough,  sometimes  simulating  whooping- 
cough,  without  any  other  indication  in 
the  pharynx  or  bronchi  to  account  for  it. 
A  fifth  and  most  dangerous  condition  is 
otitis  media.    It  is  not  always  easy  in  a 
very   young    infant    to    determine    the 
presence  of  adenoids,  but  it  can  be  done 
by  rapid  manipulation.    The  right  index 
finger  being    rapidly    passed    into    the 
mouth  while  the  jaw  is  held  open  by  the 
ends  of  the  fingers    of    the    left   hand 
pressing  on  the  teeth,  the  rough  surface 
of  the  adenoid  can  be  detected  by   the 
skilled    physician    and    sometimes    so 
quickly  that  the  baby  does  not  even  cry. 
The  author  describes  the  operation  of 
removal  of  adenoids  which  can  be  done 
quickly  without  an  ana?sthetic  and  with 
very  little  shock  or  lasting  fright.    If  an 
anajsthetie  is  used  it  should  be  nitrous 
oxide  and  only  enough  to  produce  pri- 
mary anaesthesia  and  the  patients  should 
be  warned  of  the  possibility  of  a  lym- 
pathic  constitution  and  the  dangers   of 
ansesthesia  in  that  case.     Adenoid  hy- 
pertrophy which  causes  persistent  symp- 
toms should  be  operated  on  as  early  as 
the  third  or  fourth  month  of  life.    The 
operation  should  be  done  rapidly  and 
without  an  anaesthetic.    E.  G.  Freeman 
(Journal  American  Medical  Association, 
August  21,  1909). 

BTJTTEEMILK  IN  INFANT  FEEDING. 

The  superiority  of  buttermilk  in  ions 
adapts  it  better  for  infant  feeding  than 
cow's  milk.    Human  milk  contains  little 


albumin,  little  ash  and  large  proportions 
of  ions ;  cow's  milk,  much  albumin,  much 
ash,  few  ions,  while  "buttermilk  gruel" 
contains  much  albumin,  much  ash  and 
quantities  of  ions.  Cow's  milk  contains 
casein  in  the  form  of  casein  salt,  while  in 
buttermilk  it  is  in  the  form  of  casein 
acid,  which  explains  its  greater  digesti- 
bility. 

The  writer  regards  the  introduction 
of  buttermilk  into  infant  feeding  as  not 
only  a  progress  in  respect  to  practical 
results  but  also  in  the  deeper  insight  it 
allows  into  the  desiderata  of  infant 
feeding.  He  approves  of  the  "butter- 
milk gruel,"  wliich  is  made  of  sour 
cream,  the  acidity  not  too  pronounced. 
The  buttermilk  must  be  fresh  each  day ; 
one  liter  is  mixed  with  60  Gm.  cane 
sugar  and  15  Gm.  wheat  flour,  boiled  up 
three  times  and  then  distributed  in 
sterilized  bottles  each  representing  one 
meal.  The  ions  in  the  buttermilk  evi- 
dently cause  inversion  of  the  cane  sugar 
to  some  extent.  H.  Koeppe  (Deutsche 
medizinische  Wochensehrift,  June  17, 
1909;  Journal  American  Medical  Asso- 
ciation, July  31,  1909). 

ECZEMA,  TREATMENT  OF. 

A  number  of  patients  with  eczema  are 
reported  by  the  author,  who  had  been 
successfully  treated  with  crude  coal  tar, 
which  he  regards  as  superior  as  a 
siccative  and  antipruritic  to  all  other 
topical  applications.  The  agent  is 
employed  in  the  following  manner: 
The  surface  to  be  treated  is  first 
thoroughly  freed  from  crusts  and 
scales  and  then  carefully  washed  with 
boiled  water,  and  if  not  too  sensitive  it  is 
afterward  soaped  and  wiped  off  with 
ether.  The  tar  is  then  applied  in  a 
thick  layer  and  allowed  to  dry  for  a  con- 
siderable time,  the  longer  the  better,  the 
drying  being  an  important  part  of  the 


638 


ELEPHANTIASIS. 


EPISTAXIS. 


technic.  When  it  has  dried  as  long  as 
possible,  not  less  than  twenty  minutes, 
several  hours  if  jiossible,  it  is  powdered 
with  talc  and  enveloped  in  a  soft  cloth. 
If  the  skin  is  not  too  much  inflamed 
nor  the  oozing  too  abundant,  it  is  well 
not  to  touch  the  dressing  for  two  days. 
If  the  inflammation  and  oozing  are 
marked  it  is  useful  to  dress  the  parts 
with  a  simple  zinc  paste  the  next  day. 
After  five  to  six  days  the  application  of 
the  tar  may  be  repeated.  Usually  three 
to  five  applications  are  sufficient  for  a 
cure.  Exceptionally  it  may  excite  in- 
flammation, but  the  writer  finds  that  it 
is  better  tolerated  than  almost  any  other 
local  remedy.  Brocq  (Bull,  de  la  Soc. 
Franc,  de  dermat.  et  de  sj'phil. ;  Ameri- 
can Journal  Medical  Sciences,  August, 
1909). 

ELEPHANTIASIS,  TREATMENT  OF. 

Dr.  Dubriel  de  Broglio,  of  the  French 
colonial  medical  service  originated  a 
treatment  of  elephantiasis  consisting  of 
ihe  internal  administration  of  30  drops 
of  tinctura  ferri  chloridi  three  times 
daily,  in  combination  with  bandaging  of 
the  affected  limbs  and  complete  rest  in 
bed.  The  writer  determined  to  make 
the  experiment  of  administering  the 
tinctura  ferri  chloridi  without  banda- 
ging and  permitting  the  patient  to  follow 
liis  usual  mode  of  life.  In  every  case  so 
treated,  the  patient  lias  shown  decrease 
in  tlie  size  of  the  affected  part  within  a 
few  weeks,  and  the  effect  on  the  fever  is 
apparent  even  sooner.  He  therefore  con- 
cludes, as  a  result  of  these  experiments, 
that  tinctura  ferri  chloridi  has  a  marked 
effect  on  the  elephantoid  process,  de- 
creasing the  size  of  the  affected  parts 
and  restoring  function  to  an  even 
greater  degree.  Its  most  marked  effect, 
however,  is  on  ihe  attacks  of  elephanioid 
fever,  these  attacks  being  markedly  less- 


ened in  severity,  the  interval  between 
attacks  being  greatly  lengthened,  and  in 
several  of  the  cases  the  attacks  have  ap- 
parently ceased.  In  one  of  prolonged 
elephantoid  fever  with  very  marked  chy- 
luria  of  three  weeks'  duration,  the  ch}'- 
iuria  disappeared  entirely  within  sixty 
hours  under  the  administration  of  tinc- 
tura ferri  chloridi  alone.  So  far  as  can 
be  judged  from  the  number  of  cases 
treated,  elephantiasis  appears  to  be  ar- 
rested by  this  treatment  if  continued 
for  six  to  twelve  months,  and  if  some 
method  can  be  devised  in  conjimction 
therewith  to  dispose  of  the  elephantoid 
tissue  already  formed,  the  author  be- 
lieves that  a  cure  may  be  looked  for. 
P.  S.  Eossiter  (United  States  Kaval 
Medical  Bulletin,  July,  1909). 

EPISTAXIS,  TREATMENT  OF. 

The  essential  thing  to  do  in  order  to 
stop  a  too  abundant  epistaxis  is  to  plug 
the  nasal  passages  properly  and  effec- 
tively. This  may  be  done  by  taking  a 
strip  of  aseptic,  absorbent  cotton,  such 
as  comes  in  layers,  and  twisting  it  round 
and  round,  so  that  it  becomes  the  size 
of  the  little  finger;  then  with  a  good 
light  the  lower  and  middle  meatus 
should  be  filled  as  far  back  as  possible, 
on  one  or  both  sides  of  the  nose,  using 
a  nasal  speculum,  and  a  director  or  stiff 
probe  for  the  purpose.  Post-nasal  plug- 
ging is  rarely  called  for.  When  the  epis- 
taxis is  slight,  or  moderate,  it  is  as  a 
nilo  unwise  to  attempt  to  stop  it.  Cold 
may  be  applied  to  the  frontal  region,  or 
a  little  cold  water  may  be  snuffed  up. 
Nature  not  infrequently  allows  bleeding 
from  the  nose  as  a  relief  from  symptoms 
or  as  a  protection  from  other  troubles 
more  important.  Profuse  nasal  hemor- 
rhage, arterial  in  character,  comes  from 
the  artery  of  the  septum,  not  far  back 
from  the  anterior  nares.     A  saturated 


EXOPHTHALMIC    GOITER. 


HAEMOPTYSIS, 


639 


solution  of  copper  sulphate,  applied  one 
or  more  times  by  means  of  a  cotton- 
covered  probe,  ^rill  probably  cure  it. 
This  the  ^Titer  considers  the  best  local 
application  to  make  and  is  superior  to 
chromic  acid,  silver  nitrate,  or  the  elec- 
tric cauteiy.  Beverly  Eobinson  (New 
York  Medical  Journal,  July  31,  1909). 

EXOPHTHALMIC  GOITER. 

A  new  lid  sign  has  been  observed  by 
the  writer.  It  consists  of  the  following 
manifestation :  While  on  downward  ro- 
tation of  the  globe  the  lower  lid  is  gen- 
tly fixed,  the  patient  is  then  requested  to 
rotate  the  globe  rapidly  upward  while 
gentle  retraction  is  made  on  the  lower 
lid;  the  globe  now  ascends  in  an  un- 
steady manner — much  in  the  same  way 
as  the  upper  lid  does  in  the  von  Graef  e's 
sign.  It  is  markedly  accentuated  in  the 
presence  of  an  exophthalmos,  but  is 
just  as  variable  in  its  appearance  as  any 
of  the  other  symptoms  and  no  more 
value  is  to  be  attached  to  it  than  to  any 
of  the  preceding  ones.  It  has  been  found 
more  often  in  the  absence  of  exophthal- 
mos than  with  it — however,  most  often 
in  conjunction  with  a  von  Graefe  or  Gif- 
ford  sign.  G.  F.  Suker  (Ophthalmic 
Eecord,  July,  1909). 

HiEMOPTYSIS,  TREATMENT  OF. 

If  the  smallest  amount  of  blood  stain- 
ing is  noticed  in  the  sputum  it  should  be 
looked  on  as  a  danger  signal,  and  the  pa- 
tient ought  at  once  to  be  put  to  bed. 
Calomel  gr,  ij,  iij,  or  iv,  should  be  given, 
depending  on  the  patient,  followed  in  the 
morning  by  5j  or  more  of  magnesium  sul- 
phate; if  necessary,  this  may  be  repeated 
in  the  day.  The  patient  remains  in  bed 
for  a  couple  of  days,  taking  the  mag- 
nesium sulphate  each  morning,  and  if  no 
more  staining  appears  he  is  allowed  to 
get  up,  beginning  with  two  or  three  hours 


the  first  day.  If  the  staining  conthiues 
while  the  above  treatment  is  given,  the 
amount  of  milk  may  be  reduced  to  one 
pint  daily  and  the  patient  is,  of  course, 
kept  in  bed  till  the  sputum  is  clear  for  at 
least  three  days. 

Acute  hfemoptysis  is  treated  by  prop- 
ping up  the  patient  in  bed.  Amyl  nitrite, 
minims  10  to  15,  is  inhaled.  In  a  slight 
ha?morrhage  this  is  usually  sufficient. 
Smaller  amounts  than  10  minims  do  not 
usually  have  much  effect.  In  larger 
haemorrhages,  particularly  when  the  nose 
gets  blocked  up  with  blood  it  may  be 
necessary  to  put  from  30  to  GO  minims 
on  a  piece  of  lint  and  hold  it  over  the 
patient's  mouth.  In  some  cases,  this  has 
been  repeated,  and  the  only  complaint 
the  patient  made  was  that  it  produced  a 
feeling  of  nausea.  Turpentine  (m.  xxx 
to  Ix)  may  be  used  as  an  inhalation  when 
amyl  nitrite  is  not  at  hand,  or  spirits  of 
turpentine  (m.  x  to  xxx)  may  be  given 
internally  and  repeated.  Morphin  has 
been  given  with  good  results  in  slight 
cases;  its  action  is  probably  due  to  the 
relief  of  anxiety  from  the  sedative,  M'ith 
consequent  quieter  action  of  the  heart. 
Adrenalin  (m.  v  of  a  1  to  1,000  solution) 
has  been  injected.  It  is  said  to  be  use- 
ful in  cavity  cases  where  it  is  likely  that 
the  hemorrhage  is  due  to  the  erosion  of  a 
medium-sized  vessel.  On  the  other  hand, 
it  is  said  to  be  contraindicated  when  the 
haemorrhage  is  from  a  ruptured  vessel, 
but  is  useful  in  congestive  hwmorrhnge. 

It  should  be  a  general  rule  that  when 
the  haemorrhage  is  large  and  the  cavity  is 
known  to  be  present,  the  patient  should 
be  made  to  lie  on  the  side  on  which  the 
cavity  is  located.  Subsequent  to  acute 
ha-morrhage  the  patient  is  kept  in  bed,  if 
possible,  propped  up  a  little.  Purgatives 
are  given,  beginning  with  calomel  (gr.  ij 
to  iv),  followed  by  magnesium  sulphate, 
one,    two    or    three    times    daily;     the 


540 


LARYNGEAL  TUBERCULOSIS. 


LOBAR   PNEUMONLi. 


amount  and  time  must  depend  on  the 
jjatient's  condition.  Milk,  one  pint, 
must  be  given  in  twenty-four  hours,  and 
all  other  fluid  cut  off  as  much  as  possible, 
and  the  patient  fed  on  solids.  In  some 
cases  calcium  lactate,  gr.  xv,  has  been 
given  thrice  daily  for  three  days  and  then 
omitted  for  three  days,  and  so  on.  Or 
calcium  chlorid  (gr.  x  to  xlv)  in  water 
or  milk,  every  four  or  six  hours,  may  be 
given  in  a  similar  manner.  These  cal- 
cium salts  increase  the  coagulability  of 
the  blood  and  thus  tend  to  check  hremor- 
rhage.  It  is  not  wise  to  examine  the 
chest  too  frequently  during  or  immedi- 
ately after  an  attack  of  hsemoptysis.  J. 
E.  Squire  (Clinical  Journal,  June  16, 
1909). 

LARYNGEAL  TUBEECULOSiS. 

Tuberculous  hyperplasia  in  the  larynx 
has  not  infrequently  undergone  resolu- 
tion, in  whole  or  in  part.  Unmistakable 
tuberculous  ulcers  have  occasionally 
healed  and  remained  healed.  Favorable 
negative  qualities  have  characterized  in 
common  the  cases  which  have  proved  to 
be  capable  of  arrest  or  recovery;  for  in- 
stance, the  lar}Tigeal  hyperplasia  has 
been  less  progressive,  less  diffused,  and 
less  prone  to  ulceration;  the  underlying 
pulmonary  infection  has  been  less  ex- 
tended; there  were  fewer  tubercle  bac- 
illi, a  lower  pulse-rate,  and  less  emacia- 
tion. These  qualities  persisting,  the 
patients  who  are  capable  at  least  of  a 
hopeful  resistance,  can  be  distinguished, 
thus  justifying  every  effort  at  any  sacri- 
fice to  invoke  the  methods  likely  to  ar- 
rest the  disease  and  lead  to  recovery,  in- 
cluding intralaryngeal  surgery  when  the 
lesions  in  degree  and  kind  are  suitable 
for  it.  In  like  manner  the  nonresistant 
type  should  be  recognized  and  those  pa- 
tients guarded  from  the  privation  and 
distress  which  surely  follow  in  the  wake 


of  an  indiscriminate  exposure  to  the  ele- 
ments and  to  the  hardships  of  travel  in 
distant  climes.  In  them  surgery  is  con- 
traindicated  excepting  to  prevent  air 
hunger  and  suffocation,  or  to  prevent 
starvation  by  the  removal  of  some  par- 
ticularly painful  impediment  in  swal- 
lowing. W.  E.  Casselberry  (Journal 
American  Medical  Association,  August 
7,  1909). 

LOBAH    PNEUMONIA,    EMPYEMA    AND 
DELAYED  RESOLUTION  IN. 

From  a  study  of  a  series  of  cases  in 
lobar  pneumonia,  the  writer  concludes 
that  in  the  majority  of  instances  empy- 
ema may  be  regarded  as  a  complication 
of  pneumonia,  rather  than  a  sequel.  It 
occurs  relatively  much  more  often  in  the 
colored  than  in  the  white  race.  Fever 
■was  the  only  manifestation  always  pres- 
ent. The  physical  signs  are  variable, 
and  it  is  well  to  remember  that  vocal 
fremitus  may  be  retained,  even  v;ith  a 
considerable  amount  of  exudate.  Of  the 
physical  signs,  changes  in  the  breath  and 
voice  sounds  were  the  most  useful  single 
manifestations  in  diagnosis.  The  re- 
peated use  of  the  needle  in  all  doubtful 
cases  is  important. 

The  factors  usually  considered  to  be  of 
importance  as  affecting  the  occurrence  of 
delayed  resolution,  such  as  apical  involve- 
ment, advanced  age,  debility,  and  cach- 
exia, do  not  seem  to  have  any  influence. 
As  regards  age,  three  quarters  of  the 
patients  were  between  the  ages  of  seven- 
teen and  forty  years.  The  conditions 
whicli  did  seem  to  affect  the  incidence 
especially  were  (a)  color  and  (b)  in- 
volvement of  the  lower  right  lobe.  The 
colored  showed  a  relative  high  incidence 
as  compared  with  the  white  race.  The 
lower  lobe  of  the  right  lung  was  con- 
cerned much  more  frequently  than  any 
other,  both  in  the  total  number  of  cases 


LUPUS   ERYTHEMATOSUS. 


NAUSEA. 


541 


aud  relatively  in  proportion  to  the  num- 
ber of  cases  in  which  it  was  involved  in 
the  pneumonic  process.  The  cause  of 
this  is  obscure,  unless  it  be  diminished 
movement  on  account  of  the  relationship 
to  the  liver. 

The  physical  signs  show  great  varia- 
tion and  no  general  description  can  be 
given  of  them.  This  applies  both  to  the 
sijms  during  the  continuance  of  the 
delayed  resolution  and  during  clearing. 
The  diagnosis  must  frequently  offer  diffi- 
culty and  can  often  only  be  made  by 
exclusion  of  other  possibilities.  Empy- 
ema and  tuberculous  pneumonia  are  the 
conditions  which  give  the  greatest  trouble. 

As  regards  prognosis,  while  the  danger 
to  life  is  not  great,  it  is  never  safe  to 
predict  absolute  restoration  in  the  lung. 
Permanent  change  may  appear  in  a  short 
time.  The  use  of  the  x-rays  is  the  most 
hopeful  therapeutic  measure,  but  these 
must  always  be  used  with  caution  aud 
only  after  the  diagnosis  is  positive. 
Thos.  McCrea  (Montreal  Medical  Jour- 
nal, July,  1909). 

LUPUS  ERYTHEMATOSUS,  SOLID  CARBON 
DIOXID  IN. 
During  the  last  two  years  the  writer 
has  employed  only  the  solid  carbon 
dioxid  in  the  treatment  of  lupus  erythe- 
matosus, and  has  found  it  very  effective. 
Being  a  solid  body  it  can  be  whittled  into 
any  desired  shape.  The  strength  and 
amount  of  application  can  be  gauged 
with  the  utmost  nicety  by  varying  the 
time  and  the  pressure.  Solid  carbon 
dioxid,  however,  has  further  advantages. 
It  is  a  cold  cautery,  and  therefore  an 
anaesthetic  cautery.  This  is  a  most  im- 
portant point.  While  other  efficient 
cauterizing  agents,  almost  without  excep- 
tion, are  so  painful  that,  save  with 
patients  of  considerable  fortitude,  a  local 
anaesthetic  at  least  is  required  when  they 


are  used,  carbon  dio>dd  can  be  employed 
on  women  and  children  without  any 
trouble  at  all.  The  intense  cold  itself  is 
a  local  anajsthetic.  The  pain  at  the  time 
of  the  application  is  trivial;  a  few 
minutes  later  there  is  a  moderate  amoimt 
of  burning  similar  to  that  after  a  frost- 
bite. This  wears  off  entirely  in  an  hour 
or  two.  W.  S.  Gottheil  (Xew  York 
Medical  Journal,  July  3,  1909). 

NAUSEA. 

The  symptom  of  nausea  has  received 
insufficient  attention  from  medical  men. 
The  author  enumerates  the  causes,  in- 
cluding parasites,  especially  intestinal, 
arteriosclerosis,  retention  of  urine  from 
prostatic  hypertrophy,  brain  tumors, 
urasmia,  and  icterus.  In  these  cases  the 
nausea  is  accompanied  by  other  more 
prominent  subjective  and  objective 
symptoms.  It  is  rare  in  gastritis,  but 
may  be  found  in  connection  with  vomit- 
ing in  conditions  of  stasis,  and  is  com- 
mon when  there  is  abnormal  formation 
of  gas  in  the  stomach  or  intestine.  Of 
the  cases  in  which  nausea  is  the  promi- 
nent s}Tnptom  the  majority  are  in  fe- 
males and  a  close  connection  with  the 
various  phases  of  menstruation  is  found. 
Genital  and  other  hasraorrhages  are  apt 
to  induce  it.  Slighter  causes  may  sufffee 
to  evoke  it,  and  it  is  frequently  purely 
of  psychic  origin.  A  condition  of  under- 
nutrition is  generally  present.  Nausea 
is  not  closely  connected  with  the  taking 
of  food,  but  is  more  influenced  by  posi- 
tion and  is  usually  removed  or  lessened 
by  recumbency.  The  symptom  probably 
depends  on  a  vasomotor  disturbance  of 
the  cerebral  circulation  which  is  favored 
by  anaemia,  but  with  which  the  stomach 
itself  has  nothing  to  do,  as  is  sho\vn  by 
the  fact  that  the  secretory  activity  of 
the  organ  is  unaltered,  or,  if  there  is  a 
slight  deviation,  it  is  in  the  direction  of 


542 


OVERFEEDING  OF  CHILDREN. 


hypoacidily  rather  than  hyperacidity. 

The  diagnosis  is  usually  easy,  but,  es- 
pecially in  men,  careful  physical  exam- 
ination should  eliminate  all  possible  or- 
ganic causes.  Even  in  women,  too  ready 
recourse  to  a  psycluc  explanation  may 
cause  a  beginning  pregnancy  to  be  over- 
looked. The  prognosis  is  usually  good, 
although  there  are  rare  obstinate  cases. 
If  the  malady  is  very  chronic  a  long 
course  of  treatment  will  be  needed. 

In  the  treatment  proper  psychic 
measures  should  be  instituted  and  rest 
should  be  insisted  on  as  the  most  im- 
portant remedy.  The  diet  should  be 
easily  digestible,  palatable,  and  suffi- 
ciently nourishing.  Hot  compresses  to 
the  head  have  been  useful  in  the  writ- 
er's experience.  Massage  is  objection- 
able in  the  early  stages  and  forced  or 
excessive  feeding  should  be  avoided. 
The  bromides  are  useful  in  cases  of  mod- 
erate severity.  Chloral,  which  may  give 
good  results  in  mild  cases,  fails  utterly 
in  the  severe  ones.  Chloroform  is  pallia- 
tive, but  of  no  permanent  value,  and 
cocaine  has  proved  disappointing.  Mor- 
phine in  small  doses  hypodcrmically  is 
indicated  only  in  the  severe  cases,  and 
here  the  author  regards  its  use  as  ques- 
tionable on  account  of  possible  serious 
consequences  and  of  the  uncertainty  of 
its  effect.  While  medicinal  treatment  is 
of  little  value,  rest  and  patience  will 
usually  load  to  success,  I,  Boas  (Ber- 
liner klinische  Wochenschrift,  June  14, 
1909;  Journal  American  Medical  Asso- 
ciation, July  31,  1909). 

OVEREEEDINQ  OP  CHILDREN, 

The  taking  of  too  much  food  of  all 
kinds  usually  causes  such  attacks  as  are 
described  by  the  laity  as  biliousness. 
The  attacks  recur  with  greater  or  less 
frequency,  and  are  characterized  by  fever, 
a  coated  tongue,  foul  breath,  headache, 


malaise,  often  drowsiness;  there  is  often 
vomiting  or  diarrhoea  or  both,  and  the 
liver  may  be  somewhat  enlarged  and  ten- 
der. A  brisk  purge  and  limitation  of 
the  diet  usually  are  all  that  is  needed. 
Too  much  protein  causes,  as  a  rule,  much 
the  same  symptoms.  Sometimes  some 
one  symptom  is  especially  prominent,  as 
recurring  headache,  or  recurring  neural- 
gia or  attacks  of  vomiting,  or  in  milder 
cases  periods  when  the  tongue  is  furred 
and  breath  foul  without  much  other  dis- 
turbance. Too  much  fat  is  a  frequent 
cause  of  trouble,  and  many  cliildren  are 
often  intentionally  overfed  with  fat. 
These  are  cases  of  malnutrition  in  which 
large  quantities  of  butter,  cream,  cod- 
liver  oil,  and  other  fats  are  given  with 
the  idea  of  fattening  the  child  and  re- 
storing its  normal  condition.  The  result 
is  that  the  nutrition  is  not  improved,  but 
is  usually  made  worse.  The  child  is 
unwell,  has  a  pale,  muddy  skin,  and  large 
dark  circles  under  the  eyes;  one  of  the 
most  striking  features  is  a  coated  tongue 
and  exceedingly  foetid  breath.  There  is 
gastric  disturbance  and  vomiting  is  fre- 
quent, and  there  is  often  diarrhoea  with 
the  passage  of  undigested  fat  in  the 
stools. 

The  carbohydrate  cases  are  the  com- 
monest of  all,  owing  to  the  fact  that  a 
great  many  children  are  given  large 
quantities  of  starches  and  sugars,  not 
only  at  their  meals,  but  between  meals  in 
the  shape  of  sweets  of  various  kinds, 
often  of  the  cheaper  varieties  of  candies. 
Many  children  have  a  very  low  capacity 
for  utilizing  sugar,  and  some  for  both 
sugar  and  starches.  As  in  the  other 
forms  the  periodicity  of  the  attacks  is  the 
most  striking  feature.  Perhaps  the  com- 
monest form  of  the  attack  is  recurrent 
vomiting,  although  this  may  be  seen  in 
cases  in  which  protein  metabolism  is  at 
fault.     In  some  instances  the  attack  con- 


POSTANiESTHETIC  VOMITING. 


TRYROID   INSTABILITY. 


)43 


sists  merely  of  fever,  or  a  sick  headache, 
while  in  other  cases  there  are  attacks  of 
asthma  wliieh  sometimes  follow  indiscre- 
tions in  diet. 

Having  found  out  the  food  factor  at 
fault,  an  effort  should  be  made  to  deter- 
mine about  what  quantity  of  that  par- 
ticular food  can  be  utilized,  then  to  keep 
the  child  on  a  diet  well  within  the  limits 
of  its  powers  of  assimilation.  In  addi- 
tion to  this  it  is  exceedingly  important 
to  see  that  the  bowels  are  regular,  and  a 
rather  good  plan  is  to  use  some  fairly 
active  purge  at  least  once  a  week.  Out- 
door life  and  plenty  of  exercise  are 
exceedingly  important  and  many  patients 
are  greatly  benefited  by  a  sojourn  in  the 
country,  not  at  a  summer  resort,  but  on  a 
farm  where  a  very  active  outdoor  life 
may  be  led  without  too  much  restriction 
in  the  matter  of  observing  social  forms. 
John  Euhrah  (Journal  American  Medi- 
cal Association,  July  10,  1909). 

P0STAN2ESTHETIC  VOMITING,  TREAT- 
MENT OF. 

The  most  rational  way  to  treat  and 
prevent  nausea  and  vomiting  after  amics- 
thcsia  appears  to  be  to  promote  in  every 
way  the  elimination  of  the  circulating 
anaesthetic.  That  is  to  say,  the  patient 
should  be  kept  warm  so  that  the  skin  may 
act  frccl}^,  and  renal  secretion  should  be 
helped.  For  this  purpose  saline  enemata 
are  of  great  value,  and  one  should  be 
introduced  slowly  as  soon  as  the  patient 
is  back  in  bed.  In  some  hands  large 
quantities  of  saline  solution  are  intro- 
duced under  the  skin  slowly  and  for  long 
periods  of  time  after  severe  operations, 
and  it  is  claimed  that  not  only  is  shock 
diminished  in  this  way,  but  after-vomit- 
ing is  much  less  frequent.  While  elimi- 
nation is  thus  going  on,  the  less  put  into 
the  stomach  the  belter.  There  is  no  call 
for  anything  at  all  except  through  thirst. 


and  this  gives  little  trouble  if  enemata 
or  subcutaneous  injections  are  used. 
Washing  out  the  mouth  with  lemon  juice 
and  water  is  pleasant  for  the  patient, 
and  helps  to  allay  feelings  of  thirst. 
Preventive  treatment  with  glucose,  based 
on  chemical  theories  explaining  delayed 
chloroform  poisoning,  has  been  given  a 
trial  at  St.  George's  Hospital;  the 
results  do  not  show  any  marked  altera- 
tion of  the  ordinary  percentage  of  cases 
of  after-sickness.  J.  Blumfeld  (Medical 
Press  and  Circular,  June  16,  1909). 

THYROID  INSTABILITY. 

The  term  thyroid  instability  is  applied 
by  the  authors  to  a  series  of  morbid  con- 
ditions between  the  extremes  of  myxoe- 
dema  and  exophthalmic  goiter.  Condi- 
tions may  be  observed  in  which  the  symp- 
toms, simultaneous  or  successive,  indicate 
both  deficient  and  excessive  thyroid 
functioning.  This  is  the  result  of  a  gen- 
eral law  of  nature  that  an  organ  func- 
tioning defectively  strives  to  restore 
normal  balance,  and  when  this  is  reached, 
is  liable  to  go  beyond  it  with  an  exagger- 
ated function.  In  the  present  communi- 
cation the  authors  call  attention  to  a 
special  paroxysmal  form  of  thyroid  in- 
stability. This  comprises  a  number  of 
syndromes,  previously  classified  as  ncu- 
roarthritism  :  migraine,  periodical  vomit- 
ing, asthma,  urticaria,  eczema,  attacks  of 
mucomembranous  enteritis  and  waves  of 
chronic  rheumatism.  These  syndromes 
are  encountered  in  persons  with  pro- 
nounced thyroid  instability,  and  during 
the  paroxysm  the  whole  picture  of  thy- 
roid instability  is  observed,  while  certain 
symptoms  which  form  part  of  it  had  been 
hitherto  latent.  Another  argimient  is 
the  connection  between  these  syndromes 
and  the  sexual  sphere ;  owing  to  the  close 
relation  between  the  ovaries  and  the  thy- 
roid the  syndrome  sometimes  leads  to 


544      TROPICAL  ABSCESS  OF  LIVER. 


YEAST  IN  ABSCESS  IN  THE  EAR. 


h3'poplasia.  The  most  importaut  argu- 
ment, however,  is  that  thyroid  treatment 
will  cure  these  symptoms  and,  inversely, 
thyroid  treatment  is  capable  of  reproduc- 
ing them.  In  myxoedema  the  thyroid 
functioning  is  at  such  a  low  ebb  that 
there  is  no  reaction  for  restoration  of 
balance,  and  the  symptoms  are  contin- 
uous. Huchard  comments  \v'ith  approval 
on  the  authors'  work  in  this  unexplored 
field,  and  adds  that  essential  paroxysmal 
tachycardia  is  probably  due  to  paroxys- 
mal hyperfunctioning  of  the  thyroid. 
The  influence  of  the  thyroid  on  vascular 
affections  is  a  further  field  that  will  repay 
study.  Leopoid-Lev}^,  II.  de  Eothschild 
and  Huchard  (Bulletin  de  1' Academic  de 
medecine.  May  18,  1909 ;  Journal  Ameri- 
can Medical  Association,  July  10,  1909). 

TEOPICAI  ABSCESS   OF  IIVER,  PREVEN- 
TION OF. 

Ipecac  has  been  found  of  great  value  in 
the  treatment  of  the  hepatic  complica- 
tions of  ama^bic  dysentery  by  the  writer, 
preventing  suppuration  if  given  in  the 
presuppurative  stage  and  preventing  re- 
currences if  given  after  surgical  treat- 
ment. For  the  last  three  years  it  has 
been  usual  to  continue  full  doses  of  20 
to  30  grains  once  a  day  for  one  or  two 
weeks  after  the  temperature  fell  to  nor- 
mal, and  in  smaller  doses  for  some  time 
longer  in  the  more  acute  cases.  Full 
doses  arc  required,  and  as  much  as  60 
grains  at  a  time  have  been  administered. 
However,  full  effects  can  be  obtained  with 
half  that  amount,  while  in  feeble  pa- 
tients or  women  20  grains  usually  suffice. 
In  one  case  only  5-grain  doses  were  given 
by  mistake,  and  a  very  acute  hepatitis 
sul)sided  completely,  although  much  more 
slowly  than  is  usual  under  fuller  doses  in 


other  cases.  The  usual  method  is  to  give 
it  as  a  powder  twenty  minutes  after  a 
dose  of  tincture  of  opium,  or  better,  20 
grains  of  chloral  hydrate,  no  food  or 
drink  being  given  for  several  hours  be- 
fore and  after,  the  patient  being  kept  as 
quiet  as  possible  and  instructed  to  try  not 
to  vomit.  A  method  used  with  success  in 
the  Philippine  Islands,  and  also  recently 
in  Calcutta,  is  to  make  fresh  5-grain  pills 
of  ipecacuanha,  and  brush  them  over  with 
a  thick  coating  of  melted  salol,  which 
does  not  readily  dissolve  in  the  stomach. 
The  author's  plan  is  to  put  up  the 
powdered  drug  in  5-grain  doses  in  ker- 
atinized capsules,  which  do  not  dissolve 
in  the  stomach,  but  carry  the  drug  into 
the  bowel,  where  its  action  is  required. 
This  method  has  done  much  to  overcome 
the  objections  to  the  treatment.  L.  Rog- 
ers (Therapeutic  Gazette,  June,  1909). 

YEAST  IN  THE  TREATMENT  OF  ABSCESS 
IN  THE  EAR. 

Six  cases  are  reported  by  the  writer  in 
which  circumscribed  otitis  in  the  outer 
ear  was  treated  internally  with  yeast, 
taken  two,  three  and  four  times  a  day. 
The  tendency  to  recurring  furuncles  in 
the  ear  was  promptly  arrested  and  there 
has  been  no  recurrence  since.  The  pa- 
tients took  the  yeast  for  about  a  week. 
This  yeast  treatment  was  supplemented 
by  local  application  of  medicated  gauze. 
Under  the  influence  of  the  3'east  the  pain 
and  the  morbid  tendency  rapidly  sub- 
sided, although  the  furunculosis  had  long 
persisted  immodified  by  other  measures. 
N.  Antenore  (Gazetta  degli  Ospedali  e 
delle  Cliniche,  May  4,  1909;  Journal 
American  Medical  Association,  July  3, 
1909). 


ONTHLY    Cyclopaedia 

AND 

EDicAL   Bulletin 


Published  the  Last  of  Each  Month 


Medical  Bulletin  Section 


Vol.  II.  PHILADELPHL\,  SEPTEMBER,  1909.  No.  9. 


Clinical  Lecture 


GASTRIC  ULCER. 
By  JOHN  V.  SHOEMAKER,  M.D.,  LL.D., 

PHILADELPHIA. 

Professor  of  Materia  Medica,  Therapeutics,  Clinical  Medicine,  and  Diseases  of  the  Skin, 
in  the  Medico- Chirurgical  College  and  Hospital  of  Philadelphia. 

Gentlemen  :  Here  is  a  young  woman,  age  22  years ;  occupation,  house- 
wife; nativity.  United  States;  who  is  a  chronic  sufferer  of  gastric  pains  for 
the  past  seven  months.  She  was  admitted  into  the  hospital  by  the  chief  of  our 
out-patient  department. 

Family  History. — Her  father  died  of  cancer  of  the  stomach  at  the  age 
of  forty-nine  years,  and  her  mother  of  cancer  of  the  breast,  at  the  age  of  fifty- 
three  years.  She  has  two  brothers  living  and  in  good  health,  their  age  being 
thirty-three  and  twenty-six  years  respectively.  Her  only  sister,  age  twenty 
years,  is  living  and  well.  One  brother  died  in  infancy.  She  has  no  knowledge 
of  her  grandparents.  One  maternal  uncle  died  of  cancer  of  the  rectum,  and 
an  aunt  of  typhoid  fever. 

Previous  Personal  Uistory. — As  a  child  she  had  measles,  diphtheria  and 
whooping-cough.  At  the  age  of  16  years  she  had  an  attack  of  inflammatory 
rheumatism.     She  saw  her  first  menstruation  at  fourteen  years  of  age. 

Social  History. — She  is  married  and  has  one  child,  age  two  years.  Her 
husband  is  living  and  in  good  health.     Her  habits  are  good. 

Present  Ulness. — About  seven  months  ago  she  first  had  occasional  attacks 
of  pain  in  her  stomach  after  eating  a  full  meal.  In  the  course  of  a  few  weeks 
later  the  pain  became  more  severe  and  at  times  would  not  be  relieved  until 
vomiting  occurred.  By  experience  she  soon  learned  that  soft  and  liquid  foods 
agreed  much  better  with  her  stomach  and  thus  abstained  from  solid  foods. 
During  the  past  month  she  has  Tomited  two  or  three  times  and  each  time  the 

5  (545) 


546 


GASTEIO  ULCER. 


vomitus  contained  bright  blood.  She  complains  of  a  localized  pain  in  the 
epigastric  region,  two  inches  to  the  right  of  the  mid-sternal  line. 

Physical  Examination. — She  is  emaciated,  looks  pale  and  the  mucous  mem- 
brane of  the  mouth,  gums  and  conjunctivae  present  every  evidence  of  anemia. 
An  examination  of  the  thoracic  and  abdominal  viscera  does  not  reveal  any 
abnormality. 

Urinalysis. — Albumin,  negative;  glucose,  negative;  specific  gravity,  1018; 
reaction,  acid;   bile,  absent;   indican,  slight  reaction. 

Microscopic  Examination. — Casts,  absent;  erythrocytes,  absent;  leucocytes, 
absent;    phosphates,  absent;    urates,  absent. 

Blood  Examination. — Erythrocytes,  3,248,846;  leucocytes,  8,640;  hemo- 
globin, 70  per  cent. 

Diagnosis. — This  is  certainly  a  case  of  gastric  ulcer.  Her  age,  the  physical 
condition,  the  subjective  symptoms  of  localized  pain  in  tlic  epigastric  region 
the  bloody  vomitus  and  an[emia  are  tj'pical  symptoms  of  gastric  ulcer.  Chronic 
gastritis,  gastralgia  and  cancer  of  the  stomach  should  in  all  cases  be  dis- 
tinguished from  gastric  ulcer. 

Differential  Diagnosis : — 


Oastric  Ulcer. 

1.  Disease  is  primary. 

2.  Constant  thirst. 

3.  Hsematenicsis   common. 

4.  Presence  of  increased  amount  of  HCl. 

5.  Vomiting  is  combined  with  severe  par- 

oxysms of  pain. 

6.  Vomitus    contains    large    quantities    of 

blood. 

7.  Emaciation  rapid. 

Gastric  Ulcer. 

1.  Pain  intermittent  worse  after  eating. 

2.  Occurs  usually  in  adults. 

3.  Vomiting   of   large    amounts    of    bright 

red  blood. 

4.  Pain  is  relieved  by  vomiting. 

5.  Anaemia. 

6.  No  tumor  in  the  region  of  the  stomach. 

Ulcer  of  Stomach. 
1.  General   health  of  patient   is   impaired. 


2.  Paroxysms  of  pain  usually  come  on  a 

definite  period  after  eating. 

3.  Shorter  intervals  between  attacks. 

4.  Eating  rarely  relieves  pain. 

5.  Tenderness  on  pressure  between  attacks 

of  pain. 


Chronic  Gastritis. 

1.  Secondary    disease    of    heart,    liver,    or 

kidneys. 

2.  No  thirst. 

3.  Hffimatemesis  rare. 

4.  Diminution    in    proportionate    amount 

of  HCl. 

5.  Not  so. 

6.  Vomitus  contiiins  little  blood. 

7.  No   rapid   emaciation. 

Cancer  of  Stomach. 

1.  Pain  constant. 

2.  Occurs  usually  after  40  years  of  age. 

3.  ITieraatemesis     small     in     amount     and 

"coffee  grounds"  in  appearance. 

4.  Pain  is  not  relieved  by  vomiting. 

6.  Extreme   emaciation  and   cachectic   ap- 
pearance. 

6.  Presence    of     palpable     tumor  in     the 
epigastric  region. 

Gastralgia. 

1.  General    health    not    so    much    affected. 

Less     chlorosis     and     menstrual     de- 
rangement. 

2.  Paroxysms  more  frequent  when  stomach 

is  empty  tlian  soon  after  meals. 

3.  Longer  intervals  between  attacks. 

4.  Eating  xisually   brings   relief. 

5.  Not  so. 


GASTRIC  ULCER.  547 

6.  History  of  certain  occupations.    Antemia,       G.  History  of  neurastlienia,  neuralgia  and 
clilorosis,     amcnorrhcea,     tuberculosis  hysteria  common, 

and  diseases  of  the  heart  are  common. 

Pathology. — The  typical  gastric  ulcer  is  circular  in  outline  and  varies 
in  diameter  from  a  few  millimeters  to  three  or  five  centimeters.  The  majority 
are  not  larger  than  a  dime.  They  have  sloping  clean  cut  sides,  furnishing  a 
crater  or  truncated  cone-shape  with  the  broad  end  superficially  placed  corres- 
ponding to  that  of  an  infarcted  area  due  to  embolism  or  thrombosis.  The 
edges  may  be  irregular  and  rough,  but  are  often,  especially  in  older  ulcers,  quite 
smooth  and  roimded.  The  floor  of  the  ulcer  is  generally  clean  and  at  the 
autopsy  is  seen  below  the  mucous  membrane.  This  is  due  to  its  tendency  to 
extend  in  depth.  The  muscular  and  serous  coats  very  frequently  form  the  base 
of  the  ulcer  and,  sometimes,  the  ulcerative  process  extends  through  the  walls  of 
the  stomach.  The  lesser  curvature  and  posterior  wall  are  the  most  frequent 
seats.  Occasionally  they  are  found  at  the  fundus  or  at  the  cardiac  end.  In 
the  healing  of  ulcers,  scars  are  formed  in  the  walls  of  the  stomach.  They 
heal  by  cicatrization.  When  the  cicatrix  is  large,  it  causes  contraction  and 
deformity  producing  a  stenosis  of  the  pylorus  by  distorting  the  organ  even  to 
hour  glass  shape. 

The  organ  with  which  the  stomach  becomes  agglutinated  may  be  pen- 
etrated by  the  ulcerative  process  resulting  in  suppurative  inflanmiation  or 
there  may  be  a  fistulous  connection  between  the  stomach  and  other  adjacent 
structures.  Perforation  is  more  liable  to  take  place  when  the  ulcer  is  in  the 
anterior  wall.  Cases  have  been  reported  where  the  pericardium,  left  ventricle, 
spleen,  pancreas,  have  been  invaded. 

Constant  oozing  of  blood  may  be  due  to  the  erosion  of  the  surface  and 
larger  haemorrhages  may  result  from  ulceration  of  one  of  the  larger  arterial 
branches  of  the  stomach. 

Etiology. — The  great  majority  of  the  cases  of  gastric  ulcer  occur  in  young 
women  between  the  ages  of  twenty  and  thirty.  In  men  it  occurs  between 
thirty  and  forty.  It  is  especially  more  common  in  those  women  suffering  with 
chlorosis  or  anaemia  and  general  malnutrition.  It  is  often  secondary  to 
amenorrhoea.  Much  dispute  has  been  occasioned  as  to  the  pathogenesis  of 
these  ulcers  and  it  has  been  definitely  settled  as  due  to  the  digestion  of  a  part 
of  the  mucous  membrane  to  various  depths  resulting  in  the  formation  of  an 
ulcer.  Another  imiversally  accepted  view  is  that  it  is  due  to  a  reduction  in 
the  alkalinity  of  the  part  affected.  Other  factors  which  lessen  the  supply  of 
alkaline  arterial  blood  and  thus  permit  the  solvent  action  of  the  hydrochloric 
acid  are  thrombosis  and  embolism  of  the  nutrient  artery  with  infarction. 
Some  authorities  hold  that  this  disease  is  a  neurosis.  Spasm  of  the  blood- 
vessels in  localized  areas  and  thickening  of  the  walls  of  the  vessels  loading  to 
anaemia  have  been  advanced  as  causes.  Feeble  nutrition  and  traumatism  are 
important  factors.  Traumatic  injuries  may  be  produced  by  the  various 
occupations  in  which  the  pressure  is  exerted  upon  the  costal  cartilages  and 
which,  in  turn,  are  pressed  against  the  stomach,  such  as  in  shoemakers,  tailors, 


548  HEADACHES  AND  THEIR  TREATMENT. 

servants,  etc.     Tight  lacing  and  overdistention  of  the  stomach  are  considered 
by  some  as  important  causes  since  they  occasion  circulatory  disturbances. 

Treatment. — Diet  plays  an  important  role  in  the  successful  treatment 
of  gastric  ulcer.  Eest  in  bed  with  very  little  food  by  mouth,  and  lavage  of  the 
organ  will  do  more  to  relieve  her  symptoms  and  hasten  granulation  of  the 
idcer  than  all  other  medication.  We  will  keep  the  patient  alive  by  nutritive 
enemata  containing: — 

U  One  egg, 

Liquid  peptonoid    f3ij. 

Peptonized   milk    foVJ. 

Mi  see.     Signa.     Per  rectum  every  four  hours. 

To  keep  the  rectum  clean  and  healthy  so  that  the  best  results  of  the 
enemata  may  be  obtained,  a  cleansing  enema  of  a  normal  saline  solution  should 
be  given  at  least  once  daily.  The  patient  will  receive  nothing  by  mouth  for 
ten  days,  except  a  little  water  to  quench  the  thirst.  Lavage  with  a  gallon  of 
normal  saline-solution,  twice  dail}^,  is  followed  by  silver  nitrate,  grains  one- 
fourth  in  a  dram  of  mucilage  of  aeacise.  If  at  the  end  of  ten  days  the  patient 
has  sufficiently  improved,  peptonized  milk  broths,  lemon  and  orange  albumin 
are  given  by  mouth,  and  a  nutritive  enema  twice  daily.  Of  course,  as  the 
patient  progresses  more  liquid  foods  are  allowed  and  the  nutritive  enemata 
discontinued.  Lavage  once  daily  is  continued  until  all  symptoms  of  the  ulcer 
have  disappeared.  Our  attention  should  then  be  given  to  the  constitutional 
condition  of  the  patient.  She  is  angemic  and  emaciated;  hence,  good  food 
and  hsematinics  are  indicated.  A  formula  which  I  often  use  in  tliese  particular 
cases  contains: — 

IJ  Ferri   pyrophosphatis   solubilis    gr.   iij. 

Maugani  dioxidi   prsecipitati, 

QuininiB  bisulphatis,  of  each    gr.  j. 

Extracti   nucia   vomicae    gr.   i^. 

Extracti  gentianae    gr.   ij. 

Misee.    Fiat  capsula  No.  i. 

Signa.     One  sucli  capsule  four  times  daily. 


Original  Articles 


HEADACHES  AND  THEIR  TREATMENT.* 

By  GUTHRIE  RANKIN,  M.D.,  F.R.C.P.   (Lond.  and  Edin.), 
Physician  to  the  Dreadnought  and  Royal  Waterloo  Hospitals. 

There  is  probably  no  symptom  of  ill-health  more  frequently  encountered 
than  headache.  It  forms  part  of  the  picture  in  the  early  stages  of  most  of  the 
acute  organic  disorders;  is  a  frequent  accompaniment  of  chronic  disease;   and 

•  A  lecture  delivered  at  the  London  School  of  Clinical  Medicine. 


HEADACHES  AND  THEIR  TREAT^IENT.  549 

is  a  characteristic  phenomenon  in  many  functional  disturbances.  Its  manifes- 
tations are  varied  and,  in  some  of  its  more  distinctive  types,  it  constitutes  the 
predominant  feature  of  an  illness  and  guides  us  unerringly  to  the  correct 
recognition  of  its  cause.  It  is  uncommon  in  infancy  and  old  age,  and  is  much 
more  frequently  encountered  in  women  than  in  men.  It  may  be  induced  by  a 
variety  of  local  conditions,  such  as  disorders  of  the  teeth;  disease  in  the  throat, 
nose,  ear  or  eye;  refractive  errors;  rheumatic  or  gouty  affections  of  the  scalp 
muscles  or  fascia3;  or  it  may  ensue  upon  an  inflammatory  or  traumatic  lesion 
of  the  cranium.  It  is  not  infrequently  incited  by  atmospheric  conditions,  such 
as  a  cold  north-east  wind,  the  electrical  disturbance  of  the  air  accompanying  a 
thunderstorm,  or  atmospheric  impurities  in  an  overcrowded  room.  It  may 
result  from  sudden  and  extreme  exertion,  or  from  protracted  mental  or  physi- 
cal eSort.  But  most  frequently  of  all  it  depends  upon  errors  of  metabolism 
consequent  upon  irregular  habits  of  diet  and  exercise,  or  upon  the  occurrence 
of  constitutional  or  organic  lesions.  It  must  be  apparent  that  a  pain  which 
owns  such  a  multiplicity  of  causes  demands  considerable  care  in  its  investiga- 
tion, and  that  nothing  can  be  more  illogical  than  the  blind  faith  with  which 
the  public  swallows  this,  that,  or  the  other  headache-cure  boldly  advertised 
by  the  unscrupulous  quack  as  infallible.  It  is  impracticable,  in  the  time  at  my 
disposal,  to  present  any  complete  classification  of  all  the  varieties  of  headache. 
All  I  shall  attempt  is  to  select  a  few  of  the  leading  types  and  to  ask  you  to 
consider  with  me  how  these  can  be  differentiated  from  one  another,  and  along 
what  lines  their  treatment  may  be  conducted  with  the  best  chance  of  being 
successful. 

And  in  the  first  place  let  us  glance  at  the  most  frequent  of  all  forms  of 
headache — that  which  results  from  a  toxsemic  condition  of  the  blood.  A 
toxasmia  may  be  induced  either  by  poisons  introduced  from  without  or  by 
poisons  created  within  the  body.  Certain  drugs,  such  as  iron,  quinine,  salicin 
or  opium;  unwholesome  food  containing  ptomaines;  alcohol  when  taken  in 
more  than  physiological  amount;  and  tobacco  excessively  indulged  in  may  be 
mentioned  as  familiar  examples  of  substances  which  may,  when  taken  into  the 
body,  cause  headache.  The  cure  of  this  form  of  headache  is  obvious  and  con- 
sists in  the  withdrawal  of  the  poisonous  substance  which  is  responsible  for  its 
production.  When  it  happens  in  connection  with  the  legitimate  administra- 
tion of  drugs  for  curative  purposes,  the  headache  may  often  be  obviated  by 
their  admixture  with  suitable  correctives.  Quinine  can  often  be  tolerated  when 
combined  with  hydrobromic  acid;  opium  when  associated  with  belladonna  or 
one  of  the  aperient  alkalies ;  and  the  salicylates  when  presented  with  bicarbon- 
ate of  potash  or  aromatic  spirits  of  ammonia.  In  the  case  of  iron,  it  is  often 
found  that  one  of  the  milder  preparations  agi'ees  perfectly  when  the  more 
potent  varieties  of  the  drug  are  upsetting.  Also  it  is  noteworthy  that  the 
influence  of  the  milder  drug  may  be  reinforced  by  the  choice  of  a  combined  salt 
which  provides  with  the  iron  another  drug  selected  to  meet  the  diathetic  indica- 
tions of  the  case.  Such  useful  remedies  as  the  citrate  of  manganese  and  iron, 
the  valerianate  of  iron,  the  salicylate  of  iron,  the  syrup  of  quinine,  strychnine 
and  iron,  the  citrate  of  quinine  and  iron,  and  the  peptonate  of  iron,  may  be 


550  HEADACHES  AND  THEIR  TREATMENT. 

enumerated  as  useful  examples  of  this  class  of  drug.  In  regard  to  alcohol,  the 
subject  of  treatment  is  too  large  to  enter  upon  here,  but  it  may  be  mentioned,  in 
passing,  that  in  order  to  assist  the  patient  to  accomplish  the  total  abstinence 
which,  in  cases  of  an  established  alcoholic  habit,  is  essential,  he  may  be  helped 
by  such  a  prescription  as  the  following:  Extract  of  hydrastis,  two  grains; 
extract  of  belladonna,  one-twelfth  of  a  grain;  capsicin,  one-eighth  of  a  grain; 
and  strychnine,  one-thirtieth  of  a  grain:  given  in  the  form  of  a  pill  three  times 
a  day  after  meals.  Of  the  poisons  created  within  the  body,  apart  from  visceral 
disease,  those  which  ensue  upon  a  faulty  digestion,  excessive  alimentation, 
insufficient  exercise  with  consequent  ineffective  elimination  of  waste  products 
are  mainly  responsible  for  headache  and  other  evil  consequences.  This  variety 
of  headache  is  due  primarily  to  interference  with  hepatic  activity  and  to 
fermentative  or  putrefactive  processes  in  the  gastro-intestinal  tract.  For  its 
relief  the  food  must  be  of  the  simplest  and  most  bland  description  and  should 
be  carefully  adapted  to  the  patient's  digestive  capacity.  In  cases  where  the 
stomach  is  dilated  and  its  walls  are  flabby,  a  few  m.orning  washouts  through 
a  syphon-tube  followed  by  the  application  of  the  faradic  current  and  twenty 
minutes'  massage  to  the  abdominal  walls  will  be  found  useful.  In  patients 
who  have  to  blame  an  overnight  revel  or  an  unwise  evening  meal  for  their 
licadache,  the  speediest  means  of  relief  is  afforded  by  an  emetic.  In  order 
to  stimulate  hepatic  activity,  podophyllin,  gray  powder,  blue-pill,  calomel, 
iridin,  or  ieptandrin,  combined  with  either  colocynth  or  rhubarb  should  be 
resorted  to.  For  the  prevention  of  intestinal  fermentation,  antiseptics  are 
valuable  and  may  be  given  in  an  acid  or  alkaline  mixture  according  to  the 
indications  of  the  case. 

(a)  Dilute  hydrochloric  acid,  twenty  minims;  pure  carbolic  acid,  two 
grains;  strychnine  solution,  five  minims;  tincture  of  ginger,  twenty  minims; 
decoction  of  cinchona  bark  to  one  ounce:  to  be  taken  three  times  a  day  one 
hour  after  meals. 

(b)  Sulphocarbolate  of  soda,  ten  grains;  bicarbonate  of  foda,  fifteen 
grains;  tincture  of  nux  vomica,  ten  minims;  spirits  of  chloroform,  twenty 
minims;  compound  infusion  of  gentian  to  one  ounce:  to  be  taken  three  times 
a  day  one  hour  before  meals. 

In  cases  wliich  come  under  this  category,  lielp  is  also  afforded  by  the 
inclusion  in  the  daily  dietary  of  one  pint  of  sonred  milk.  This  is  conve7iiently 
prepared  at  home  by  the  use  of  the  lactic-acid  tabloids  put  up  by  Alien  and 
Hanbury  under  the  name  of  "Sauerin."  The  proper  degree  of  "souring"  is 
produced  in  the  milk  by  its  treatment  in  the  Sauerin  apparatus  supplied  by 
the  same  firm  which  is  sent  out  with  complete  directions. 

It  is  important  to  remember  that  in  all  these  conditions  personal  suscep- 
tibility plays  a  prominent  part.  One  person,  though  dyspeptic  all  his  life,  may 
Dover  have  known  what  headache  meant;  another,  on  the  slightest  upset  of  his 
digestion,  experiences  such  commanding  discomfort  or  pain  in  his  head  that 
he  is  thrown  quite  hors-dc-combat  so  far  as  work  or  effort  of  any  kind  is  con- 
corned.  To  one  person  alcohol  or  tobacco  seems  innocuous  even  in  liberal 
allowance;    to  another  the  most  moderate  indulgence  in  either  is  disastrous. 


HEADACHES  .\ND  THEIR  TREATMENT.  551 

To  the  average  person,  iron  or  opium,  in  proper  quantity,  produces  no  discom- 
fort, but  exceptions  are  not  uncommon  of  others  who  are  hopelessly  intolerant 
of  either  or  of  both.  Headache  accompanies  all  acute  fevers  and  inflammatory 
disorders.  It  is  as  a  rule  confined  to  the  earlier  stages  of  the  illness  and 
may  be  allayed  by  ice  or  cold-water  cloths  applied  to  the  scalp,  or  by  a  mustard 
piaster  to  the  nape  of  the  neck,  but  otherwise  its  treatment  becomes  merged  in 
that  of  the  general  disorder.  In  those  organic  diseases  which  occasion  con- 
tamination of  the  blood,  headache,  more  or  less  severe,  is  likely  to  be  in  evidence 
and  is  often  so  much  the  prominent  symptom  that  the  patient  begs,  above  all 
else,  to  be  speedily  relieved  of  it.  The  pain  of  the  toxsemic  headache,  however 
derived,  is  of  a  dull,  heavy  character,  is  generally  referred  to  the  forehead  and 
temples,  is  often  associated  with  flushing  of  the  face  and  injection  of  the 
conjunctivae,  and  is  accompanied  by  a  sense  of  mental  and  physical  prostration. 
Its  incidence,  duration  and  degree  vary  according  to  the  exciting  cause  and  it 
sometimes  presents  features  which,  when  read  into  the  text  of  the  general 
condition,  help  to  reveal  the  disease  behind  it;  as,  for  instance,  in  influenza, 
we  find  the  pain  is  specially  intense  in  the  globes  of  the  eyes,  or  in  enteric  fever 
where  it  is  often  the  earliest  and  most  continuously  persistent  symptom,  slight 
in  the  morning  but  increasing  in  intensity  towards  evening.  In  these  instances, 
and  many  similar  might  be  quoted,  the  meaning  of  the  headache  is  subsequently 
explained  by  the  evolution  of  the  disorder  producing  it,  but  regarded  'per  se, 
its  own  characteristics  often  serve,  from  the  beginning,  to  guide  the  diagnosis. 
The  susceptibility  of  gouty  and  rheumatic  people  to  headache  peculiar  to  their 
diathesis  is  not  sufiBciently  recognized.  In  a  patient,  proved  to  be  gouty  from 
the  experience  of  one  or  more  attacks  of  classical  great-toe  inflammation,  we 
are  not  surprised  to  find  a  history  of  frequent  moderate  headaches  which  yield 
to  a  dose  of  calomel  and  a  temporary  application  of  the  muzzle,  and  we  regard 
Buch  occurrences  as  the  inevitable  consequence  of  a  sluggish  liver  or  of  some 
passing  dietetic  indiscretion.  But  there  is  another  fonn  of  headache  to  which 
the  gouty  are  liable  which  is  of  more  serious  consequence  and  which  is  not 
infrequently  misinterpreted.  The  pain  is  of  sudden  onset  and  frequently  sets 
in  after  a  time  of  unusunl  stress;  it  is  bitemporal  in  situation,  throbbing  in 
character,  accentuated  by  movement,  accompanied  by  vertigo  on  any  sudden 
change  of  position,  and  frequently  increased  during  the  night.  It  is  mostly 
met  with  in  men  of  a  full  habit  of  body  and  is  accompanied  by  a  flushed  face; 
a  scanty  secretion  of  high-colored  urine  which  may  or  may  not  throw  down 
a  copious  deposit  of  lithates  on  standing;  nausea  and  loss  of  appetite; 
irregularity  of  bowels  with  abnormally  pale  stools;  mental  depression  and  con- 
fusion of  thought;  and  by  a  small,  rapid,  high-tension  pulse  often  associated 
with  palpitation  and  shortness  of  breath  on  exertion.  This  variety  of  headache 
is  suggestive  of  apoplexy  and  always  demands  prompt  and  active  attention. 
The  rheumatic  headache  is  of  quite  a  different  type.  It  affects  tbe  epicranial 
aponeurosis  and  the  tendinous  terminations  of  muscles.  The  pain  is  super- 
ficial and  causes  tenderness  of  the  scalp ;  it  is  often  specially  pronounced  over 
certain  circumscribed  areas  of  the  vertex  or  at  the  seat  of  one  or  more  tendinous 
insertions,  where  small  fibrous  swellings  are  not  uncommonly  to  be  felt  on 


552  HEADACHES  AND  THEIR  TREATMENT. 

palijation.     It  is  worse  in  the  evenings,  but  is  subject  to  constant  variations 
in  intensity  and  can  be  readily  excited  by  movements  of  rotation  of  the  head. 
In  tlie  headache  wliich  belongs  to  renal  disease,  the  pain  is  dull,  severe,  and 
constant;    it  occupies  the  entire  forehead,  and  is  accompanied  by  a  sensation 
of  fulness  within  the  head,  surging  in  the  ears,  dimness  of  sight,   and   a 
tendency  to  slight  delirium  and  subsequent  drowsiness.     Confirmatory  evidence 
of  its  etiology  is  furnished  by  vomiting  and  diarrhoea,  by  the  presence  in  the 
urine  of  albumin  and  casts;    sometimes  by  the  existence  of  retinal  changes; 
and  by  oppression  in  the  chest  and  asthma.     The  headache  which  occurs  as  a 
prominent  symptom  of  influenza  is  rapidly  relieved  by  such  a  prescription  as 
this:     Autipyrin,  ten  grains;    aspirin,  ten  grains;    citrate  of  eaffein,  three 
grains;    dispensed  in  a  cachet  and  given  every  three  or  four  hours  until  the 
pain  is  relieved.     In  enteric  fever,  headache  does  not  yield  in  the  same  satis- 
factoiy  way  to  analgesic  remedies;  it  is  more  amenable  to  chloral  hydrate  and 
potassium  bromide  than  to  most  other  drugs.     Ten  grains  of  chloral  with 
twenty  grains  of  one  of  the  bromide  salts  seldom  fail  to  give  temporary  relief. 
Bromidia,  which  is  a  mixture  of  chloral,  bromide  and  cannabis  indica,  is  a 
useful  preparation  in  many  enteric  cases ;   its  administration  at  bedtime  often 
ensures  a  good  night's  rest.     The  headache  which  so  often  troubles  the  person 
of  gouty  proclivities  ought  to  be  treated  on  the  lines  indicated  for  the  manage- 
ment of  dyspeptic  conditions,  but  in  that  form  of  sudden  and  severe  pain  in  the 
head  which  has  been  referred  to  as  a  specially  important  incident  in  patients 
who   have   previously   suffered   from   acute   gout,    more   active  measures    are 
indicated  and  in  addition  to  colchieum,  citrate  of  potash  and  the  usual  anti- 
gouty  remedies,  four  or  six  leeches  should  be  applied  to  the  temples,  and  the 
bowels  ought  to  be  copiously  evacuated  by  a  five-grain  dose  of  calomel  given  at 
bedtime,  followed  in  the  early  morning  by  two  teappoonfuls  of  Carlsbad  salt, 
repeated  every  hour  until  a  satisfactory  result  is  obtained.     The  headache  of 
rheumatism  is  always  relieved  by  the  local  application  of  warmth,  and  often 
yields  speedily  either  to  salophen  in  twenty-grain  doses  every  four  hours,  or 
to  a  combination  of  chloride  of  ammonium,  twenty  grains ;  saliein,  ten  grains ; 
and  phenacetin,  ten  grains :   given  three  or  four  times  a  day.     In  renal  head- 
ache simple  diluents  should  be  given  freely  and  the  diet  restricted  to  milk.     All 
the  eliminating  organs  must  be  stimulated.     The  skin  is  most  speedily  acted 
upon  by  pilocarpine  given  hypodermically  in  a  daily  dose  of  one-sixth  "to  one- 
quarter  of  a  grain,  the  patient  being  previously  placed  in  a  hot  pack  where  he 
should  remain  for  an  hour.     The  free  action  of  the  kidneys  will  be  promoted 
by  squills,  digitalis,  spirits  of  juniper,  acetate  of  potash,  or  cream  of  tartar; 
these  failing,  success  often  follows  the  administration  of  diuretin  in  ten-grain 
doses  every  four  hours.     The  bowels  should  be  excited  to  purgative  action  by 
compound  jalap  powder  in  forty-   to  sixty-grain  doses,  or  elaterium  in  a  dose 
of  one-quarter  of  a  grain,  or  croton  oil  in  such  a  pill  as  this :   Croton  oil,  one 
minim;    oil   of   earraway,   one   minim;    extract   of  colocynth,   three   grains. 
When  high  arterial  tension  and  asthma  are  obtrusive  symptoms,  as  they  often 
are  in  advanced  cases  of  interstitial  nephritis,  their  early  relief  is  an  urgent 
necessity.     This  is  sometimes  satisfactorily  accomplished  by  the  following  pre- 


HEADACHES  AND  THEIR  TREATMENT.  553 

scription:  Iodide  of  potassium,  ten  grains;  the  one-per-cent.  solution  of  nitro- 
glycerine, two  minims;  aromatic  spirit  of  ammonia,  half  a  drachm,  and 
chloroform  water  to  half  an  ounce — to  be  given  every  three  or  four  hours. 
When  the  iodides  disagree,  a  good  substitute  will  be  found  in  Gardner's  syrup 
of  hydriodic  acid,  every  drachm  of  which  contains  iodine  equivalent  to  ten 
grains  of  either  of  the  salts. 

Another  form  of  headache  which  demands  the  constant  attention  of  most 
of  us  is  migraine — or  as  otherwise  known,  on  account  of  its  common  unilateral 
distribution,  hgemicrania.  It  occurs  more  often  in  women  than  men,  is  more 
common  on  the  left  than  on  the  right  side  of  the  head,  and  is  often  hereditary. 
It  is  almost  as  frequent  in  childhood  as  in  adult  life,  and  generally  diminishes 
or  disappears  in  old  age.  It  is  always  associated  with  vasomotor  phenomena, 
and  is  frequently  accompanied  by  high  arterial  tension.  It  manifests  itself 
in  paroxysmal  attacks  and  is,  in  many  respects,  analogous  to  epilepsy.  The 
two  disorders  not  uncommonly  co-exist  in  different  members  of  the  same 
family.  The  migrainous  attack  usually  sets  in  during  the  early  hours  of  the 
morning  and  is  preceded  by  prodromal  warnings  such  as  vertigo,  yawning, 
dancing  specks  before  the  eyes,  zigzag  patterns,  or  tinnitus  aurium.  These 
sensations  correspond  closely  to  the  aura  that  precedes  an  epileptic  seizure. 
The  leading  feature  of  the  attack  is  pain  which  is  at  first  localized  to  a 
circumscribed  spot  over  one  eye  or  in  the  temple,  and  from  there  spreads  cir- 
cumferenlially.  It  often  remains  limited  to  one  side  of  the  head,  but  in  severe 
attacks,  it  may  involve  both  temples,  though  continuing  most  severe  on  the 
side  of  its  origin.  The  pain  is  continuous  and  steadily  increases  in  intensity 
until,  after  a  period  varying  from  one  to  six  or  more  hours,  it  reaches  its  acme 
in  an  attack  of  violent  retching  and  vomiting,  by  which  the  severity  of  the  suffer- 
ing is  considerably  diminished.  The  pain  is  accompanied  by  extreme  intoler- 
ance of  noise  or  light,  and  by  a  supreme  desire  to  be  left  alone  and  undisturbed. 
Finally  the  attack  terminates  in  a  troubled  sleep  from  which  the  sulierer 
awakes  free  of  headache,  but  languid  and  irritable.  Complete  restoration  to 
comfort  is  not  achieved  until  the  effect  of  the  nerve-stoiTa  upon  the  digestive 
organs  is  overcome  by  rest  together  with  suitable  medicinal  and  dietetic 
measures. 

Eemedics  for  the  relief  of  migraine  are  almost  without  number,  but  the 
most  that  can  be  expected  of  any  of  them  is  a  diminution  of  the  severity  and 
a  curtailment  of  the  duration  of  the  pain  once  the  attack  has  become  fairly 
established.  Preventive  treatment  can  do  no  more  than  endeavor  to  improve 
the  patient's  general  health  by  correcting  unhygienic  conditions  or  pernicious 
habits  so  that  an  increased  resisting  power  is  acquired  by  the  establishment  of 
greater  nerve  stability  and  increased  physiological  activity  in  the  secretory  and 
excretory  functions  of  the  various  organs.  On  the  first  threatcnings  of  an 
attack,  the  patient  should  lie  down  in  a  darkened  room,  and  if  the  cause  be 
immediately  preceding  fatigue,  ten  grains  of  antij)yrin  swallowed  with  one 
tablespoonful  of  brandy  and  water  will  often,  when  combined  with  one  or  two 
hours'  rest,  cut  short  the  pain.  In  more  acute  cases  such  simple  measures  are 
insufficient.     It  is  then  necessary  for  the  patient  to  go  to  bed  and  to  submit  to 


554  HEADACHES  AND  THEIR  TREATMENT. 

wholesome  starvation  for  twenty-four  hours.  Primary  relief  is  afforded  by  the 
application  of  cold  to  the  head  and  of  a  mustard-plaster  the  whole  length  of 
the  spine.  If  there  is  reason  to  suppose  that  the  stomach  contains  a  quantity 
of  undigested  and  fermentating  food,  it  should  be  emptied  by  an  emetic :  Thirty 
grains  of  sulj^hate  of  zinc  by  the  mouth,  or  one-eighth  of  a  grain  of  apomorpliia 
hypodermically.  For  the  immediate  relief  of  pain  there  is  a  long  list  of 
analgesic  drugs  to  choose  from.  I  find,  in  my  own  experience,  one  or  other 
of  the  following  combinations  most  effective: — 

(a)  Antifebrin,  two  grains;  citrate  of  caffein,  three  grains;  lupulin,  one 
grain. 

(b)  i\jitipyrin,  ten  grains;  aspirin,  ten  grains;  codein,  one-quarter  of 
a  grain. 

(c)  Pyramidon,  seven  grains;  dried  bromide  of  strontium,  ten  grains; 
valerianate  of  zinc,  two  grains. 

To  be  put  up  in  cachet  form  and  one  to  be  taken  every  two  hours  for  three 
doses  or  until  the  pain  subsides.  Afterwards  the  doses  to  be  taken  at  longer 
intervals. 

In  cases  of  extreme  severity,  when  all  the  remedies  of  the  foregoing  class 
fail,  it  may  be  exceptionally  necessary  to  resort  to  a  hypodermic  dose  of  one- 
quarter  of  a  grain  of  cocaine  or  morphia,  the  latter  being  most  efficacious  if 
given  in  combination  with  one-hundredth  of  a  grain  of  atropin.  When  the 
migrainous  attack  is  associated  with  a  pulse  of  high  tension,  whatever  remedy 
is  chosen  should  be  accompanied  by  nitro-glycerine  in  one  or  two  minim  doses, 
each  tabloid  being  allowed  to  melt  slowly  in  the  mouth.  Between  the  attacks 
of  pain  something  may  be  done  in  the  way  of  prevention  by  proper  regulation 
of  the  daily  life  as  regards  diet,  exercise,  clothing,  occupation,  etc. ;  by  keeping 
the  liver  active  with  occasional  small  doses  of  calomel  and  rhubarb,  and  by 
administering  arsenic  and  cannabis  indica  in  combination  with  an  intestinal 
antiseptic,  as  in  this  prescription:  Bctanaphthoj,  five  grains;  arsenate  of 
soda,  one-thirtieth  of  a  grain;  extract  of  cannabis  indica,  one-third  of  a  grain; 
extract  of  gentian,  two  grains :  to  be  put  into  a  capsule  and  taken  three  times 
a  day  after  meals. 

Closely  allied  to  migraine  is  yet  another  variety  of  headache  associated 
with  disturbance  of  one  or  other  branch  of  the  trigeminal  or  fifth  cranial  nerve. 
The  most  frequent  cause  of  this  neuralgic  headache  is  exposure  to  cold  and 
damp,  but  it  may  also  be  produced  by  the  irritation  of  a  decayed  tooth,  by 
disease  in  the  antrum,  or  by  the  pressure  of  an  inflammatory  exudation  or 
morbid  growth  near  one  of  the  bony  canals  traversed  by  a  branch  of  the  nerve. 
The  pain  is  deep-seated  and  of  a  stabbing  and  burning  character.  It  may 
involve  any  of  the  three  divisions  of  the  nerve  and  is  always  confined  to  one 
side  of  the  face.  It  varies  in  intensity,  but  in  its  more  severe  manifestations 
it  is  accompanied  by  spasmodic  unilateral  contraction  of  the  facial  muscles  and 
causes  the  patient  to  cry  out  with  the  agony  he  suffers;  it  is  then  known  as  tic 
douloureux.  Tender  spots  along  the  course  of  the  affected  nerve  are  character- 
istic and  are  most  commonly  found  at  the  supra-orbital  notch,  over  the  infra- 
orbital foramen,  in  front  of  the  ear,  or  at  the  seat  of  exit  of  the  inferior  dental 


HEADACHES  AND  THEIR  TREATMENT.  555 

nerve.  Another,  but  less  common,  form  of  neuralgic  headache  is  confined  to 
the  occipital  region  and  is  met  with  when  the  posterior  branches  of  the  first 
four  pairs  of  spinal  nerves  are  the  seat  of  disturbance.  The  first  indication 
for  treatment  is  the  removal  of  the  cause  when  this  can  be  ascertained  and  is 
possible  to  deal  with.  The  ears,  mouth,  throat  and  antra  must  be  investigated, 
and  particularly  the  teeth  should  be  minutely  examined,  special  care  being 
taken  to  ascertain  that  a  buried  stump  or  a  small  root-abscess  is  not  primarily 
responsible  for  the  pain.  The  local  application  of  sedatives  may  succeed  in 
relieving  the  intensity  of  the  suffering.  The  following  applications  are  useful 
for  this  pui-pose: — 

(a)  Menthol,  two  drachms;  pure  chloroform,  two  drachms;  olive  oil,  one 
and  a  half  ounces. 

(b)  Sulphate  of  atropin,  five  grains  dissolved  in  one  oimce  of  distilled 
water. 

(c)  Liniment  of  belladonna,  liniment  of  chloroform,  liniment  of  aconite 
and  soap  liniment  in  equal  parts. 

When  the  pain  becomes  very  acute  it  will  be  found  necessary  to  obtain 
initial  relief  from  one  or  more  subcutaneous  injections  of  moi-phia,  and,  to  be 
effective,  the  dose  must  be  from  one-quarter  to  half  a  grain.  Hyoscine  is  some- 
times more  successful  than  morphia.  It  may  be  given  hypodermically  in  doses 
of  one  two-hundredth  of  a  graui.  In  this  variety  of  headache,  gelsemium, 
which  seems  to  exercise  a  specific  influence  upon  the  peripheral  branches  of  the 
fifth  nerve,  should  always  be  administered.  It  is  well  to  search  for  some 
dyscrasial  tendency — gouty,  rheumatic,  malarial,  syphilitic,  or  anemic — as  a 
guide  to  the  selection  of  medicaments  which  may  enhance  the  curative  influence 
of  gelsemium,  and  from  the  following  formulae  that  should  be  chosen  v/hich 
seems  best  to  meet  the  indications  of  the  case  under  observation: — 

(a)  Citrate  of  potash,  thirty  grains:  compoimd  tincture  of  colchicum, 
twenty  minims;  tincture  of  gelsemium,  fifteen  minims;  decoction  of  tarax- 
acmn,  to  one  ounce. 

(b)  Salicylate  of  soda,  fifteen  grains;  antipyrin,  ten  grains;  tincture  of 
gelsemium,  fifteen  minims;   camphor  water,  to  one  ounce. 

(c)  Sulphate  of  quinine,  five  grains;  hydrobromic  acid,  half  a  drachm; 
tincture  of  gelsemium,  fifteen  minims ;  infusion  of  orange,  to  one  ounce. 

(d)  Iodide  of  potassium,  ten  grains;  Fowler's  solution,  three  minims; 
tincture  of  gelsemium,  fifteen  minims;  decoction  of  sarsaparilla,  to  one  ounce. 

(e)  Ammoniatcd  citrate  of  iron,  ten  grains;  acetate  of  ammonia  solution, 
one  drachm;  tincture  of  gelsemiimi,  fifteen  minims;  tincture  of  nux  vomica, 
ten  minims ;  peppermint  water,  to  one  ounce. 

Any  of  these  mixtures  may  be  taken  every  four  or  six  hours. 

In  some  intractable  cases  croton-chloral  succeeds  better  than  any  other 
druo-.  It  may  be  given  in  the  following  combination:  Croton-chloral-hydrato, 
four  grains;  extract  of  gelsemium,  one-quarter  of  a  grain;  lieroin,  one-twelfth 
of  a  grain:  in  a  pill,  every  three  or  four  hours  imtil  relief  is  obtained. 

Recently  cases  have,  from  time  to  time,  been  recorded  of  striking  tem- 
porary relief  being  obtained  by  injecting  the  main  trunks  of  the  nerve  at  their 


556  HEADACHES  AND  THEIR  TREATMENT. 

points  of  emergence  from  the  skull  with  an  eighty-per-cent.  solution  of  alcohol, 
according  to  Schlosser's  method.  The  administrative  teclmic  is  difficult, 
requires  the  assistance  of  an  annssthetic,  and  is  attended  with  a  considerable 
degree  of  subsequent  discomfort.  The  method  is  still  in  the  experimental 
stage  but  is  worthy  of  trial  before  being  driven  to  the  extreme  alternative  of 
resection  of  the  nerve  or  exi;irpation  of  the  Gasserian  ganglion. 

Time  will  only  permit  me  to  refer  casually  to  a  few  other  forms  of  head- 
ache. That  which  is  caused  by  organic  changes  affecting  either  the  meninges 
or  the  brain,  and  which  accompanies  such  conditions  as  meningitis,  intra- 
cranial tumor,  abscess,  or  hamiorrhage,  is  deep-seated  and  continuous,  is  made 
worse  by  stooping  or  exertion,  and  is  markedly  increased  at  night.  Its  dis- 
tribution is  often  frontal,  but  it  is  occipital  when  the  cerebellum  is  the  seat 
of  lesion,  and  may  occupy  any  part  of  the  scalp  in  an  area  overlying  a  cortical 
lesion.  Among  the  more  important  accompanying  symptoms  are  vomiting, 
optic  neuritis,  vertigo,  irregularity  of  pulse,  ocular  or  other  paralyses,  con- 
vulsive movements,  intellectual  aberration,  and  coma.  The  headache  of 
syphilis  is  peculiarly  given  to  nocturnal  exacerbation;  if  it  moderates  during 
the  day,  it  will  increase  in  severity  towards  a  certain  hour  of  the  night  and 
prevent  sleep.  In  meningitis,  the  pain  is  diffused  over  the  slmll  and  is 
accompanied  by  pyrexia,  photophobia,  retraction  of  the  head,  and  delirium. 
It  is  usually  accompanied  by  Kernig's  sign  and  by  a  recurrent,  sharp,  piercing 
cry.  In  apoplexy,  there  is  almost  always  a  prodromal  headache,  limited  to  one 
parietal  or  temporal  region  and  often  accompanied  by  confusion  of  thought 
and  vertigo.  The  headache  which  results  from  an  intracranial  gro'ui;h  should 
be  treated  initially  by  iodide  of  potassimn.  If  the  tumor  is  specific,  the  iodide 
may  prove  completely  curative,  but  it  is  also  capable  of  relieving,  to  a  certain 
extent,  the  pain  and  local  congestion  induced  by  non-specific  swellings.  It  is 
of  importance  to  remember  in  connection  with  the  administration  of  the  drug 
in  such  cases  that,  to  be  effective,  the  dosage  must  be  large — from  thirty  to 
forty  or  even  sixty  grains  three  or  four  times  a  day.  Many  of  you  saw  a  case 
with  me  in  the  wards  of  this  hospital  a  few  weeks  ago  in  which  forty  grains 
of  iodide  of  potafsium  given  every  six  hours  relieved  in  the  most  striking 
manner  Mdthin  a  week  the  agonizing  pain  of  a  headache  v/hich  had  almost 
driven  the  sufferer  craz,y,  and  which  for  a  considerable  time  previously  had 
made  sleep  at  night  an  impossibility.  If  treatment  by  iodide  fails  and  if 
the  clinical  signs  enable  the  situation  of  the  tumor  to  be  localized,  the  question 
of  possible  relief  from  surgical  interference  must  ahvays  be  considered.  When 
the  headache  is  due  to  meningitis,  thrombosis,  or  hremorrhage,  treatment  of 
the  pain  becomes  merged  in  that  of  the  general  condition.  The  headache 
of  eye-strain  dependent  upon  astigmatism,  presbyopia,  or  glaucoma  requires 
ophthalmoscopic  and  retinoscopic  examination  for  its  diagnosis  and  its  cure 
falls  within  the  province  of  the  ophthalmic  surgeon. 

The  headache  of  neurasthenia  is  probably  due  to  some  form  of  auto- 
intoxication, and  demands  for  its  relief  the  treatment  described  as  suitable  for 
toxfemic  headaches,  plus  the  system  of  rest,  massage,  isolation,  and  super- 
alimentation associated  with  the  Weir  Mitchell  plan  of  management.     It  may 


MEDICO-LEGAL.  557 

be  worth  mentioning  that  when  these  neurasthenic  cases  are  associated  as 
they  so  often  are,  with  disturbance  of  the  vasomotor  system,  distinct  improve- 
ment often  ensues  upon  the  exhibition  of  iehthyol  which  seems  to  have  a 
specific  influence  upon  the  vasomotor  centres  as  well  as  an  antiseptic  effect 
upon  the  gastro-intestinal  tract.  The  following  prescription  has  proved  of 
signal  service  to  me  in  a  large  number  of  such  cases:  Iehthyol,  four  grains; 
valerianate  of  zinc,  three  grains;  extract  of  cannabis  indica,  one-third  of  a 
grain;  arsenious  acid,  one-fortieth  of  a  grain;  iridin,  one  grain:  put  up  in  a 
capsule  and  given  after  food  three  times  a  day. 

Another  common  source  of  headache  is  met  with  in  the  two  opposite 
vascular  conditions  of  plethora  or  anaemia.  The  plethoric  headache  is  that 
which  characterizes  gouty  conditions,  or  threatened  apoplexy,  already  referred 
to,  but  it  is  also  met  with  at  the  onset  of  pyrexial  disorders,  in  certain  fonns  of 
valvular  heart  disease,  after  an  epileptic  seizure,  as  a  consequence  of  alcoholic 
excess,  or  sometimes  in  sudden  menstrual  suppression.  The  pain  is  best 
relieved  by  cold  to  the  head;  temporarj^  abstinence  from  food;  diluents; 
lactate  of  calcium,  or  an  alkaline  mixture  containing  bromide  of  potassium; 
and  temporary  rest  in  bed.  In  cases  where  the  cerebral  vessels  are  very 
loaded,  the  most  speedy  relief  is  obtained  by  venesection  or  the  use  of  leeches, 
and  by  sinapisms  applied  over  the  abdominal  wall. 

The  anfemic  headache  is  most  frequently  vertical,  but  it  often  assumes 
the  neuralgic  type.  It  is  accompanied  by  pallor,  throbbing  in  the  head,  dizzi- 
ness, palpitation,  feelings  of  faintness,  and  mental  depression.  All  remedies 
which  increase  vascular  tension,  accelerate  the  circulation  through  the  brain, 
and  improve  the  quality  of  the  blood  are  serviceable,  of  these  the  most  valuable 
are  arsenic,  iron,  and  citric  acid  which  may  be  ordered  in  many  varieties  of 
combination  to  meet  the  requirements  of  individual  patients.  Causes  which 
contribute  to  the  anffimia,  such  as  constipation,  leucorrhcea  or  other  exhausting 
discharge,  etc.,  must  be  dealt  with  as  part  of  the  cure.  Anajmic  headaches 
are  relieved  by  alcohol,  and  its  administration  in  moderate  quantity,  in  the 
form  of  a  light  red  wine  with  luncheon  and  dinner,  is  often  advantageous. 

The  subject  of  headache  is  too  large  to  be  overtaken  in  the  course  of  a 
short  lecture,  and  I  apologize  for  the  fragmentary  and  incomplete  story  I 
have  attempted  to  put  before  you  in  sketchy  outline.  Many  of  the  details 
which  I  have  omitted  will  be  supplied  out  of  the  fulness  of  your  own  experience. 
If  I  have  succeeded  in  giving  you  material  for  consideration  and  criticism, 
I  shall  have  accomplished  my  desire  and  maybe  shall  not  have  occupied  your 
time  altogether  fruitlessly. 


MEDICO-LEGAL. 

By  E.  S.  McKEE,  M.D., 

CINCINNATI. 
DEVIATION   OF   THE   COMPLEMENT. 

This  method  originated  by  Bordet  and  Gengou,  and  adopted  by  Neisser 
and  Sachs,  is  of  much  service  in  scientific  laboratory  work  where  pure  albu- 


558  MEDICO-LEGAL. 

minous  solutions  are  under  investigation.  These  eminent  German  patholo- 
gists of  Berlin  have  recently  discussed  this  subject  in  a  pamphlet  of  recent 
pul^lication.  Uhienhuth  from  his  high  position  as  an  authority  on  forensic 
medicine,  naturally  possesses  an  opinion  of  much  value.  He  attaches  less  value 
to  it  in  forensic  practice  where  we  have  to  deal  with  traces  of  blood,  subject  to 
all  sorts  of  contaminations.  Fallacies  arising  from  many  of  these  complica- 
tions may  be  eliminated  by  special  care  and  the  employment  of  control 
experiments,  but  nevertheless  diiSculties  arise  from  the  fact  that  the  "deviation" 
is  so  sensitive  that  it  gives  positive  results  with  sweat,  mucus,  nasal  secre- 
tions, saliva,  etc.,  and  thus  may  be  misleading.  He  maintains  that  these 
difficulties  are  not  employed  in  the  precipitine  method  employed  by  him.  He 
thinks  it  wrong  to  regard  a  positive  result  by  the  Neisser-Sachs  method  as 
overruling  a  negative  outcome  of  the  precipitine  test. 

SOCIAL  MEDICINE  CHAIR  AT  VIENNA. 

Gruen  at  a  recent  meeting  of  the  Vienna  ^rtzekammcr  proposed  that  a 
petition  should  be  presented  to  the  government,  asking  the  establislunent  of 
special  chairs  in  social  medicine  in  the  Vienna  University.  The  suggestion 
was  received  with  great  applause  and  was  made  the  special  order  for  a  later 
m„eeting.  Gruen  suggested  that  the  student  should  be  instructed :  (1)  In  the 
relation  between  the  doctor  and  the  general  public,  the  authorities  and  the  legis- 
lature. (2)  The  importance  of  medical  organization  and  the  duties  of  the 
physician  towards  it.  The  main  subjects  should  be:  Physician  and  patient; 
the  rights  and  duties  of  the  physician  in  regard  to  his  patients  and  the  public; 
the  duties  of  the  ph5^sician  in  regard  to  his  brethren  in  private  practice; 
instruction  in  medical  ethics;  rights  and  duties  of  the  doctor  in  relation  to 
contract  practice  and  sick  clubs,  insurance  companies  and  accidents;  the  rela- 
tion betv/ecn  old  age  and  invalid  pensions  and  private  practice.  Special  care 
should  be  devoted  to  medical  testimonials  and  examinations,  the  duties  of  the 
medical  practitioner  to  the  state  in  infectious  diseases  and  industrial  diseases. 
The  important  subject  of  social  hygiene  should  also  form  a  part  of  this  study. 
This  latter  subject  would  comprise  the  history  of  social  hygiene,  social  statistics 
and  special  hygiene — of  schools,  buildings,  of  food  and  of  epidemics, 

THE  INCONVENIENCE  OF  DEATH  PECDNIAmLY   CONSIDERED. 

A  Mr.  Burke  was  sent  to  Cork  to  consult  a  medical  man  and  while  in  his 
office  showed  such  marked  signs  of  uraemia,  that  he  was  sent  to  Miss  O'Toors 
private  hospital,  where  for  three  days  his  condition  was  extremely  precarious 
and  he  died  on  the  fourth  day.  The  executors  olijccted  to  pay  the  medical 
expenses  of  the  case  unless  they  were  proceeded  against.  The  county  court 
gave  judgment  for  the  three  plaintiffs,  medical  attendant,  chemist  and  pro- 
prietress of  the  private  hospital.  An  interesting  point  passed  on,  was  v/hether 
a  private  hospital  is  entitled  to  charge  for  the  inconvenience  resulting  from  the 
death  of  a  patient  residing  therein.  Apparently  his  honor  thought  so  from 
his  allowing  the  nurse's  claim.  Doubtless  many  private  hospitals  would  not 
welcome  a  death  at  this  price. 


MEDICO-LEGAL.  559 

A  DEATH   UNDER  STOVAINE. 

Patient  aged  72,  a  house  painter,  suffering  from  enlarged  prostate  and 
its  complications  had  also  a  degenerate  heart  and  diseased  lungs.  The  use  of 
both  chloroform  and  ether  were  eontraindicated  and  as  general  anjEsthctics 
and  stovaine  were  chosen  as  the  safest  of  known  local  anesthetics,  we  can  not 
presume  any  agent  which  will  absolutely  abolish  pain  to  be  absolutely  safe. 
Experience  shows  that  patients  who  bear  general  anaBsthetics  badly,  the  aged 
and  alcoholic,  usually  bear  stovaine  well  and  the  absence  of  shock,  even  after 
serious  operation  has  been  remarkable.  In  view  of  the  infrequency  of  ill 
effects  after  stovaine,  the  present  regrettable  result  may  fairly  be  taken  as  an 
exception  which  proves  the  rule.  It  is  the  rule  in  operating  under  local 
anesthesia  that  the  field  of  operation  must  be  screened  from  the  patient  and 
customary  to  distract  the  patient's  mind  from  the  operation  by  engaging  him 
in  conversation.  A  drawback  to  the  method,  especially  in  the  presence  of  heart 
weakness  is  that  the  head  must  be  kept  raised  in  order  to  protect  the  medulla 
and  its  nerves  from  the  influence  of  the  drug.  Fright  as  a  factor  in  deaths 
from  operations  recalls  the  fact  that  in  the  first  case  selected  for  the  adminis- 
tration of  chloroform  in  the  Eoyal  Infirmary  in  Edinburgh,  the  patient  died 
on  the  table  immediately  after  the  first  incision.  It  is  fortunate  for  the  future 
of  chloroform  that  the  unavoidable  absence  of  Simpson  prevented  the  adminis- 
tration of  the  anaesthetic. 

A  "stout"  fee. 

The  following  joke  is  from  the  staid  old  British  Medical  Journal,  and  as 
you  may  readily  see  can  be  understood  even  by  an  Englishman.  "A  medical 
practitioner  who  was  attending  a  licensed  victualer,  and  had  brought  a  physi- 
cian to  see  him,  said  in  an  undertone  to  the  wife  as  they  were  going  upstairs, 
that  the  fee  would  be  "three  guineas."  After  consultation  as  the  money  ciid 
not  seem  forthcoming,  he  again  mentioned  the  fee,  which  was  promptly  paid. 
The  doctors  then  prepared  to  depart  but  the  lady  of  the  house  interposed  and 
asked  what  was  to  be  done  with  the  three  glasses  of  stout,  which  they  now 
saw  with  surprise  on  the  table,  and  which  she  averred  that  her  doctor  had 
ordered  as  they  were  going  upstairs.  She  thought  "throe  Guinness"  was  the 
fee — perhaps  not  an  unnatural  mistake  for  a  publican's  wife.  It  was  a  "stout," 
if  not  exactly  a  fat,  fee. 

ACTION    FOR   INJURY   WHILE   UNDER  AN   ANiESTHIiSIA. 

A  medical  man,  who  shall  here  remain  nameless,  brought  action  against 
the  governors  of  St.  Bartholomew's  Hospital,  London.  He  was  admitted  that 
he  might  be  examined  under  an  anesthetic.  It  was  alleged  that  he  was  placed 
on  the  operating  table  in  such  a  position  that  his  arms  hung  over  the  table  and 
his  left  arm  came  in  contact  with  a  hot-water  tin  projecting  from  beneath  the 
table,  that  the  inner  part  of  the  right  arm  was  bruised  by  the  operator  or 
some  person  pressing  against  it  during  the  operation  and  that  the  results  of 
these  injuries  was  a  traumatic  neuritis  and  paral3'sis  of  both  arms,  so  that  he 
had  ever  since  been  unable  to  exercise  his  profession.  Defendants  denied  the 
alleged  negligence  and  pleaded  that  if  they  owed  any  duty  to  the  plaintiff  it 


560  MEDICO-LEGAL. 

was  to  exercise  reasonable  care  in  the  selction  of  a  hospital  stafp,  in  which  duty 
they  had  not  failed.  It  was  submitted  on  the  part  of  the  defendants  that  no 
action  could  lie  against  them  being  governors  of  a  charitable  institution.  In 
giving  judgment  for  the  defendants  the  court  said  that  he  considered  that  it 
would  be  a  fatal  policy  to  allow  such  a  case  to  go  to  the  jury  under  these  cir- 
ciunstances,  because  if  he  did  so,  everybody  who  happened  to  have  a  grievance 
against  the  hospitals  would  be  bringing  an  action  "on  spec."  and  raising  all 
sorts  of  questions,  which  would  be  disastrous  to  those  who  controlled  these 
institutions.  Certainly  a  wise  judge  and  a  just  decision.  It  is  regrettable  that 
such  an  action  was  brought  by  a  medical  man. 

PHYSICIAN    RESPONSIBLE   FOR   ORDINARY,    NOT   EXTRAORDINARY    SKILL. 

Champion  vs.  Keith,  Supreme  Court  of  Oklahoma.  The  physician  called 
in  attendance  on  an  injured  person  diagnosed  dislocation  of  the  hip.  Appre- 
hensive, however,  that  there  might  be  a  fracture  he  put  the  injured  part  up  in  a 
plaster-of-Paris  bandage,  which  he  said  was  the  proper  treatment  for  either 
condition.  The  case  turned  out  to  be  one  of  fracture  of  the  surgical  neck  of 
the  femur,  the  treatment  was  unsuccessful  and  the  patient  brought  suit  for 
damages,  claiming  that  the  physician  had  not  used  the  ordinary  care  in  making 
a  diagnosis.  The  court  held  that  the  physician  had  not  acted  in  such  a  manner 
as  to  render  himself  liable  for  damages.  A  pliysician  or  surgeon  is  never 
considered  as  warranting  a  cure  unless  under  special  contract  for  that  purpose. 
Where  no  express  agreement  is  made,  his  implied  contract  is  that  he  possesses 
ordinary  skill,  learning  and  experience,  possessed  by  others  of  his  profession; 
that  he  will  use  the  ordinary  skill  and  diligence  in  the  treatment  of  the  case, 
and  that  he  will  use  his  best  judgment  in  all  cases  of  doubt  as  to  the  proper 
course  of  treatment.  He  is  not  responsible  for  damages  for  want  of  success, 
unless  it  is  shown  to  be  the  want  of  ordinary  skill  and  learning  or  want  of 
care  and  attention.  He  is  not  presumed  to  engage  for  extraordinary  skill  or 
attention  or  diligence,  nor  can  he  be  held  responsible  for  errors  of  judgment 
or  mere  mistakes  in  matters  of  doubt  or  uncertainty. 

BLOOD  DriTERENTIATlON — HUMAN   FROM   ANIMAL. 

Uhlenhuth,  of  Grief swald,  has  discovered  a  new  method  of  distinguishing 
human  from  animal  blood.  In  1900  Uhlenhuth  published  a  very  important 
communication  on  his  investigations  with  reference  to  distinguishing  between 
the  albumin  of  eggs  of  various  birds  upon  the  basis  of  modern  science,  which 
is  mainly  the  result  of  researches  of  Bordet,  of  France,  and  Ehrlich,  of  Frank- 
fort. He  found  that  these  albumins  can  be  differentiated  biologically.  His 
researches  resulted  in  the  very  important  discovery  of  a  new  forensic  method 
of  distinguishing  animal  from  human  l)lood,  so  that  it  is  now  possible  to  tell 
with  certainty  the  origin  of  the  smallest  traces  of  blood  either  in  dry  or  putre- 
fied form.  This  method  which  he  published  in  1901,  was  soon  confirmed  on 
all  sides  and  has  become  of  fundamental  importance  for  forensic  medicine.  By 
his  method  he  can  tell  the  presence  of  horse  meat  in  sausages  and  other  smoked- 
meat  articles,  which  is  a  great  step  in  advance  for  the  examination  of  food 
stuffs. 


MEDICOLEGAL.  561 

NEGLECT  OF   HOT   WATER  BOTTLE. 

Earl  Gunter^  of  Day  Dawn,  Australia,  on  exhibiting  signs  of  collapse  after 
an  operation,  a  hot  water  bottle  was  placed  at  his  feet  which  was,  it  is  alleged, 
allowed  to  become  carelessly  imctyered  and  to  burn  his  feet  with  the  result  that 
they  have  been  bad  ever  since,  and  he  had  been  unable  to  work  for  a  long  time. 
The  court  considered  that  there  had  been  neglect,  inasmuch  as  the  water  bottle 
had  not  been  noticed  by  the  nurses  who  had  care  of  the  man  who  was  in  an 
unconscious  state.  The  court  took  into  consideration  that  the  man  had  been 
able  to  do  light  work,  and  that  the  nurses  did  not  charge  him  for  sixteen  weeks 
of  the  time  he  was  in  the  hospital.  He  considered  that  plaintiff  was  entitled 
to  fifty  pounds  and  costs  against  the  nurses. 

DAMAGES  FROM  AND  FOR  HOT  V7ATER  IN  UTERINE  HEMORRHAGE. 

A  case  was  recently  tried  in  the  coui-ts  of  Aberdeen,  Scotland,  resulting  from 
the  use  of  hot  water  in  uterine  hgemorrhage.  Damages  were  claimed  to  the 
extent  of  one  hundred  and  twenty-five  pounds.  Two  doctors  were  sued.  The 
court  found  that  the  pursuer  had  failed  to  prove  any  fault  or  negligence  on  the 
part  of  defenders,  and  he  assoilzied  them  with  expenses,  finding,  however,  that 
no  higher  charges  are  to  be  allowed  than  would  have  been  incurred  if  the 
defenders  had  lodged  joint  defences,  and  been  represented  by  the  same  law 
agent.  The  court  remarked  that  this  w^as  a  most  painful  case  to  decide  on 
account  of  the  mutual  aspersions  of  both  parties.  On  the  one  hand  he  did  not 
think  that  there  was  any  ground  for  accusing  the  pursuer  of  shamming  or 
malingering.  On  the  other  hand  he  could  not  see  how  she  could  have  suffered 
so  severely  from  the  application  of  water  not  hot  enough  to  scald  the  doctors' 
hands,  or  how  the  discoloration  of  the  skin,  observed  by  Dr.  Stephenson, 
developed  into  a  raised  scar  tissue,  upon  which  Dr.  Wallace  Minn  required  to 
operate.  In  the  absence  of  any  proof  of  fault  or  negligence  on  the  part  of 
the  defenders,  he  must  regard  the  pursuer's  scald  as  the  result  of  accident.  He 
sympathized  with  the  pursuer,  but  doubted  if  she  would  have  raised  this  action 
had  she  known  that  the  defenders,  in  all  probability,  saved  her  life  by  promptly 
applying  tbe  only  available  remedy  while  she  was  under  chloroform.  If 
desperate  diseases  call  for  desperate  remedies,  a  doctor  might  be  pardoned  for 
taking  the  risk  of  water  being  rather  too  hot  for  the  patient's  skin,  rather  than 
allow  the  patient  to  bleed  to  death.  It  was  common  ground  between  the 
parties  that  this  particular  part  could  stand  much  greater  heat  than  the  external 
skin.  As  regards  the  subsequent  treatment  of  the  case,  the  defenders  seem  to 
have  fully  done  their  duty.  Dr.  Byres  having  been  called  to  assist  was  quite 
entitled  to  leave  the  patient  to  the  care  of  Dr.  Meams.  The  case  goes  to  show 
how  medical  men  may  be  annoyed  by  actions  for  damages  and  though  the 
verdict  is  in  their  favor,  are  loaded  with  heavy  costs,  much  chagi'in  and  loss  of 
time  and  reputation. 


562  AMERICAN   PROCTOLOGIC  SOCIETY  ABSTRACTS. 


AMERICAN  PROTOLOGIC  SOCIETY  ABSTRACTS. 

Rei'okted  by  lewis  H.  ADLER,  JR.,  M.D., 
pnrL^VDELPniA. 

President's  Address. — "Progress  in  Proctology/'  by  the  President, 
Geo.  B.  Evans,  A.M.,  M.D.,  Dayton,  Ohio,  who  stated  that  not  many  years 
since,  the  creation  of  proctology  as  a  specialty  was  frowned  upon;  for  an 
indefinite  period  what  was  known  of  and  what  was  done  for  diseases  of 
the  rectum  was  largely  empiric,  and  not  due  to  special  knowledge  or  scientific 
study. 

A  few  of  us,  at  least,  can  remember  when  it  was  the  rule  among  general 
practitioners  to  make  no  special  efilort  to  determine  the  pathology  of  diseases 
of  the  rectum;  in  fact,  it  was  believed  unbecoming  the  dignity  of  a  high- 
classed,  high-toned  medical  gentleman  to  so  lightly  esteem  modesty  as  to  ask 
for  the  pri\dlege  of  seeking  the  naked  truth.  Without  attempting  to  make  a 
diagnosis,  opium  and  lead  wash,  with  catharsis,  was  deemed  a  suflacient  treat- 
ment for  any  case.  Little  was  taught  in  medical  colleges  of  these  diseases, 
for  little  was  Imown  and  no  special  desire  to  learn  much  concerning  them 
seemed  to  exist.  But,  fortunately,  in  the  natural  evolution  of  this  specialt)', 
this  ignorance  and  indifference  in  the  main,  has  been  eliminated,  and  this 
field  work  has  assumed  that  of  an  accredited  and  justifiable  specialty.  No 
longer  do  we  have  to  contend  with  the  nonrecognition  of  serious  pathology, 
because  of  interposed  modesty,  ignorance  and  criminal  indifference.  A 
knowledge  of  the  importance  of  being  able  to  diagnose  and  treat  intelligently 
diseases  of  the  rectum  is  now  considered  essential  for  every  general  practitioner, 
and  all  this  as  a  result  of  the  creation  of  proctology  by  men  who  have  made 
special  effort  to  develop  this  field  of  work.  The  credit  is  due  to  such  men  as 
Alder,  Allingham,  Ball,  Cripps,  Edwards,  Earle,  Gant,  Martin,  Pennington, 
Kelsey,  Mathews,  Tuttle  and  others.  To  them  are  we  indebted  for  progressive 
proctology. 

As  a  matter  of  course,  our  pathology  of  this  area  is  of  necessity  a  modern 
patholog}%  and  our  laiowledgc  of  valves,  varicosities,  neoplasms,  ulcerations  and 
suppurations,  are  not  based  on  hypothetical  ideas  of  a  quarter  of  a  century 
since,  but  instead  on  the  rather  exact  revelations  of  laboratory  findings.  The 
import  of  the  presence  of  staphylococci,  gonococci,  colon  bacilli  and  tubercle 
bacilli,  is  equally  of  as  much  importance  to  the  rectal  surgeon,  as  is  the  micro- 
scopical proof  of  the  malignancy  or  benignity  of  a  bit  of  tissue.  With  what 
greater  assurance  the  proctologist  approaches  examinations  of  rectal  diseases 
than  did  the  physician  of  some  years  since.  With  a  wide  open  field,  if  neces- 
sary, the  aid  of  ana:sthcsia,  the  proctoscope  and  the  laboratory,  tlicre  is  usually 
not  much  difficulty  in  making  a  diagnosis — a  diagnosis  inseparably  linked  with 
its  dependents — treatment  and  prognosis.  Under  the  influence  of  progressive 
proctologic  work,  ignorance  and  indifference  to  the  recognition  and  treatment 
of  rectal  diseases  is  rapidly  disappearing  from  the  average  medical  man,  as 


AaiERICAN  PROCTOLOGIC  SOCIETY  ABSTRACTS.  563 

well  as  from  the  average  la}Tnan.  As  a  result  of  which  the  sum  total  of  human 
suliering  is  immeasurably  lessened,  and  intlividual  exif^tcnce  is  not  so  fre- 
quently abridged.  The  victims  of  rectal  diseases  are  to  be  congratulated  that 
this  branch  of  science,  or  pseudo-science,  has  sufficiently  advanced,  that  it  now 
occupies  the  serious  attention  of  the  most  progressive  and  intelligent  men.  The 
Lister  methods  of  that  day  have  been  so  changed  and  improved  that  they  now 
seem  very  crude.  The  value  of  thorough  cleanliness,  asepsis,  and  the  antiseptic 
influence  of  certain  drugs,  is  of  immeasurable  value.  It  is  now  understood 
that  the  recto-anal  area  can  be  placed  in  a  surgically  clean  condition,  and  that 
there  need  be  no  fear  following  operative  interference.  In  not  a  few  instances, 
it  obtains  that  relief  is  dependent  on  rectal  surgery,  when  the  subjects  are  unfit 
for  narcosis  produced  from  a  general  anaesthetic,  in  cases  of  cardiac,  pulmonic 
or  nephritic  disease,  making  it  hazardous  to  use  general  anaesthesia.  Some- 
times it  would  seem  that  this  danger  of  the  uses  of  an  anesthetic  is  too  lightly 
thought  of,  and  consequently,  the  mortality  rate  is  increased.  Local  anaes- 
thesia, under  cocaine  infiltration,  for  the  most  part,  is  satisfactory,  and  is  a 
great  convenience  to  the  operator  and  a  life-saving  narcosis  in  many  instances. 

The  palliative  treatment  of  haemorrhoids  by  proctologists  is  largely  a 
matter  of  enforcement,  viz.:  where  they  are  not  permitted  the  opportunity  to 
relieve  by  radical  methods.  The  operative  methods  of  reraoving  hsmorrhoids 
are  so  well  understood,  simple  and  effective,  that  it  is  foolish  to  attempt  to 
relieve  them  by  drugs  or  palliative  measures. 

The  Allingham,  or  ligature  method,  when  correctly  and  carefully  per- 
formed, is  generally  applicable,  but  is  not  so  free  from  pain  and  so  quickly  con- 
valesced from  as  the  clamp  and  cautery  method.  Many  regard  the  last  men- 
tioned method  as  the  one  to  be  preferred.  I  believe,  however,  that  the 
enucleation  method  approaches  nearest  to  the  ideal  in  results,  and  that  the 
retention  of  the  plug  is  not  so  painful  as  some  would  have  us  believe. 

Proctoscopic  examination  is  of  importance,  and  is  a  distinct  advance  in 
rectal  work.  It  is  of  great  assistance  in  determining  disease  beyond  discovery 
by  ordinary  methods.  It  is  of  distinct  service  in  diagnosis,  and  of  great  value 
in  aiding  treatment  in  not  a  few  conditions. 

There  is  more  hope  for  the  ultimate  cure  of  tubercular  conditions;  our 
better  understanding  of  what  environment  means  to  these  people  will  go  far 
toward  helping  them  to  recovery,  and  there  is  not  so  much  reason  for  a  delayed 
recognition  of  the  condition,  which  is  of  paramount  importance. 

I  believe  there  is  possibly  a  better  understanding  of  syphilitic  conditions, 
ulcerations,  infiltrations  and  strictures,  but  the  eternal  dependence  on  anti- 
syphilitic  treatment  to  resolve  hyperplastic  tissue  is  not  so  conspicuous,  and 
progressive  workers  in  this  field  realize  that  incision  and  excision  are  often 
necessary. 

Concerning  malignant  and  benign  growths,  the  surgical  rules  that  apply 
in  other  anatomical  regions  apply  here.  Early  discovery  and  early  removal  is 
the  only  hope,  as  we  all  know,  in  malignant  conditions,  and,  as  an  advance, 
the  removal  of  cancerous  growths  not  within  easy  reach  from  below  may  be 
dealt  with  from  above,  or  suprapul)icly,  and  just  here  it  may  not  be  inoppor- 


564  AMERICAN   PROCTOLOGIC  SOCIETY  ABSTRACTS. 

tune  to  remark  that  it  is  to  be  belieyed  that  ere  long  it  will  be  realized  by  the 
average  phj'sician  that  the  removal  of  the  rectum  per  sc,  is  not  as  disastrous  a 
matter  as  it  is  sometimes  made  to  appear,  especially  since  it  is  known  that 
muscular  transplantation  will  preserve  more  or  less  perfectly  the  function  of 
the  sphincters.  The  development  of  the  teclinic  essential  to  produce  sphincteric 
power,  will  relieve  rectal  extirpation  of  one  of  its  most  unpleasant  features 
and  render  less  hesitant  many  sufferers  who  should  have  the  benefit  of  the 
operation. 

Another  matter  of  progressive  interest  is  that  colonic  or  rectal  ptosis  is 
amenable  to  intra-pelvic  or  intra-abdominal  fixation,  bringing  relief  that  in 
some  instances  cannot  be  hoped  for  by  any  other  method  of  interference. 

After  all,  the  most  encouraging  sign  is  that  the  profession  recognizes  the 
fact  that  proctologists  have  a  legitimate  right  to  exist  as  specialists,  and  that 
diseases  in  the  ano-rectal  region  deserve  the  same  consideration  as  elsewhere. 
With  the  elimination  of  indifference,  sestheticism,  modesty,  the  more  universal 
belief  in  the  necessity  of  early  examination  and  diagnosis,  we  can  but  hope  for 
greater  progress  and  more  relief  to  suffering  humanity. 

Gentlemen,  when  I  consider  the  personnel  of  this  association,  I  am  quite 
confident  of  the  perpetuity  of  proctology  as  a  distinct  entity  and  am  equally 
sure  the  progression  in  this  special  field  of  work  will  be  in  keeping  with  that  in 
other  specialties. 

"A  Eeview  of  Proctologic  Literature  from  May,  1908  to  May,  1909." 
by  Samuel  T.  Earle,  M.D.,  Baltimore,  Md.  Among  the  interesting  conditions 
referred  to  in  the  review  by  the  author,  were  the  following:  "Congenital 
Idiopathic  Dilatation  of  the  Colon"  (Hirschprung's  Disease).  In  Dr.  Finley's 
report  of  his  case  he  reviewed  the  literature  of  the  subject  to  January  1,  1908, 
and  collected  some  two  hundred  and  six  cases,  after  which  he  stated  that  while 
to  Hirschprung  belongs  the  credit  of  having  first  called  attention  to  this  disease, 
a  number  of  cases  had  been  found  in  the  literature  antedating  his  classical 
description.  In  the  article  Dr.  Finley  discussed  the  various  hypotheses  as  to 
the  etiology  of  the  disease  and  some  ten  theories,  which  have  been  suggested, 
from  time  to  time,  as  the  causation  of  the  malady,  including  that  of  hyper- 
nutrition,  which  was  the  author's  principal  theory.  His  conclusions  as  to  the 
etiology  of  the  disease  were  that  no  one  theory  apparently  explained  every  case ; 
that  each  one  explains  some. 

The  s}Tnptomatology  was  described  and  a  complete  clinical  picture  of  the 
disease  given  with  a  list  of  a  series  of  cases  discussed  in  the  Johns  Hopkins 
Hospital,  eleven  in  all.  Regarding  the  treatment,  the  author  concludes  that 
no  one  plan  seems  applicable  to  all  cases  and  suggests  the  method  employed 
in  his  own  case  as  perhaps  the  one  most  applicable  to  the  large  proportion  of 
cases,  to  wit,  a  preliminary  enterostomy;  then  a  colo-colostomy  some  months 
subsequently;  finally,  a  complete  excision  of  the  affected  portion.  This 
artificial  anus  is  left  open  until  after  the  success  of  the  preceding  steps  tire 
assured  when  it  should  be  closed  under  cocaine  anaesthesia. 


AMERICAN   PROCTOLOGIC  SOCIETY  ABSTRACTS.  565 

Dr.  Earlc  in  his  report  alluded  to  another  case  of  "Idiopathic  Dilatation  of 
the  Ecctum  and  Colon  as  far  as  the  Hepatic  Flexure,"  which  was  reported  by 
H.  Morely  Fletcher,  M.D.,  and  H.  Betham  Eobinson,  M.S.i 

Another  case  of  interest  reported  was  that  of  a  "Sarcoma  of  the  Eectum 
in  a  Boy"  aged  ten  years  by  Cecil  Eountree.^  The  pathological  examination 
showed  the  tumor  to  be  a  mixed  cell  sarcoma.  Of  five  himdred  and  ninety- 
six  cases  analyzed  in  the  Cancer  Eesearch  Laboratory,  of  the  Middlesex  Hos- 
pital Eeports,  there  were  only  six  cases  under  thirty  years  of  age,  the  age  of 
the  youngest,  a  boy  of  sixteen  years,  who  had  a  sarcoma  of  the  rectum.  There 
are  likely  to  be  many  metastases  in  sarcoma  of  the  rectum.  This  malady  is  rare 
at  any  age. 

Attention  was  called  to  the  method  of  Dr.  Dudley  Eoberts  of  Brooklyn, 
N.  Y.,3  for  "Gradual  Painless  Dilatation  of  the  Anal  Canal  by  Dilatable 
Eubber  Bags,"  which  appealed  to  Dr.  Earle  forcibly  as  a  very  satisfactory 
means  of  accomplishing  the  purpose  designed. 

Attention  was  called  to  the  article  of  Dr.  Charles  0.  Files  of  Portland, 
Maine,'^  in  which  he  considers  that  there  are  two  important  factors  that  should 
be  studied  in  connection  with  the  "Treatment  of  Pruritus  Ani."  These  are  an 
analysis  of  the  contents  of  the  rectum  and  the  physical  condition  and  mechanical 
efficiency  of  the  sphincter  ani  muscles,  external  and  internal. 

The  normal  fseces  contains  about  73  per  cent,  of  water.  This  water  holds 
in  solution  various  volatile,  fatty  acids,  and  probably  other  irritating  excremen- 
titious  substances.  During  the  retention  of  the  fa3ees  in  the  rectum  a  con- 
siderable portion  of  the  water  disappears.  In  prolonged  constipation,  the  fsces 
become  hard  and  dry,  some  of  the  fluid  passes  by  osmosis  into  the  cellular  tissue 
about  the  anus  and  thence  to  the  skin.  The  liquid  f leces  are  very  often  irritating 
to  the  mucous  membrane  of  the  anus,  and  causes  an  intense  burning  sensation. 
When  this  acrid  solution  is  absorbed  into  the  cellular  tissue,  it  causes  an  irrita- 
tion of  the  skiu,  and  we  call  that  irritation,  pruritus  ani. 

The  sphincter  muscle  as  long  as  it  remains  in  a  normal  condition,  prevents 
the  passage  of  any  appreciable  amount  of  fluid  through  it.  When,  however, 
the  action  of  the  sphincter  is  made  somewhat  iiTcgular  by  the  pressure  of  a 
ha^morrhoidal  condition,  some  of  the  fluid  leaks  through  the  anus  and  causes 
pruritus  by  direct  contact.  The  skin  about  the  anus  is  often  found  to  be  moist 
in  persons  having  hsemorrhoids. 

Dr.  F.  W.  Dudley,  of  Manila,  P.  I.,^  reports  a  "New  Bloodless  Method  of 
Amputating  the  Anus  and  Eectum."     A  description  of  the  same  being  given. 

Dr.  W.  Ernest  Miles'^  reviews  the  "Perineal  Excision  for  Carcinoma  of  the 
Eectum,  and  of  the  Pelvic  Colon,"  and  states  that,  so  far  as  he  has  been  able 
to  gather  from  the  literature  on  the  subject,  the  technic  of  previous  operations 

1  Clinical  Society's  Tninsactions,  Vol.  xl,  p.  80. 

2  Proceedings  Royal   Society  of  Medicine,   February,   1908. 

3  The  Medical  Record,  Vol.  72,  p.  985. 

4  New  York  Medical  Journal,  Vol.   87,  p.   1154. 

5  Journal  of  American  Medical  Association,  Vol.  51,  p.  991. 

6  London  Lancet,  1908,  Vol.  2,  p.  1812. 


506  MIERICAN   PROCTOLOGIC  SOCIETY  ABSTRACTS. 

seems  to  have  failed  iu  one  important  respect,  namely,  tlie  complete  eradication 
of  the  zone  of  upward  spread  of  cancer  from  the  rectum,  whereby  the  chance  of 
recurrence  of  the  disease  above  the  field  of  operation  can  be  distinguished,  if 
not  entirely  obviated.  In  his  personal  experience  of  fifty-seven  such  peritoneal 
operations,  he  foimd  that  recurrences  took  place  in  periods  from  six  months  to 
three  years  in  fifty-four  instances. 

In  order  to  ascertain  the  cause  of  his  failures  he  made  a  post-mortem 
examination  of  such  of  his  patients  who  died  and  found  that  recurrence 
appeared  in  situations  that  were  beyond  the  scope  of  removal  from  the  peri- 
tonemu,  namely:  (a)  the  pelvic  peritoneum;  (b)  the  pelvic  mesocolon;  and 
(c)  the  lymph-nodes  situated  over  the  bifurcation  of  the  left  common  iliac 
artery.  He  considers  that  this  area  constitutes  the  zone  of  the  upward  spread  of 
cancer  of  the  rectum,  the  removal  of  which  is  just  as  imperative,  as  is  the 
thorough  clearance  of  the  axilla  in  cases  of  cancer  of  the  breast,  if  freedom 
from  recurrence  is  to  be  obtained. 

The  appreciation  of  this  important  fact,  induced  him  two  years  ago,  to 
abandon  the  perineal  methods  of  excision  of  the  rectum  and  to  substitute  there- 
for an  abdominal  method,  comparable  to  those  methods  of  performing 
abdominal  hysterectomy  known  as  the  Wertheim  and  the  Kronig-Wertheim. 
He  then  gives  the  technic  of  his  operation  in  full,  and  has  formulated  what  he 
considers  certain  essentials,  which  must  be  strictly  adhered  to,  if  satisfactory 
results  are  to  be  obtained,  namely:  (1)  that  an  abdominal  anus  is  a  necessity; 
(2)  that  the  whole  of  the  pelvic  colon,  with  the  exception  of  the  part  from 
which  the  colostomy  is  made,  must  be  removed  because  its  blood-supply  is  con- 
tained in  the  zone  of  the  upward  spread;  (3)  that  the  whole  of  the  pelvic 
mesocolon  below  the  point  where  it  crosses  tlie  common  iliac  artery,  together 
with  a  strip  of  peritoneum,  at  least  an  inch  wide  on  either  side  of  it,  m.ust  be 
cleared  away;  (4)  that  the  group  of  lymph-nodes  situated  over  the  bifurcation 
of  the  common  iliac  artery  arc  in  all  instances  to  be  removed;  a)id  lastly  (5) 
that  the  peritoneal  portion  of  the  operation  should  be  carried  out  as  widely  as 
possible,  so  that  the  lateral  aiid  downward  zones  of  spread  may  be  effectively 
extirpated. 

B.  G.  A.  Moyinlian,  M.D.,  Leeds,  Eng.,'^  calls  special  attention  to  the 
"Frequent  liecurrences  After  Picmoval  of  Carcinoma  from  the  Upper  Eectum 
and  Sigmoid,"  and  also  for  the  necessity  of  inguinal  colostomy  on  account 
of  the  sacrifice  of  a  large  portion  of  the  bowel  in  perhaps  a  large  raajocity  of 
cases. 

"Treatment  of  Pruritis  Ani,  with  a  Consideration  of  Its  Pathology 
AND  Etiology/'  by  William  M.  Beach,  A.M.,  M.D.,  of  Pittsburgh,  Penna. 
The  following  conclusions  were  drawn  by  the  writer: — 

1.  That  pruritus  ani  occurs  in  mild  and  severe  forms;  mostly  in  middle 
life;  the  mild  type  with  simple  pruritus,  the  severe  type  with  marked  eczema 
and  skin  cbantrcs. 


7  Surgery,  Gynaacology  and  Obstetrics,  1908,  Vol.  G,  p.  40' 


AMERICAN    PROCTOLOGIC  SOCIETY  ABSTRACTS.  567 

2.  Certain  aberrations  in  general  metabolism,  or  in  adjacent  structures 
are  simply  incidental  and  should  be  considered  as  complications. 

3.  Intra-rectal  growths,  as  haemorrhoids,  adenomas,  etc.,  or  the  presence 
of  parasites,  are  contributory. 

4.  The  distinct  pathogenesis  of  pruritus  ani  consists  of  single  or  multiple 
burrowing  from  the  anal  pockets,  emitting  a  serous  or  sero-purulent  substance, 
which  sinus  may  be  complete  or  blind  and  is  always  accompanied  by  proctitis, 
and  frequently  by  cryptitis,  and  small  ulcers  at  the  ano-rectal  line. 

5.  These  sinuses  when  complete  are  the  sequelae  to  an  abscess  history,  but 
the  origin  of  the  blind  recesses  is  in  doubt,  and  yet  it  is  not  unlikely  due  to  an 
infection  by  the  colon  bacillns. 

6.  The  treatment  is  surgical  for  the  purpose  of  obliterating  the  sinuses, 
correcting  a  rigid  sphincter  when  necessary,  and  curing  the  proctitis  and 
ulceration. 

7.  Gastro-intestinal  and  general  metabolic  disturbances  must  be  met  by 
rational  measures. 

"Ball's  Operation  in  the  Treatment  op  Cases  of  Pruritus  Ani  with 
Eeport  of  a  Case  in  Which  Necrosis  of  the  Flap  Occurred,"  by  Louis  J. 
Krouse,  M.D.,  of  Cincinnati,  Ohio.  The  case  reported  was  that  of  a  severe 
intractable  case  of  pruritus  ani  in  a  man  well  advanced  in  years  who  under- 
went the  above  operation  for  pmiitus  with  the  result  of  having  the  anal  flap 
necrose.  He  went  into  the  pathology  as  to  the  cause  of  the  necrosis  and  came 
to  the  conclusion  that  the  trouble  lay  in  the  poor  supply  of  blood  to  the  anal 
flap.  He  claimed  that  there  is  no  anastomosis  between  the  blood-vessels  from 
within  the  anus  and  those  of  the  skin.  The  writer  called  attention  to  the 
fact  that  Sir  Charles  Ball's  operation  has  recently  been  modified  so  as  to 
prevent  sloughing  of  the  anal  flap. 

A  new  method  of  operating  was  proposed  by  the  author  which  is  some- 
what difTerent  from  that  of  Sir  Charles  Ball  and  of  that  of  Dr.  Thos.  Chas. 
Martin,  and  consists:  First,  in  doing  away  with  the  elliptical  incision  which 
cuts  off  the  greater  part  of  the  circulation  from  the  diseased  area;  and  secondly, 
in  making  six  to  eight  linear  incisions  through  the  skin  into  the  subcutaneous 
connective  tissue.  These  linear  incisions,  beginning  at  a  point  outside  of  the 
point  of  irritation,  follow  the  course  of  the  radii  of  a  circle  whose  center  is  the 
anal  canaL  The  skin  lying  l)etween  the  adjacent  radii  are  then  undercut 
until  the  whole  affected  area  is  undennined.  Should  the  dissection  bo  dillicult 
and  more  room  be  needed,  every  alternate  flap  could  then  be  loosened  at  the 
anal  margin  and  dissected  outwards  toward  the  periphery.  After  all  the 
adhesions  are  loosened  and  the  bleeding  has  been  stopped,  the  parts  are  again 
replaced  and  sutured. 

The  advantages  of  this  operation  over  the  original  one  of  Ball,  lie  mainly 
in  the  better  nourishment  of  the  flap.  The  blood  must  come  from  the 
circumference  and  must  radiate  towards  the  anal  canal. 

(To  he  continued.) 


568  MUSIC  AS  A  REMEDIAL  AGENT. 

Editorials 


MUSIC  AS  A  REMEDIAL  AGENT. 

Scientific  progress  does  not  always  consist  in  adding  new  notions  to 
the  already  existing  ones;  it  very  often  consists  in  destroying  an  old  system 
and  constructing  a  new  one.  Of  course,  no  sensible  person  would  break  down 
an  old  system  unless  he  can  substitute  sometliing  better. 

From  time  immemorial  old  remedies  have  been  discarded  and  new  ones 
adopted.  The  order  of  advance  in  the  art  of  healing  and  preventing  disease 
has  been  from  the  crude  to  the  less  crude,  and  heroic  measures  have  given  way 
to  the  more  subtle  remedies  and  the  employment  of  rational  treatment. 

One  of  the  subtle  remedies  which  should  be  given  more  consideration  is 
music.  Among  the  savages  the  influence  of  music  was  far  more  distinctly 
noticeable  than  to  any  people  of  a  higher  civilization.  "Music  is  the  direct 
and  immediate  effect  of  the  feeling  of  the  moment  that  it  is  listened  to  and 
this  is  seen  in  all  indiyiduals." 

The  idea,  that  music  may  be  so  applied  as  to  actually  heal  the  diseases 
of  the  physical  organism,  is  in  perfect  keeping  with  the  advanced  thought  of 
the  age.  That  music  hath  charms  is  observed  in  the  fact  that  a  good  singer 
often  has  a  better  effect  upon  an  audience  than  an  orator  who  delivers  a  good 
oration.  The  audience  appear  much  brighter  and  livelier  after  hearing  a  good 
solo  or  soDg  than  after  a  discourse  no  matter  how  well  delivered. 

The  soothing  and  calming  influence  of  music  is  well  known  to  all  of  us. 
It  has  surely  occurred  to  the  reader  when  he  was  depressed  by  care  and  anxiety 
and  when  he  listened  attentively  to  the  sweet  strains  of  a  violin  or  any  otlier 
form  of  music,  he  found  rest  and  oblivion.  This  comfortable  feeling  is 
brought  about  by  creating  pleasant  visions  and  thus  relieving  the  mind  of 
worried  forebodings.  It  is  also  a  well-known  fact  that  digestion  is  favored  by 
introducing  good  music  at  banquets  and  other  affairs.  This  is  due  to  the 
pleasant  entertainment  of  the  mind  and  thus  does  away  with  unpleasant 
emotions  or  thoughts  v.diich  retard  digestion. 

The  recent  s3-stcmatic  clinical  investigations  of  music  in  the  field  of 
practical  therapeutics  has  given  encouraging  results.  They  are  all  in  the 
direction  of  distracting  the  mind  from  pain  and  soothing  the  mental  irritability 
which  is  present  by  leading  it  into  more  pleasant  channels.  Indeed  music  has 
been  well  spoken  of  as  one  of  the  most  beautiful  and  glorious  gifts  of  God  to 
which  Satan  is  a  bitter  enemy.  The  recent  discoveries  in  psychology,  and 
the  recognition  and  employment  of  hypnotism  and  suggestion,  has  revealed  that 
the  power  of  thought  over  the  physical  organism  has  materially  influenced  the 
treatment  of  diseases  in  recent  years.  Late  experiments  by  physiologists  upon 
human  beings  and  animals  sliow  that  musical  sounds  produce  a  marked  effect 
upon  the  system.  The  action  of  the  heart  is  increased,  blood-pressure  is 
elevated  or  lowered  and  changes  in  respiration  are  also  observed.  The  observa- 
tions have  shown  that  the  music  affects  not  only  human  beings  but  also  animals. 


YOUR  THOUSAND  CONSUMPTIVES  STARVE  YEARLY.  569 

Spirited,  lively  airs,  exhilarated  and  increased  the  nervous  stimulation  in  a 
very  decided  manner,  while  soft  music  invariably  soothed  and  quieted.  The 
subtle  discovery  of  music  as  a  remedy  is  not  new.  Its  utilization  and  thera- 
peutic value  was  recognized  by  the  savages  in  the  healing  art.  Among  the 
Indians  the  medicine  man  treated  all  diseases  by  making  all  sorts  of  noises  and 
gestures.  Their  idea  was  to  drive  out  the  evil  spirit  which  was  the  cause  of 
the  affliction. 

The  good  results  obtained  from  the  utilization  of  music  has  made  it 
evident  that  the  day  is  not  far  distant  when  music  will  be  a  leading  factor  in 
the  cure  of  many  forms  of  disease,  especially  those  due  to  the  inharmonious 
conditions  of  the  mental  faculties.  It  has  been  stated  that  idiots  appear  to 
best  advantage  when  they  are  under  the  influence  of  music.  A  new  life  is 
impressed  into  these  unfortunate  individuals  by  the  harmony  of  the  sweet 
sounds.  In  adult  life,  when  the  musical  taste  is  more  cultivated,  the  feelings 
may  be  swayed  by  music  "from  grave  to  gay,  from  lively  to  severe."  Soldiers 
march  and  'fight  better  when  inspired  by  a  band.  The  effect  of  harmonious 
sounds  on  the  mind  is  recognized  as  beneficial  in  that  it  lifts  the  entire 
organism  into  a  higher  state.  Music  appears  to  do  its  good  by  bringing  about 
regularity  and  rhythm  and  soothing  perturbed  consciousness.  The  music 
seems  to  act  best  in  those  nervous  disturbances  in  which  tremblings  and 
palpitations  are  the  leading  symptoms.  It  tends  to  regulate  the  flow  of  the 
blood  through  the  brain  and  the  action  of  the  sounds  on  the  mind  tends  to 
arouse  certain  sentiments  which  seem  to  have  a  special  power. 

Of  course,  music  should  be  prescribed  with  due  regard  to  the  nature  of 
the  mental  or  physical  condition  to  be  treated.  To  alleviate  pain  the  music 
should  be  different  from  that  which  should  be  given  to  produce  sleep.  To 
distract  pain  the  music  should  be  of  an  attractive  order  while  music  to  pro- 
duce sleep  should  contain  no  striking  or  unexpected  effects.  It  should  pursue 
a  monotonous  course. 

The  action  of  music  upon  the  nervous  system  and  its  physiological 
influence  in  general  is  easily  seen  and  since  it  has  such  aclmowledged  thera- 
peutic value,  it  is  very  strange  that  it  is  not  more  utilized  as  a  remedial  agent. 


FOUR  THOUSAND  CONSUMPTIVES  STARVE  YEARLY. 
Many  Indigfent  Dying  Cases  are  Being  Sent  to  the  Southwest. 

Cruel  and  inhuman  practices  are  alleged  in  a  statement  given  out  to-day 
by  the  National  Association  for  the  Study  and  Prevention  of  Tuberculosis 
against  the  eastern  doctors  who  persist  in  sending  dying  cases  of  consumption 
to  the  Southwest. 

Fully  7,180  persons  hopelessly  diseased  with  tuberculosis  annually  come 
to  die  in  the  States  of  California,  Arizona,  New  Mexico,  Texas  and  Colorado, 
most  of  them  by  order  of  their  physicians.  The  statement,  which  is  based 
upon  the  testimony  of  well-known  experts,  and  all  available  statistics,  shows 
that  at  least  50  per  cent,  of  those  who  go  to  the  Southwest  every  year  for  their 


570  ADRENALIN  INrflAVENOUSLY  IN   COLLAPSE. 

health  are  so  far  advanced  in  their  disease,  that  they  cannot  hope  for  a  cure 
in  any  climate  under  any  circumstances.  More  tlian  this,  at  least  60  per 
cent,  of  these  advanced  cases  are  so  poor  that  they  have  not  sufficient  means  to 
provide  for  the  proper  necessaries  of  life,  which  means  that  4,315  consumptives 
are  either  starved  to  death,  or  forced  to  accept  charitable  relief  every  year. 

It  is  not  an  uncommon  thing,  the  National  Association  declares,  for  whole 
families,  who  can  hardly  eke  out  a  living  in  the  East,  to  migrate  to  the  West 
in  the  hope  of  saving  the  life  of  some  member  of  the  family.  In  most  instances, 
the  abject  poverty  of  such  cases  forces  them  to  beg,  or  to  live  on  a  very  low 
level.  Often  consumptives  who  cannot  afford  the  proper  traveling  accom- 
modations are  found  dead  on  the  trains  before  reaching  their  destination. 
The  resources  of  almost  every  charitable  organization  in  the  Southwest  are 
drained  ever}'  year  to  care  for  cases  which  would  be  self-supporting  in  their 
eastern  homes. 

It  costs,  on  an  average,  at  least  $50  per  month  for  the  support  of  a  con- 
sumptive in  the  Southwest,  including  some  medical  attention.  The  National 
Association  strongly  urges  no  one  to  go  to  this  section  who  has  not  sufficient 
funds  to  care  for  himself  at  least  one  year,  in  addition  to  what  his  family 
might  require  of  him  during  this  time.  It  is  also  urged  that  no  persons  who 
are  far  advanced  with  tuberculosis  go  to  so  distant  a  climate. 

Consum.ption  can  be  cured,  or  arrested  in  any  section  of  the  United  States, 
and  the  percentage  of  cures  in  the  East  and  the  West  is  nearly  the  same.  Any 
physician,  therefore,  who  sends  a  person  to  the  Southwest  without  sufficient 
funds,  or  in  an  advanced  or  dying  stage  of  the  disease,  is  guilty  of  cruelty  to 
his  patient.  Eenewed  efforts  are  being  made  to  stop  this  practice,  and  to 
encourage  the  building  of  small  local  hospitals  in  every  city  and  town  of  the 
country.  Attempts  are  also  being  made  in  Southern  California  and  in  Texas 
to  exclude  indigent  consumptives  or  to  send  them  back  to  the  East. 


Jlateria  ^edica  and  Therapeutics 


ADRENALIN  INTRAVENOUSLY  IN  travenous  injections  are  the  most  effec- 

COLLAPSE.  tive  remedies  in  the  severe  collapses  oc- 
casionally happening  from   lumbar 

Dr.  B.  Kothc,  of  the  Hospital  Moahit,  anaesthesia  and  narcosis  as  well  as    in 

of  Berlin,  states  that  adrenalin  is  the  g,,rgical  shock.     An  injection  of  a  com- 

strongest  analeptic  which  we  possess  at  tj^^^tion  of  the  adrenalin  solution  with 

the  present  time.    The  dose  is  1/2  to  1  g^i^  solution  is  exceedingly  useful    in 

cubic  centimeter  of  commercial  0.1  per  ha:,morrhages  and  in  peritonitis.    Adrcn- 

eent.  of  epirenan,  which  is  the  same  as  jj]in  should  be  on  hand,  together  with 

epinephrin.     It  is  indicated  especially  other  excitants  (camphor,  etc.),  at  every 

in  imminent  acute  disturbances  of  car-  case  of  stupor  and  insensibility.    (Thcr- 

diac  and  respiratory  actions.    These  in-  apie  de  gcgenwart,  1909,  p.  95.) 


ANTIFOPvMlN. 


OiESAKEAN  SECTION,  ADRENALIN  IN. 


571 


ANTirORMIN  IN  THE  DETECTION  OF 
TUBERCIE  BACILLI. 

Dr.  0.  Seemaiin  has  employed  anti- 
foniiin  for  the  purpose  of  facilitating 
the  detection  of  tubercle  bacilli  in  pus, 
iirine,  exudations,  stools  and  organs. 
Antifomiin  is  a  mixture  of  eau  de  Jav- 
elle  and  sodium  hydrate,  and  owes  its 
action  to  oxidation  processes.  The  au- 
thor has  found  that  it  acts  best  in  15 
per  cent,  solution.  If  sputum  is  diluted 
with  fifteen  to  twenty  times  its  volume 
of  this  solution,  the  pus  soon  becomes 
homogeneous,  and  in  from  ten  to  forty- 
five  minutes  a  clear  fluid  with  a  sedi- 
ment, which  can  be  removed  by  centrifu- 
galization,  is  obtained.  If  there  is 
no  special  hurry  to  obtain  a  specimen, 
it  is  wise  to  wash  the  sediment,  with 
distilled  water,  to  remove  the  excess  of 
alkali,  so  that  the  baciUi  may  adhere  to 
the  slide  better.  If  any  difficulty  is  ex- 
perienced in  getting  the  specimen  to  ad- 
here, a  little  of  the  fresh  sputum  may 
be  applied  to  a  clean  slide  or  some  albu- 
min water  (1  part  of  bcaten-up  egg 
white  to  10  of  distilled  water  and  1  per 
cent,  of  formaldehyde  solution)  may  be 
employed.  Tubercle  bacilli  are  not 
killed  in  15  per  cent,  antiformin  after 
one  hour,  so  that  the  method  can  be 
used  for  animal  injection  as  well  as  for 
microscopical  specimens.  The  method 
can  further  be  applied  to  examine  blood 
for  tubercle  bacilli.  This  may  prove  of 
use  in  differentiating  between  typhoid 
fever,  miliary  tuberculosis  and  sepsis. 
The  bacilli  obtained  from  the  anti- 
formin fluid  are  found  in  pure  culture, 
all  other  bacilli  having  been  dissolved. 
(Berl.  Idin.  Woch.,  April  5,  1909.) 


children.  He  states  that  bromide  erup- 
tion may  occur  in  those  who  are  suscepti- 
ble, independent  of  the  dose  of  the  drug 
or  the  length  of  administration.  The 
larger  the  dosage  and  the  longer  the 
ingestion,  the  greater  is  the  chance  of  an 
outbreak.  There  are  practically  no  con- 
stitutional or  subjective  symptoms  in 
most  cases.  Because  of  the  slow  elimina- 
tion, the  eruption  may  continue  to  appear 
for  some  weeks  after  the  drug  has  been 
discontinued.  Almost  any  type  of  erup- 
tion may  be  present;  in  childhood  the 
lesions  are  usually  larger  and  more  per- 
sistent than  in  adult  life.  The  extremi- 
ties and  the  face  are  the  parts  most 
frequently  attacked;  the  most  extensive 
eruption,  in  the  majority  of  the  cases, 
occurs  upon  the  legs.  Lesions  have  a 
great  tendency  to  occur  at  points  of 
previous  inflammation,  such  as  vaccina- 
tion, scars,  injuries,  etc.  (New  York 
Medical  Journal,  March  20,  1909.) 


BROMIDE  ERUPTION  IN  CHILDHOOD. 

Dr.  F.  C.  Knowles  reviews  the  litera- 
ture and  reports  four  cases  of  bromide 
eruption  of  unusual  tj^^e  occurring  in 


CiESAREAN  SECTION,  ADRENALIN  IN. 

Dr.  Bogdanovics  in  a  case  of  Ciesarean 
section  where  the  wounded  uterus  con- 
tracted badly  after  extraction  of  the 
fcetus,  acted  on  the  recommendation  of 
Neu,  who  used  adrenalin  to  bring  about 
contractions.  Schiifer  had  long  since 
pointed  out  that  this  compound  acted 
very  definitely  on  the  muscular  tissue 
of  the  non-gravid  uterus.  Bogdanovics's 
patient  was  a  primipara,  aged  31,  with 
a  typical  flat,  rickety  pelvis  and  knock- 
kneed.  The  child  was  well  developed, 
and  the  head  presented;  the  os  was  be- 
ginning to  dilate.  The  mother  desired 
to  have  a  living  child  and  consented  to 
any  operation  likely  to  save  it.  Sym- 
physiotomy and  delivery  of  the  cbild 
through  the  rigid  soft  parts  of  this 
elderly  primipara  seemed  dangerous  on 
the  child's  account.  Caesarean  section 
was  preferred.    A  transverse  fundal  in- 


572 


CALCIUM  SALTS  IN   SKIN  DISEASES. 


CEREBELLAR  TUMOR. 


cision  was  made,  the  child  extracted 
alive,  the  membranes  removed,  and  the 
uterine  woiind  sutured  with  catgut. 
The  uterine  muscle,  however,  was  high- 
ly atonic  and  free  irrigation  with  Avarm 
saline  sohiLion  failed  to  set  up  contrac- 
tions. Bogdanovics  therefore  injected 
into  four  different  points  in  the  uterine 
wall  1  cubic  centimeter  of  a  1  in  10,000 
fresh  solution  of  Eichter's  tonogen,  a 
preparation  of  adrenalin  recommended 
by  Neu.  The  uterus  at  once  contracted 
till  it  became  of  stony  hardness,  and  the 
hfemorrhage  from  the  incision  ceased  at 
once.  The  ojDeration  was  concluded 
without  any  further  complications  and 
the  puerperium  vras  normal.  (Zentralbl. 
f.  Gynak.,  No.  19,  1909.) 


CALCIUM  SALTS  IN  SKIN  DISEASES. 

Dr.  Bettmann  has  obtained  remark- 
able benefit  in  a  certain  proportion  of 
itching  skin  affections  from  internal  ad- 
ministration of  calcium  lactate  in  a  5 
per  cent,  solution,  one  or  two  table- 
spoonfuls  an  liour  before  meals,  three 
times  a  day,  for  three  or  four  weeks. 
His  experience  with  seventy  cases 
showed  that  the  remedy  failed  to  influ- 
ence the  affection  in  the  majority  of 
cases,  but  in  others  the  effect  was 
marked  and  encourages  further  trials 
of  this  simple  medication,  which  his 
experience  has  shown  to  be  harmless. 
It  proved  efficient  in  conditions  pecu- 
liarly rebellious  to  other  measures,  es- 
pecially in  the  "toxicodcrmias."  In 
senile  pruritus;  in  particular,  the  effect 
was  marked.  (Miinchener  medizinische 
Wocbenscbrift,  June  22,  1909.) 


CHOLERA  INFANTUM,    CARROT  SOUP    IN 

THE   TREATMENT   OP. 

Dr.  C.  Beck  states  that  carrot  soup 

used  at  the  proper  time  will  prove    a 

good  substitute  for  salt  infusion  in  chol- 


era infantum.  In  acute  gastro-intes- 
tinal  disturbances  the  great  loss  of 
fluids  from  the  body  is  a  direct  menace 
to  life.  The  introduction  of  salt  by 
mouth,  or  subcutaneously,  leads  to  re- 
tention of  water  and  is,  therefore,  of 
great  therapeutic  value  in  these  cases. 
Many  infants,  however,  will  persistently 
refuse  to  take  salt  solution  even  when 
the  salty  taste  is  somewhat  disguised 
by  the  addition  of  bicarbonate  of  soda. 
For  some  time  the  author  has  adminis- 
tered in  these  cases  carrot  soup  with 
very  gratifying  results.  It  is  prepared 
as  follows :  A  pound  of  carrots  is  cut  up 
into  small  pieces  and  boiled  in  water  for 
one  to  two  hours;  this  is  then  strained 
through  a  fine  sieve  into  a  liter  of 
bouillon  made  from  a  pound  of  beef. 
To  this  is  added  a  teaspoonful  of  table 
salt.  A  liter  of  this  soup  has  a  caloric 
value  of  250.  The  soup  was  readily 
taken  and  retained  by  all  infants  even 
when  all  other  foods  were  rejected. 
Large  quantities,  200,  300  cubic  centi- 
meters were  given  at  intervals  of  three 
to  four  hours.  The  severe  s}T:nptoms  of 
collapse  usually  disappeared  within  one 
to  three  days,  the  temperature  dropped 
and  the  weight  increased.  The  stools 
became  pultaccous,  of  reddish-yelloAvish 
color,  and  the  odor  disappeared.  With 
the  exception  of  a  few  gram-negative 
bacteria  all  micro-organisms  disap- 
peared from  the  stools.  (Jahrb  flir 
Kinderhk.,  May  5,  1909.) 


CEREBELLAR  TUMOR,  REMOVAL  OF. 

Drs.  T.  Diller  and  Otto  C.  Gaub, 
Pittsburg,  have  analysced  the  statistics 
of  removal  of  cerebellar  tumors  and 
find  that  the  mortality  of  the  operation 
has  been  notably  reduced  within  the  last 
few  years.  They  also  quote  a  letter 
from  Dr.  Harvey  Gushing,  of  Baltimore, 
giving  his  opinion  based  on  experience 


ETHYL  CHLORIDE  AS  AN  ANAESTHETIC. 


573 


of  thirty  cases,  who  thinks  that  with  a 
certain  method  of  operating  the  results 
may  be  as  favorable  as  in  the  case  of 
lesions  of  the  cerebral  hemisphere.    He 
says:     "It  is  my    feeling    that  with    a 
proper  face  down  position  on  a  suitable 
operating  table,  with  a  skilled  anaesthe- 
tist and  with  a  low  operation  with  re- 
moval of  the  posterior  half  of  the  fora- 
men magnmn  so  as  to  get  below    the 
lips  of  the  cerebellmn  and  evacuate  fluid 
before  the  dura  is  freely  opened,  these 
cases,  contrary  to  the  opinion  that  has 
been  expressed  by  others,  are  as  favor- 
able, if  not  more  favorable,  for  opera- 
tion as  lesions    of  the    cerebral    hemi- 
sphere."   The  other  side  of  the  case  has 
been  shown  by  Knapp,  of  Boston,  who, 
in  his  paper  published    in    1906,    con- 
cludes from  the  study  of  104  autopsies 
of  brain  tumor,  that  only    four    were 
anatomically   accessible    and  presented 
enough  clinical  s3^mptoms  to  be  correctly 
located  for  the  purpose  of  operation. 
A    number    of    other    authorities    are 
quoted  and  the  clinical  and  pathologic 
record  of  their  own  cases  is  given  with 
special  detail.     The  operation  seems  to 
have  been  done  according  to  Cushing's 
method  for  the  most  part,  except  that 
the  patient  was  placed  on  his  left  side 
with  a  sand  bag  under  the  head.     The 
operation  was  a  success.     The  patient 
was  relieved  and  has  continued    to  do 
well.     The  features  which  seem  to  the 
authors  specially  noteworthy  are  given 
as  follows:  "1.    The  excellent  recovery 
of  the  patient  after  the  operation   and 
his  great  improvement.     2.     The  posi- 
tion of  the  head,  bent  forward  to  the 
left  on  the  chest  and    rotated    to    the 
right.     This    is    against    the    common 
statement  that  in  cerebellar  tumors  the 
head  is  drawn  backward.    3.     The  very 
rapid  subsidence  of  the  optic    neuritis 
following  the  operation.     4.     The  fact 


that  the  optic  neuritis  was  greater  on 
the  right  side — the  side  of  the  tmnor — 
than  the  other  side.  5.  The  great 
practical  value  of  exposing  the  cere- 
bellum over  both  sides;  this,  not  only 
because  it  is  frequently  difficult  to  de- 
cide on  which  side  a  tumor  is  located, 
but  because  such  an  opening  allows  for 
far  better  manipulation  and  exploration 
of  the  cerebellum.  Without  this  double 
opening  the  tumor  in  this  case  probably 
could  not  have  been  enucleated.  6.  The 
fact  that  considerable  manipulation  and 
even  destruction  of  the  cerebellar  lobe 
is  compatible  with  life.  7.  The  posi- 
tion of  the  patient  on  the  operating 
table  and  the  surgical  technic  are  of 
the  greatest  importance.  8.  The  cardiac 
complication — the  apparent  develop- 
ment of  an  endocarditis  which  seems  to 
have  disappeared  now."  The  tumor  was 
situated  in  the  right  lobe,  from  one- 
third  to  one-half  of  which  was  cut  away 
in  removing  it.  Its  size  was  about  that 
of  a  hickory  nut  and  the  pathologic 
diagnosis  was  myxosarcoma  teleangiec- 
tatum.  (Journal  of  the  American  Med- 
ical Association,  July  31,  1909.) 


ETHYL  CHLORIDE  AS  AN  ANiESTHETIC. 
Dr.  A.  H.  Miller  says  that  the  relative 
danger  from  an  anaesthetic  depends  on 
two  factors:  the  margin  of  safety  of  the 
drug,  and  the  character  of  the  danger 
signs.  The  margin  of  safety  of  an  anaes- 
tlictic  may  be  represented  by  the  propor- 
tion of  the  drug  which  may  be  adminis- 
tered beyond  the  amoimt  required  to  pro- 
duce anaesthesia  without  causing  symp- 
toms of  danger.  Nitrous  oxide  has  a 
small  margin  of  safety,  but  the  danger 
signs  are  so  Tuarked  that  nitrous  oxide 
anesthesia  is  tlic  safest  known.  Ether 
has  a  fairly  large  margin  of  safety  and 
quite  well  marked  danger  signs,  so  it  is 
quite    a    safe    anesthetic.      Chloroform 


574 


FACIAL  PARALYSIS. 


GASTRIC  ULCER. 


has  but  a  small  margin  of  safety,  and  the 
danger  signs  are  readily  overlooked.  It 
is  always  a  dangerous  anaesthetic,  but 
especially  so  in  inexperienced  hands. 
Ethyl  chloride  has  a  large  margin  of 
safety,  but  the  danger  signs  are  not 
marked.  While  it  is  very  safe  when 
administered  by  an  expert,  it  may  be  very 
dangerous  in  unskilled  hands.  With  an 
expert  administrator,  it  should  be  safer 
than  ether,  but  less  safe  than  nitrous 
oxide.  With  an  unskilled  or  careless 
administrator,  it  is  probably  more  dan- 
gerous than  ether,  but  not  as  dangerous 
as  chloroform.  (Boston  Medical  and 
Surgical  Journal,  May  30,  1909.) 


FACIAL  PAEALYSIS,  TREATMENT  OF. 
Dr.  F.  Marsh  reports  the  treatment  of 
facial  paralysis  in  two  patients  due  to 
the  division  of  the  facial  nerve  in  the 
mastoid  operation.  They  show  (1)  that 
if  division  of  the  facial  nerve  is  recog- 
nized at  the  time  of  operation,  careful 
adjustment  in  the  manner  indicated  (the 
use  of  strands  of  chromicized  catgut) 
will  probably  result  in  the  restoration  of 
the  function;  (2)  that  if  division  has 
not  been  recognized  the  wound  should  be 
reopened  and  the  nerve  ends  adjusted  at 
the  earliest  opportunity;  (3)  that  if  a 
careful  adjustment  has  been  made  a 
second  operation  should  not  be  imder- 
taken  within  three  or  four  months;  (4) 
that  this  method  of  adjustment  should  be 
tried  before  anastomosis  with  the  hypo- 
glossal or  spinal  accessory  nerves  is 
attempted,  the  results  of  which  are  not 
always  gi-atifying.  (  British  Medical 
Journal,  June  5,  1909.) 


FARADIC  CURRENT  IN  OTOSCLEROSIS. 

In  an  interesting  and  exhaustive  com- 
pilation, author  gives  different  views  as 
to  the  nature  and  etiology  of  otosclerosis 
which  he  himself  considers  a  disease  of 


tlie  inner  muscles  of  the  ear.  Finding 
the  cause  in  this,  he  directs  his  treat- 
ment towards  the  weakness  and  atrophy 
of  these  muscles,  the  stapedius  and  the 
tensor  tympani,  using  the  electro  mas- 
sage, lie  reports  twenty  cases  treated 
in  this  manner  and  noticed  a  decided 
improvement  in  the  function  of  the 
stapedius  as  well  as  in  the  tensor  tym- 
pani, causing  a  diminution  disappear- 
ance of  the  tinnitus  aurium,  as  well  as 
an  improvement  in  the  hearing.  He 
reaches  the  following  conclusions  based 
on  his  experience:  1.  In  all  persons 
afflicted  with  otosclerosis  the  function 
of  the  tensor  tympani  is  impaired  or 
lost  entirely;  very  rarely  is  it  retained 
and  in  this  case  we  must  therefore  con- 
sider an  isolated  primary  affection  of 
the  stapedius  muscle.  2.  Ear  noises, 
under  the  influence  of  faradization  dis- 
appear entirely  or  diminish  to  such  a 
degree  that  they  do  not  annoy  the  pa- 
tient. 3.  By  this  method  of  treatment 
the  hearing  distance  is  increased,  due  to 
the  improvement  in  the  capacity  of  ac- 
commodation. 4.  In  faradization  one 
electrode  is  introduced  into  the  opening 
of  the  Eustachian  tube  and  the  button 
of  the  electrode  pressed  against  the  su- 
perior wall.  The  second  electrode  is 
placed  on  the  angle  between  the  lower 
jaw  and  the  mastoid  process.  5.  The 
intensity  of  the  current  varies  in  differ- 
ent individuals.  As  a  rule  the  strongest 
current  that  the  patient  can  stand 
should  be  used.  6.  The  duration  of  the 
sitting  should  be  three  to  five  minutes, 
the  frequency  of  the  sittings  not  less 
than  three  times  a  week.  (The  Medical 
Fortnightly,  July  10,  1909.) 


GASTRIC  ITLCER,  TREATMENT  OF. 
Dr.    Mayerele    reviews    the    various 
methods  in  vogue  and    reports    his  re- 
sults in  71  cases  of    gastric    ulcer    in 


VAGINAL  C^ESAREAN    SECTION. 


BOOK  IlEVIEWS. 


575 


which  he  applied  Lenhartz's  method. 
The  hst  includes  29  recent,  bleeding  gas- 
tric ulcers,  17  chronic  and  25  uncompli- 
cated recent  cases.  His  verdict  is  favor- 
able on  the  whole,  as  smooth  recovery 
was  noted  in  C5  per  cent.,  slow  recovery 
without  recurrence  in  11  per  cent.,  and 
with  recurrence  in  14  per  cent.  In  10 
per  cent,  no  benefit  was  apparent,  or  it 
was  transient  while  in  7.1  per  cent,  the 
diet  was  not  tolerated.  In  no  case  was 
any  injury  apparent  from  the  diet  com- 
menced immediately  after  the  haemor- 
rhage. Occasionally  the  Lenhartz  diet 
seemed  to  increase  the  tendency  to  hy- 
perchlorhydria  and  the  allied  hyperse- 
cretion. In  these  cases  it  was  found 
necessary  to  increase  the  proportion  of 
fat  in  the  diet,  while  reducing  the  pro- 
portion of  albumin.  In  the  chronic 
cases  with  reduced  acidity  a  diet  with 
less  albumin,  moderate  fat  and  carbohy- 
drates predominating  answered  the  pur- 
pose better.  (Archiv.  fiir  Verdauungs- 
Krankheiten,  Berlin,  June,  1909.) 


VAGINAL     CESAREAN     SECTION,     TECH- 
NIQUE AND  INDICATIONS  FOR  THE. 

Dr.  A.  Duhressen  in  (Gyn.  Eund., 
Jahr.  II,  Heft  22)  gives  the  technique 
of  the  vaginal  Caesarean  section  as  fol- 
lows: The  operation  is  preceded  by  an 
injection  of  ergotin,  an  incision  is  then 


made  on  the  right  side  of  the  vagina 
through  the  perineimi  large  enough  to 
admit  the  fist  of  a  full-sized  man.  The 
cervix  is  now  grasped  with  forceps  and 
the  posterior  lip  split  up  to  the  roof  of 
the  vagina;  by  prolonging  this  Incision 
backward  the  cul-de-sac  of  Douglas  is 
opened,  and  the  peritoneum  separated 
from  the  uterus.  The  anterior  lip  and 
vaginal  junction  are  split  in  the  same 
way,  and  the  urinary  bladder  separated 
in  a  similar  manner;  thus  the  anterior 
and  posterior  walls  of  the  body  are 
exposed  for  a  distance  of  six  centimeters 
and  this  is  now  quickly  incised  with  a 
pair  of  scissors,  the  resulting  opening 
shows  the  amniotic  sac  large  as  a  man's 
fist.  A  hand  is  pushed  into  the  uterus, 
the  foot  of  the  foetus  is  grasped,  and 
the  child  is  extracted.  The  indications 
for  this  operation  are  eclampsia,  in 
Avhich  better  results  are  obtained  by 
this  method  than  by  any  other;  placenta 
prsBvia,  when  the  cervix  is  not  widely 
dilated  enough  to  allow  the  use  of  a 
rubber  balloon,  and  combined  version, 
or  when  the  delay  would  destroy  the 
life  of  the  child.  The  author  has  never 
seen  lesions  of  the  bladder  produced  by 
this  operation.  In  cases  of  danger  to 
the  child  alone  with  undilatable  cervix, 
the  vaginal  section  is  indicated,  (l^ash- 
ville  Journal  of  Merlicine  and  Surgery, 
July,  1909.) 


9ool{  Reviews 


The  Principles  of  Pharmacy.  By  Henry  V.  Amy,  Ph.G.,  Ph.D.,  Professor  of  Phannnoy 
at  the  Cleveland  School  of  Pharniacv,  Pharmacy  Department  of  Western  Rosorve  Uni- 
versity. Octavo  of  1175  Paj^es.  with  24G  Illustrations,  Mostly  Original.  Cloth,  $.5.00  net; 
Half-morocco,  $6.50  net.     Pliilaclolpliia  and  London:     W.  B.  Saunders  Company.  1900. 

This  volume,  which  is  clearly  written  and  well  illustrated,  aims  to  give  a  succinct  account 
of  the  Pharmacopoeia  from  its  pharmaceutical  standpoint.  No  author  has  undertaken  to 
go  so  fully  and  exactly  into  details  as  the  author  of  this  work  which  is  as  complete  as  any 
work  now  before  the  pharmaceutical  and  medical  profession.     It  is  divided  into  seven  parts: 


576  BOOK  REVIEWS. 

Part  I. — Pharmaceutic  Operations. 

Part  II. — Galenic  Pharmaceutic  Preparations. 

Part  III. — Inorganic  Chemistry, 

Part  IV. — Organic  Chemistry. 

Part  V. — Pharmaceutic  Testing. 

Part  VI. — The  Prescription. 

Part  VII. — Laboratory  Exercises. 

The  work  has  been  prepared  with  great  care  and  accuracy  and  the  special  features  are 
equation  writing,  chemical  arithmetic,  and  a  grouping  of  all  the  tests  of  the  pharmacopoeia. 

The  text  is  well  written  and  omits  all  useless  verbage  and  no  point  desirable  in  such 
a  work  has  been  overlooked.  The  book  Is  handsomely  bound,  well  written,  and  is  printed 
in  very  readable  type.  A  contribution  to  pharmaceutic  literature  by  so  high  an  authority 
as  Dr.  Arny  Is  worthy  of  mention. 

Diet  in  Heaxth  a^d  Disease.  By  Julius  Frledenwald,  M.D.,  Professor  of  Diseases  of  the 
Stomacli  iu  the  College  of  Physicians  and  Surgeons,  Baltimore;  and  John  Ruhrlih,  M.D., 
Professor  of  Diseases  of  Children  in  the  College  of  Physicians  and  Surgeons,  Baltimore. 
Third  Revised  Edition.  Octavo  of  764  Pages.  Cloth,  $4.00;  Half-morocco,  $5.50  net. 
Philadelphia  and  London:    W.  B.  Saunders  Company.   1909. 

This  work  combines  a  knowledge  of  the  various  kinds  of  foods,  their  composition,  uses, 
and  the  principles  of  diet  both  in  health  and  in  disease.  The  aim  of  the  authors  has  been 
to  present  in  a  brief  space  diet  lists  and  recipes  for  the  benefit  of  the  practitioner  as  well  as 
the  student.  Fortunately  for  the  reader  who  is  not  familiar  with  the  present  day  knowledge 
of  chemistry  and  physiology  of  digestion,  the  book  begins  with  the  chemistry  of  digestion  and 
gives  a  thorough  consideration  to  absorption,  metabolism,  and  the  different  enzymes. 

Among  the  topics  considered  are:  "Classes  of  Foods,"  "Beverages  and  Stimulants," 
"Various  Factors  and  Their  Bearing  on  Diet,"  "Infant  Feeding,"  "Diet  for  Special  Con- 
ditions," "Special  Methods  of  Feeding,"  "Diet  in  Disease,"  "Special  Cures,"  "The  Dietetic 
Management  of  Surgical  Cases,"  "Army  and  Navy  Rations,"  "Dietaries  in  Public  Institu- 
tions," "Recipes,"  "The  Chemical  Composition  of  American  Food  Materials,"  "Rapid  Refer- 
ence Diet  Lists."  The  dietetic  treatment  of  diabetes  is  very  elaborate  and  there  are  many 
tables  containing  foods  sanctioned  and  forbidden  by  the  various  authorities.  The  methods 
of  treating  obesity  also  deserve  mention.  On  the  whole  the  book  cannot  be  too  highly 
commended  as  a  practical  handbook  for  every  day  use. 

The  Ameeican  Pocket  :Medical  Dictionaey.  Edited  by  W.  A.  Newman  Dorland,  M.D., 
editor  "The  American  Illustrated  Medical  Dictionary."  Sixth  Revised  Edition.  32mo 
of  598  Pages.  Flexible  Morocco,  gold  edges,  $1.00  net;  thumb  indexed,  $1.25  net. 
Philadelphia  and  London:    W.  B.  Saunders  Company,  1909. 

This  small  volume  is  very  handy  in  size,  and  at  the  same  time  it  is  very  rich  in 
material.  It  contains  a  maximum  amount  of  information  in  a  minimum  amount  of  space, 
arranged  for  quick  study  and  reference.  This  book  will  prove  valuable  to  not  only  the 
practitioner  but  also  to  the  student  in  preparing  for  examinations. 

A  commendable  feature  of  this  unique  little  book  is  the  tables  which  contain  exact  and 
valuable  knowledge  so  conveniently  arranged  and  classified  and  also  gives  the  desired 
information  concerning  the  newer  and  more  recent  words. 

The  print  is  excellent  and  the  terms  are  easily  understood  and  will  indeed  prove  an 
indispensable  work  of  reference. 

Tbeatment  of  the  Diseases  of  Children.  By  Charles  Gilmore  Kerley,  M.D.,  Professor  of 
Diseases  of  Children,  New  York  Polyclinic  Medical  School  and  Hospital,  etc.  Second 
Revised  Edition.  Octavo  of  629  Pages,  Illustrated.  Cloth,  $5.00  net;  Half -morocco, 
$6.50  net.     Philadelphia  and  London:    W.  B.  Saunders  Company,  1909. 

The  material  of  this  book  has  undergone  a  thorough  revision  and  contains  extensive 
changes  in  accordance  with  the  modern  methods  of  management  and  tlierapeutic  measures 
in  the  treatment  of  children.  The  author  has  had  exceptional  opportunities  and  this  volume 
is  the  result  of  years  of  experience  and  the  comparative  study  of  many  cases. 

The  scope  of  this  work  is  clearly  indicated  by  its  title  and  the  first  one  hundred  and 
fifty  pages  are  devoted  to  information  of  a  preliminary  nature  in  regard  to  feeding, 
nutrition  and  growth  of  the  infants.  The  classification  of  diseases  is  rational  and  con- 
venient and  the  general  and  hygienic  treatment  is  well  pointed  out  and  constitutes  an 
important  feature. 

The  special  features  of  the  book  are  the  chapters  dealing  with  "Vaccine  Therapy,"  in 
which  the  authors  describes  the  new  diagnostic  methods,  "Gymnastic  Therapeutics."  Among 
other  chapters  worthy  of  mention  are  "Diseases  of  the  Respiratory  Tract,"  "Contagious 
Diseases,"  "Constitutional  Disorders,"  "Infectious  Diseases.  The  book  is  exceedingly 
valuable  to  the  practitioner. 


ONTHLY    Cyclopedia 

AND 

EDicAL   Bulletin 


Published  the  Last  of  Each  Month 


Montlily  Cyclopaedia  Section 


Vol.  II.  PHILADELPHIA,  OCTOBER,  1909.  No.  10. 


Original  Articles 


Deimrtment  in  charge  of  J.  MADISON  TAYLOR,  A.M.,  M.D. 


CONSTITUTIONAL  CONDITIONS  AFFECTING  NASAL  CATARRH. 

By  CHARLES  W.  RICHARDSON,  M.D., 

Professor    of    Laryngology    and    Otologj^    in    the    Medical    Department   of    the    George 

Washington  University. 

WASHINGTON,    D.    C. 

It  is  not  my  purpose  in  treating  of  this  subject  to  take  up  the  consideration 
of  those  organic  lesions  of  the  various  organs  and  systems  of  the  body  which 
are  well  known  to  have  as  correlated  symptoms  some  disarrangement  of  the 
mucosa  of  the  upper  air  tract,  but  rather  to  call  your  attention  to  the  subtle 
influences  that  certain  conditions,  unattended  with  any  organic  change,  exert 
upon  the  mucous  membrane  of  the  nose,  throat  and  even  the  bronchial  mucous 
tract.  During  the  early  stages  of  these  disturbances,  and  ofttimes  nearly 
throughout  the  history  of  these  cases,  the  evidences  of  perverted  function  will 
be  manifested  solely  in  the  regions  indicated.  The  local  manifestation  of 
these  disturbances  are  more  frequently  in  the  form  of  vascular  changes  in  the 
turbinal  tissue  of  the  nasal  tract.  They  may  be  divided  into  three  groups,  viz. : 
(a)  paroxysmal  form  of  vasomotor  turgescence  of  the  nasal  mucosa,  occurring 
occasionally  at  periods  during  the  day,  more  frequently  at  night;  (b)  a  more 
or  less  constant  type  of  vasomotor  turgescence  of  the  nasal  mucosa,  which  is  most 
intense  during  the  night;  (c)  a  vasomotor  turgescence  of  the  nasal  mucosa 
occurring  at  night,  and  which  is  attended  with  a  similar  condition  in  the 
bronchial  tract,  as  evidenced  by  coughing  and  wheezing. 

The  etiolo;i-ical  factor  that  enters  into  causation  of  these  disturl)ances  is 
an  inordinate  demand  made  upon  the  nervous  system  without  a  proportionate 
amount   of   physical   exercise   and   rest.     The  type   exemplified   by   the   first 

3  C^^?) 


578        CONSTITUTIONAL   CONDITIONS  AFFECTING   NASAL   CATARRH. 

group  occurs  most  frequently  in  vigorous  males,  who  are  addicted  to  intense 
mental  work  to  which  they  enslave  themselves.  They  are  usually  of  the  neu- 
rotic temperament.  They  are  sedentary  in  their  habits,  do  not  participate  in 
any  form  of  physical  exercise,  and  abide  most  of  the  time  in  badly  ventilated, 
overheated  office  rooms.  A  typical  case  of  this  form  is  represented  by  a  young 
man  who  came  under  my  observation  several  months  past.  The  patient  was  a 
vigorous,  healthy  individual  of  twenty-eight  years.  He  complained  of  a 
moderate  degree  of  difficulty  in  breathing  through  the  nasal  chambers  during 
the  day.  His  great  distress  occurred  usually  between  one  and  two  o'clock  in  the 
morning,  when  he  would  be  awakened  by  sneezing,  coughing,  or  a  sensation 
of  impending  suffocation.  Nasal  obstruction  was  complete  at  this  time.  The 
remainder  of  the  night  would  be  passed  in  a  more  or  less  troubled  slmnber.  A 
violent  paroxysm  of  sneezing  usually  transpired  on  arising  in  the  morning. 
Physical  examination  demonstrated  the  turbinates  very  much  congested  and 
so  hypertrophied  as  to  nearly  fill  out  the  lumen  of  the  nasal  cavities.  Con- 
traction M^as  quite  fair  under  cocaine,  only  showing  here  and  there  areas  of 
structural  hypertrophy.  The  history  obtained  was  as  follows :  He  is  employed 
in  one  of  the  scientific  laboratories  of  the  Government  where  his  work  is  very 
exacting  in  character.  His  hours  of  employment  are  from  nine  in  the  morn- 
ing until  four  in  the  afternoon.  For  two  years  he  has  been  attending  a 
course  in  one  of  the  law  schools.  It  was  his  habit  to  go  from  the  Depart- 
ment to  the  University,  where  he  spent  from  two  to  three  hours  in  lectures, 
etc. ;  his  evenings  were  invariably  spent  in  study ;  his  retiring  hour  was  about 
twelve  and  he  rose  about  seven  in  the  morning;  his  digestion  was  good; 
urine  showed  excess  of  phosphate,  no  indican;  he  took  no  physical  exercise  and 
always  used  the  cars  instead  of  walking.  I  indicated  to  him  the  necessity  of 
cutting  out  much  of  his  work,  the  taking  of  a  certain  amount  of  physical 
exercise,  and  living  a  more  normal  life.  I  refused  through  cauterization  or 
other  surgical  methods  of  attempting  to  restore  the  patency  of  his  nasal  cavities. 
My  efforts,  though  repeated  and  insisted  upon  at  each  subsequent  visit,  seem- 
ingly fell  upon  barren  soil,  and,  as  usual,  he  sought  other  advice.  About  six 
weeks  thereafter  he  returned  to  me  and  recounted  his  experience.  Several 
cauterizations  had  taken  place  without  relief,  and  he  had  been  twice  advised — 
even  to  insistence — that  he  should  have  his  turbinates  torn  out.  A  thorough 
consideration  of  the  subject  again,  caused  him  to  follow  my  advice,  finally 
deciding  to  relinquish  his  law  course.  At  the  end  of  two  months  he  reported  for 
inspection,  announcing  that  he  had,  for  over  two  weeks,  felt  entirely  well.  On 
inspection  of  the  nasal  chambers,  I  found  them  in  a  perfectly  normal  state. 

The  second  group  of  cases  occurs  almost  entirely  among  the  female  sex; 
it  is  evident  in  those  of  a  neurasthenic  temperament,  most  frequently  in  women 
who  are  office  workers,  whose  duties  are  exacting,  and  require  the  expenditure 
of  great  nervous  energy.  Individuals  coming  under  this  group  take  very  little 
physical  exercise,  their  lives  both  in  and  out  of  their  duties  being  very  sedentary. 
An  example  of  this  form  is  represented  by  a  young  woman  stenographer  of 
twenty-eight  years  of  age,  employed  in  a  local  business  office.  In  order  to 
increase  her  financial  resources,  she  is  employed  in  the  evening  as  stenographer 


CONSTITUTIONAL   CONDITIONS   AFFECTING    NASAL    CATARRH.        579 

in  the  office  of  one  of  the  correspondents  of  an  out-of-town  newspaper.  She  pre- 
sented herself  to  me  some  months  ago  for  professional  advice.  She  is  of  mod- 
erate height,  of  slight  form,  and  quite  nervous  manner.  She  stated  that  she  had 
great  difficult}'-  of  breathing,  which  was  almost  constant,  the  obstruction  being 
complete  at  night;  headache  was  more  or  less  constant  and  very  intense  after 
paroxysms  of  sneezing,  which  occurred  in  paroxysms  of  great  intensity  often 
attended  with  great  exhaustion.  Examination  of  nasal  chambers  demonstrated 
the  nasal  mucosa  somewhat  paler  than  normal.  The  mucosa  over  the  turbinates 
was  of  a  pale  pinlcish-white  color.  The  turbinates  were  intensely  relaxed,  so 
much  so  as  to  fill  out  completely  the  lumen  of  the  nasal  cavities.  The  tur- 
binates contracted  up  rather  slowly  unless  under  the  use  of  cocaine;  the  urine 
showed  excess  of  phosphate — no  indican.  The  relinquishing  of  the  excess  w^ork, 
the  administration  of  the  proper  nervines,  the  taking  of  a  proper  amount  of 
exercise,  the  obtaining  of  the  normal  amount  of  rest,  and  the  administration  of 
the  required  local  treatment  brought  about  complete  resolution  after  several 
months'  care. 

The  third  type  is  not  so  intensely  individual  in  its  character  as  the  first 
two.  It  may  be  engrafted  on  either  of  the  former  conditions  after  they  have 
existed  for  a  varying  period,  or  may  have  no  antecedent  vasomotor  disturbance. 
This  condition  may  be  exemplified  by  the  history  of  a  very  busy  office  worker. 
The  patient  is  a  man  of  f  ort^'-eight  years  of  age,  in  apparently  excellent  health ; 
no  disease  demonstrated  in  any  of  the  organs  or  great  systems  of  the  body; 
a  most  intense  worker,  especially  during  the  season  when  his  activities  are  in 
greatest  demand ;  eats  sparingly  though  always  with  good  appetite ;  takes  prac- 
tically no  regular  exercise;  states  that  for  several  months  he  has  had  a  dry. 
paroxysmal  cough,  which  comes  on  at  varying  periods  of  the  day,  which  w^ould 
endure  for  an  hour  or  more  and  then  subside.  Ofttimes  he  would  be  entirely 
free  of  the  cough  throughout  the  da}',  when  towards  the  late  afternoon,  after  a 
particularly  arduous  and  trying  day,  it  would  start  up.  At  times,  he  thouglit 
the  paroxysms  of  coughing  occurred  at  intervals  of  about  six  hours,  when  this 
theory  would  be  broken  up  by  its  absence  throughout  the  whole  day.  The 
paroxysms  occurring  about  two  to  three  in  the  morning  were  the  most  dis- 
tressing. The  paroxysms  of  coughing  during  the  night  were  always  attended 
with  complete  nasal  respiratory  blockage  of  one  or  the  other  nostril,  frequently 
with  both.  The  same  degree  or  a  more  moderate  obstruction  to  nasal  breathing 
was  frequently  manifested  with  the  day  paroxysms.  There  was  frequently 
an  uncomfortable  feeling  of  tightness  about  the  sternal  region  during  the 
paroxysms.  Distinct  wheezing  was  occasionally  felt  but  no  characteristic 
asthmatic  manifestation  had  as  yet  developed.  Examination  of  the  nasal  cham- 
bers showed  the  existence  of  a  moderate  hypertrophic  nasal  catarrh ;  examina- 
tion of  urine  showed  excess  of  phosphate  but  no  other  abnormality.  Under  the 
appropriate  treatment  this  patient  made  a  slow  but  continuous  restoration. 
Violation  of  the  within  laid  down  rules  would  be  speedily  followed  by  its  own 
punishment. 

The  above  described  conditions  have  several  features  in  common.  They 
have  a  common  origin  and  similar  etiological  factors.     They  are  tlie  product  of 


580    ■'-'^lE  i'KO(iN'OSTS  OK  FE13RJLE  CAbES  OF  I'l  LMlLNAKY  Tl  BERCULOSiS. 

unhygienic  methods  of  living  and  working;  they  are  the  result  of  overworking 
the  entire  nervous  system,  which  is  followed  by  impairment  of  the  harmony  of 
action  of  the  vasomotor  system.  The  rational  treatment  of  these  cases  is  to 
diminish  the  amount  of  work,  increase  the  amount  of  exercise,  living  in  the  open 
air  as  much  as  possible  with  rest  and  proper  diet.  Unfortunately  the  proper 
correlation  of  constitutional  and  local  treatment  is  not  always  carried  out. 
The  local  treatment  is  the  form  that  frequently  receives  the  greatest  attention, 
and,  as  a  result,  these  unfortunates  suffer  cauterization  of  the  turbinates  and 
even  the  horrors  of  partial  or  complete  turbinotomy.  Under  my  observation 
these  patients  usually  fare  best  with  the  mildest  of  local  treatment,  of  which 
cauterization  and  turbinotomy  form  no  part,  with  the  most  assiduous  care  to 
their  welfare,  viz.,  the  searching  for,  and  removal  of,  the  causes. 


THE  PROGNOSIS  OF  FEBRILE  CASES  OF  PULMONARY  TUBERCULOSIS.* 

By  harry  lee  BARNES,  M.D., 
Superinteiideiii   of    the    State    Sanatorium,    Walhuu    Lake,    R.    I. 

An  accurate  prognosis  of  febrile  cases  of  pulmonary  tuberculosis  must  be 
made  from  a  consideration  of  all  the  factors  which  enter  into  the  prognosis  of 
all  cases  whether  febrile  or  afebrile.  The  facts  as  to  age,  sex,  race,  and  social 
condition  are  to  be  v/eighed,  but  they  are  iisually  of  no  great  importance.  An 
examination  of  the  luugs  will'  usually  give  an  approximate  idea  of  the 
damage  done  and  this  amount  of  lung  involvement  should  be  considered  in 
connection  witli  the  presumable  duration  of  the  disease,  for  this  is  the  most 
practical  way  of  measuring  the  virulence  of  the  infection  against  the  patient's 
resistance  to  that  infectiou.  If  five  lobes  are  involved  after  five  years,  tlie 
prognosis  may  be  much  better  than  when  two  lobes  have  been  involved  in  two 
months. 

A  very  impoi'tant  consideration  is  the  amount  of  intelligence,  self-control, 
and  willingness  to  co-operate  manifested  by  the  patient.  It  usually  matters 
little  whether  the  pneumonia  or  typhoid  patient  has  intelligence,  but  if  the 
tuberculous  patient  is  so  lacking  in  common  sense  or  character  that  he  cannot 
or  will  not  follow  a  physician's  advice,  he  will  frequently  pay  for  his  foolishness 
or  willfulness  with  his  life. 

Of  15  incipient  patients  who  left  the  Ehode  Island  State  Sanatorium  against 
advice,  the  subsequent  histories  16  months  after  discharge  showed  that  40  per 
cent,  were  wxll,  40  per  cent,  living,  and  20  per  cent,  dead,  while  the  subsequent 
liistorics  of  all  incipient  cases  discharged  by  the  sanatorium  taken  on  an  average 
of  18  montlis  after  discharge  showed  85.7  per  cent,  well,  and  14.3  per  cent.  dead. 
Of  124  inoderately  advanced  cases  who  left  fi gainst  advice  the  subsequent  his- 
tories, 13  months  after  discharge,  showed  that  17.7  per  cent,  were  well,  50  per 

*  Read  before  the  Americmi  Cliniatolof^ical  Association,  at  Fortress  Monroe, 
Virginia,  Jime   4,   1900. 


THE  PROGNOSIS  OF  FEBRILE  CASES  OF  PULMONARY  TUBERCULOSIS.   581 


cent,  were  living,  and  32.2  per  cent,  were  dead,  while  the  subsequent  his- 
tories of  all  (162)  moderately  advanced  cases  for  the  same  period  showed  40  per 
cent,  well,  30.2  per  cent,  living,  and  29.2  per  cent.  dead.  Stated  in  a  few  words, 
the  patients  who  reject  our  advice  throw  away  over  half  their  chances  of  getting 
well  and  keeping  well.  Many  cases  occur  in  which  lack  of  money  to  procure 
good  food,  good  housing,  fresh  air,  and  freedom  from  work  during  active  dis- 
ease, has  a  marked  influence  on  the  prognosis.  Yet  our  statistics  tend  to  show 
that  this  is  usually  not  the  case  with  our  patients. 

We  have  compared  the  subsequent  histories  of  265  of  our  pay  patients  with 
those  of  all  our  patients  (TO  per  cent,  of  which  are  free),  and  find  that  two 
years  after  discharge  76.9  per  cent,  of  all  our  incipient  patients  are  well,  as 
compared  to  54.2  per  cent,  of  our  incipient  pay  patients,  and  that  35.4  per  cent, 
of  all  our  moderately  advanced  patients  are  well,  as  against  18.1  per  cent,  of  the 
moderately  advanced  pay  patients. 

A  comparison  of  the  subsequent  histories  of  pay  patients  with  those  of  all 
patients,  according  to  the  condition  on  discharge,  also  results  unfavorably  to  the 
pay  patients,  as  shown  by  the  following  table  coinputed  22  months  after 
discharge. 


ALL  CASES 

PAY  CASES 

Well 

Living        Dead 

Well 

Living 

Dead 

Percent. 

Per  Cent.  Per  Cent. 

Per  Cent. 

Per  Cent. 

Percent. 

Apparently  Cured 

78.5 

14.2      1        7.1 

1      70.0 

25.0 

5.0 

Disease  Arrested 

50.0 

19.6           30.3 
13.6           65.2 

!      33.7      '      46.0 

20.2 

Disease  Active 

21.0 

6.7            26.3 

66.8 

While  a  considerable  proportion  of  our  pay  patients  are  enabled  to  pay  only 
from  benefits  received  and  practically  ail  are  from  the  working  classes,  yet  it  is 
undoubtedly  true  that  the  standard  of  living  averages  better  among  the  pay 
patients.  The  supervision  of  free  patients,  after  discharge,  by  the  clinics  and 
visiting  nurses  may  account  to  some  extent  for  the  good  results  among  the  free 
patients. 

In  this  series  of  153  cases  there  was  an  increase  in  the  activity  of  the 
lesions  as  showTi  by  increase  of  some  one  or  all  of  the  signs  usually  accepted  as 
evidence  of  the  progress  of  the  disease,  namel}^  dullness,  broncho-vesicular  breath- 
ing, increased  voice  conduction,  and  rales,  in  50  cases,  or  32. G  per  cent.  The 
average  duration  of  the  fever  in  these  cases  before  the  increase  in  signs  was 
noted  was  5  weeks.  In  33  cases,  or  21.5  per  cent.,  signs  of  disease  appeared  in 
lobes  in  which  it  had  not  previously  been  detected.  Of  30  of  these  patients  who 
could  be  traced  24,  or  80  per  cent.,  were  dead,  the  average  length  of  life  being  5 
months.  The  total  number  of  cases  in  which  the  signs  of  disease  were  cither 
increased,  or  appeared  in  lobes  in  which  they  had  nnt  been  found  before,  was 


582   I'J^^^  PROGNOSIS  OF  FEBRILE  CASES  OF  PULMONARY  TL-fiERCULOSIS. 

74,  or  48,3  per  cent.  The  fact  that  about  50  per  cent,  of  these  fever  cases 
showed  no  signs  of  tlie  extension  of  tlie  disease  is  probably  in  part  explained  by 
the  short  period  in  which  the  fever  was  observed  in  many  cases  (59  less  that 
one  month),  and  by  other  cases  having  had  an  extension  of  the  signs  shortly 
before  admission  (fever  present  on  admission).  It  must  be  admitted,  however, 
that  patients  quite  occasionally  have  fever  lasting  several  weeks  in  which  no 
signs  of  extension  of  the  disease  can  be  detected. 

Of  the  153  cases  whose  fever  was  under  observation  for  a  period  averaging 
4.1  weeks,  17,  or  11.1  per  cent.,  developed  cavity  signs.  Sixty-two  of  these 
patients  were  under  observation  for  periods  of  but  one  to  four  weeks,  and 
doubtless  many  patients  developed  cavity  signs  after  leaving  the  sanatorium. 
T3'mpany  and  amphoric  resonance  were  frequently  found  as  cavity  signs,  but 
no  case  was  considered  to  have  a  cavity  unless  whispering  pectoriloquy,  cavernous 
or  amjjhoric  breathing  and  large  moist  rales  were  present.  Eleven,  or  64.1  per 
cent.,  of  the  cases  having  cavity  signs  developed  them  within  the  first  month  and 
13,  or  76.4  per  cent.,  within  tlie  first  six  weeks.  While  these  signs  are  frequently 
not  found  when  cavities  are  present,  yet  the  fact  that  most  of  the  cavity  signs 
appeared  early  in  the  course  of  the  fever,  and  that  of  53  cases  in  which  the 
fever  had  lasted  from  six  weeks  to  five  months,  but  3  developed  cavity  signs, 
seems  to  indicate  that  long  continued  fever  more  frequently  accompanies  a 
general  spreading  of  the  infection  than  cavity  formation.  Only  one  case 
developed  cavity  signs  without  fever.  The  subsequent  histoi'ies  of  51  patients 
having  cavity  signs  are  shov\'n  by  the  following  table.  "Length  of  life"  in  the 
febrile  cases  refers  to  the  time  elapsed  between  the  onset  of  the  fever  and  the 
death  of  the  patient.  In  all  the  subsequent  tables  the  patient's  condition  was 
determined  at  periods  averaging  27  months  after  the  onset  of  the  fever,  and 
averaginsf  23  months  after  discharo:e  from  the  institution. 


!     Cases 

_  1 

Cavity  Siprns  Developed  in  the 
Sauatorivim.     Febrile 16 

Cavity  Signs   Present   on  Ad- 
mission.    Febrile I       24 

Cavity   Signs   Present   on   Ad- 
mission.    Afebrile >       11 

~  ! 

Total 61 


I  I 

Well    i    Living        Dead      Length  op  Life 


13  8.9  Months 


21  13.9  Months 


6  15.2  Months 


1  10  40 

or       j       or  or  12.4  Mouths 

1.9  ^        19.6  fo    I    78.4  fc    \ 


A  consideration  of  the  two  following  tables  will  show  that  while  many 
patients  who  lose  weight  during  febrile  attacks  recover,  their  mortality  is, 
nevertheless,  far  greater  in  a  given  time  than  that  of  patients  who  gain  weight 
during  the  fever.     A  study  of  the  chancres  in  bodily  weight  is  shown  to  b«  of 


THE  PROGNOSIS  OF  FEBRILE  CASES  OF  PULMONARY  TUBERCULOSIS.   583 

much  more  prognostic  vnliie  in  those  cases  in  which  the  fever  was  not  reduced 
than  in  tho?e  in  which  it  was  reduced. 

Of  the  "unreduced  cases"  those  patients  who  gained  weight  lived  for  an 
average  period  of  11.3  months,  while  those  patients  who  lost  weight  lived  for  an 
average  period  of  but  6  months. 


Seventy  Cases.     Feveb  Reduced. 


31  cases  gained  weight. 

Average  gain,  5.2  pounds. 
Well.  4  cases,  or  12.9  per  cent. 
Living.  1.3  cases,  or  41.9  per  cent. 
Dead,  14  cases,  or  45.1  per  cent. 
Average  duration  of  life,  10  months. 


39  cases  lost  weight. 

Average  loss,  9.3  pounds. 
Well.  10  cases,  or  25.6  per  cent. 
Living,  6  cases,  or  15.3  per  cent. 
Dead,  23  cases,  or  58.9   per  cent. 
Average  duration  of  life,   13   months. 


Forty  Cases.     Feveb  Unreduced. 


12  cases  gained  weight. 

Average  gain,  4.7  pounds. 
Well.  1  case,  or  8.5  per  cent. 
Living.  1  case,  or  8.5  per  cent. 
Dead,  10  cases,  or  83.8  per  cent. 
Average  duration  of  life,  11.3  months. 


28  cases  lost  weight. 

Average  loss,  5  pounds. 
Well.  1  ease,  or  3.5  per  cent. 
Living.   1  case,  or  3.5  per  cent. 
Dead,  26  cases,  or  92.8  per  cent. 
Average    duration    of   life,    6   months. 


In  the  following  tables  two  daily  observations  of  the  pulse  (morning  and 
evening)  were  averaged  for  one  week  during  which  the  fever  was  highest.  They 
confirm  the  generally  accepted  view  that  a  consideration  of  the  pulse-rate  is  of 
great  value  in  the  prognosis  of  tuberculosis. 

Pulse  records  and  subsequent  histories  of  54  cases  having  daily  maximum 
fever  of  99.5°  F.  to  100°  F.: 


Pdlsb 

Well 

Living 

Dead 

Total 

No. 

Percent. 

No. 

Per  Cent. 

No. 

Per  Cent. 

No. 

Per  Cent. 

70  to  80 

0 

or   0. 

5 

or  100. 

0 

or   0. 

5 

or  100. 

80  to  90 

6 

or  31.2 

6 

or  37.6 

6 

or  31.2 

16 

or  99.9 

90  to  100 

1 

or   6.2 

7 

or  43.7 

8 

or  50.0 

16 

or  99.9 

100  to  110 

3 

or   21.3 

3 

or   21.3 

8 

or   57.1 

14 

or   99.7 

110  to  120 

2 

or  33.3 

1 

or   16.6 

3 

or  50.0 

6 

or  99.9 

Over  120 

0 

or   0. 

0 

or   0. 

2 

or  100. 

2 

or   100. 

Pulse  records  and  subsequent  histories  of  141  cases  having  daily  nia.xiniuni 
fever  of  100°  F.  or  over: 


584   THE  PROGNOSIS  OF  FEBRILE  CASES  OF  PULMONARY  TUBERCULOSIS. 


Pulse 

Well 

Living 

Dead 

Total 

No. 

Percent. 

No. 

Per  Cent. 

No. 

Percent. 

No. 

Percent. 

70   to   80 

2 

or      100. 

0 

or       0. 

0 

or       0. 

2 

or      100. 

:80  to   90 

4 

or      23.5 

9 

or      62.9 

4 

or      23.5 

17 

or      99.9 

90  to    100 

5 

or     11.6 

12 

or      27.9 

26 

or      C0.4 

43 

or      99.9 

100  to   110 

10 

or      18.5 

9 

or      16.6 

35 

or      64.8 

54 

or      99.9 

110   to   120 

1 

or       5.2 

3 

or      15.7    ' 

15 

or      78.9 

19 

or      99.8 

Over   120       { 

1 

or      16.6 

0 

or       0.0 

5 

or      83.4 

6 

or      100. 

Of  54  cases  in  which  the  daily  maximum  temperature  ran  from  99.5°  F.  to 
100°  F.,  but  5  cases,  or  9.3  per  cent.,  were  well  whose  pulse-rate  averaged  over 
100.  Of  141  cases  in  which  the  daily  maximum  temperature  averaged  100°  F. 
or  over,  but  12,  or  8.5  per  cent.,  of  those  whose  pulse  averaged  over  100  were  well, 
and  but  1  of  the  141  cases  was  well  whose  pulse  averaged  over  120  (125).  This 
patient  is  a  man  who  has  worked  steadily  as  a  hospital  porter  for  over  three  years. 

The  continued  presence  of  fever,  especially  after  rest  in  bed,  usually  means 
renewed  activity  of  old  lesions  or  the  extension  of  the  disease  to  healthy  tissue. 
The  following  study  was  made  from  the  records  of  153  febrile  cases  of  pul- 
monary tuberculosis  treated  at  the  Ehode  Island  State  Sanatorium  during  the 
past  four  years.  Only  cases  having  an  average  daily  maximum  temperature  of 
100°  F.  or  over  for  at  least  one  week  were  included.  In  the  statements  con- 
cerning the  length  of  fever,  reference  is  m.ade  to  the  whole  period  of  abnormal 
temperature,  the  last  few  days  of  temperature  below  100°  F.  being  included. 

Of  50  patients  who  ran  an  average  daily  maximum  temperature  of  100°  F. 
for  periods  averaging  3.3  weeks,  there  were,  27  months  after  the  onset  of  the 
fever : 


Well    7   cases,   or    14   per   cent. 

l^iving    8  cases,  or   IG   per  cent. 

^f^^d    .35   cases,   or   70   per  cent. 

Total    50   cases,   or   100  per   cent. 

Of  66  patients  who  ran  an  average  daily  maximum  temperature  of  100°  F. 
to  101°  F.,  for  periods  averaging  4.9  weeks,  there  were: 

Well  8  cases,  or  12.1  per  cent. 

Living  14  cases,  or  21.2  per  cent. 

Dead  44  cases,  or  63.6  per  cent. 

Total  06  cases,  or  99.9  per  cent. 


THE  PROGNOSIS  OF  FEBRILE  CASES  OE  PULMONARY  TUBERCULOSIS.  585 

Of  15  patients  who  ran  an  average  daily  maximum  temperature  of  101°  F. 
to  103°  F.,  for  periods  averaging  3.4  weeks,  there  were: 

Well    3  cases,  or  20      per  cent. 

Living    2  cases,   or   13.3  per  cent. 

Dead    10  cases,  or  66.6  per  cent. 

Total    15   eases,  "or   99.9   per  cent. 

Two  patients  having  an  average  daily  maximum  temperature  of  from  103° 
F.  to  103°  F.  died  3  and  2-i  months,  respectively,  after  discharge.  From  these 
tables  it  appears  that  the  height  of  the  temperature  within  the  above  limits  is 
of  no  prognostic  significance,  probably  because  many  small  acute  lesions  are 
accompanied  by  higher  temperatures  than  larger  chronic  ones. 

That  the  duration  of  the  fever  is  of  marked  value  in  prognosis  is  well  shown 
by  the  percentage  of  dead  in  the  followiug  table : 

Condition  Twesty-sevex  Months  After  the  Onset  of  Feveb. 


Duration   of 

Cases 

Well 

Living 

Dead 

Length  of  Life 

Fevee 

No. 

Per 

Cent. 

No. 

Per 

Cent. 

No. 

Per 

Cent. 

IN  Months, 
After  Discharge 

1  and  2  Weeks 

35 

6 

17.1 

7 

20. 

22 
15 

62.8 

8.3   Months 

3  to  4   Weeks 

27 

6 

22.2 

6 

22.2 

55.5 

6.1   Months 

1  to  2  Months 

39 

6 

15.3 

6 

16.3 

27 
8 

69.2 

12.8  Months 

2  to  3   Months 

11 

3 

27.2 

0 

0. 

73.8 

10.8  Months 

3  to  4  Months 

12 

1 

8.3 

2 

16.6 

9 

74.9 

16.6  Months 

Over  4  Months 

13 

2 

15.3 

1 

7.6 

10 

76.9 

16.6  Months 

Total 

137 

24 

17.5 

22 

16. 

91 

66.4 

10.3  Months 

In  103  cases  the  fever  was  reduced  by  complete  rest  in  bed.  The  subse- 
quent histories  of  93  of  these  cases  wliich  have  been  traced  show  that  there  were  : 

Well    24  cases,  or  2.5.7   per  cent. 

Living    18   cases,  or   19.4   per  cent. 

Dead    51   cases,  or  54.8  per  cent. 

Total    93   cases,   or   99.9   per  cent. 

Frequent  relapses  of  fever  occurred  in  most  of  tlie  fatal  cases. 

In  44  cases  which  were  treated  for  periods  varying  from  1  to  24  weeks 
and  averaging  3.6  months  the  fever  was  not  reduced.  The  subsequent  histories 
show  that  there  were: 


586  THE  PROGNOSIS  OF  FEBRILE  CASES  OF  PULMONARY  TUBERCULOSIS. 

Well    0  cases,   or     0      per  cent. 

Living    4  cases,  or     9      per  cent. 

Dead    40   cases,   or  90.9   per   cent. 

Total    44   cases,  or   99.9   per   cent. 

In  considering  the  respiratory  rate  in  its  relation  to  prognosis  considerable 
allowance  must  be  made  in  individual  cases  for  the  height  of  the  fever  and  for 
the  element  of  nervousness,  especially  in  women.  The  subsequent  histories  of 
71  febrile  patients  obtained  23  months  after  discharge,  showed  that  of  52 
patients  whose  respirations  were  under  30  per  minute,  Gl%o  per  cent,  were 
dead,  while  of  19  patients  whose  respirations  were  over  30,  7S%o  per  cent, 
were  dead.  An  increase  in  the  respiratory  rate  in  afebrile  cases  is  of  more 
serious  import. 

Conclusions. — Patients  who,  from  lack  of  intelligence  or  unwillingness  to 
sacrifice  jjleasures  and  comforts,  leave  the  sanatorium  against  our  advice,  lose 
over  50  per  cent,  of  their  chances  of  recovery. 

2.  The  subsequent  histories  of  patients  at  the  Ehode  Island  State  Sana- 
torium show  that  the  results  of  treatment  of  pay  patients  are  less  favorable 
than  those  of  all  patients. 

3.  Of  153  febrile  cases,  an  extension  of  the  lung  disease  was  indicated  by 
an  increase  of  physical  signs  in  50  cases,  or  32.6  per  cent.,  and  by  the 
appearance  of  signs  in  lobes  previously  clear  in  33,  or  21.5  per  cent. 

4.  The  average  number  of  fever  patients  under  observation  from  1  to  4 
weeks  was  106  and  of  this  number  11,  or  10  per  cent.,  developed  cavity  signs. 

5.  Of  IS  patients  under  observation  while  cavity  signs  developed,  17,  or 
94.4  per  cent.,  had  fever.  Thirteen,  or  76.4  per  cent.,  developed  cavity  signs 
within  6  weeks  from  the  onset  of  fever. 

6.  Of  16  febrile  patients  in  whom  development  of  cavity  signs  was  observed, 
13  died  in  periods  varying  from  2  to  14  months,  the  average  duration  of  life 
being  8.9  months. 

7.  Of  24  febrile  patients  having  cavity  signs  on  admission,  21,  or  87.5  per 
cent.,  died  within  2^^  years,  the  average  duration  of  life  being  13.9  months. 

8.  Unreduced  fever  cases  who  gain  weight  during  the  fever  live  about  twice 
as  long  as  those  who  lose  weight. 

9.  Only  8.5  per  cent,  of  febrile  cases  whose  pulse  averaged  over  100  were 
well  22  months  after  discharge. 

10.  It  is  of  comparatively  little  importance  whether  the  average  daily  maxi- 
mum temperature  is  100°,  101°,  or  102°  F.,  the  duration  rather  than  the 
height  of  the  fever  being  the  deciding  factor  in  the  prognosis. 

11.  The  subsequent  histories  of  febrile  patients  27  months  after  the  onset 
of  fever  showed  that: 

Of  62  patients  who  had  fever  1  to  4  weeks  59.6  per  cent,  were  dead. 
Of  39  patients  who  had  fever  1  to  2  months  69.2  per  cent,  were  dead. 
Of  11  patients  who  had  fever  2  to  3  months  72.7  per  cent,  were  dead. 
Of  12  patients  who  had  fever  3  to  4  months  75  per  cent  were  dead. 
Of  13  patients  who  had  fever  over  4  months  77.7  per  cent,  were  dead. 


TREATMENT  Oi<^  DRUG  AND  ALCOHOL  PIABITUES  WITH  HYOSCINE.    587 

12.  Of  93  cases  in  whieli  the  fever  was  reduced  after  periods  of  treatment 
averaging  5.9  weeks,  there  were  27  months  after  tlie  onset  of  fever : 

Well    24  cases,  or  25.7   per  cent. 

Living    18  cases,  or   19.4   per   cent. 

Dead    51   eases,  or  54.8   per  cent. 

Total    93   cases,  or  99.9   per   cent. 

13.  Of  44  cases  in  which  the  temperature  could  not  be  reduced  after  treat- 
ment from  1  to  G  months,  40,  or  90.9  per  cent.,  were  dead,  the  duration  of  life 
varying  from  1  to  18  months,  and  the  average  duration  of  life  after  the  onset  of 
fever  being  6.7  months. 


./ 


THE  THREE-DAY  TREATMENT  OF  DRUG  AND  ALCOHOL  HABITUES 

WilH  HYOSCINE. 

By  H.  V.  RIEWEL,  M.D., 

CLEVELAND,   OHIO. 

The  name  hyoscine  was  first  applied  by  Ladenburg  in  1880  to  an  alkaloid 
of  hyoscyamus  possessing  nerve  depressant,  mydriatic  and  hypnotic  properties. 
Individual  patients  show  a  varying  degree  of  susceptibility  or  idiosyncrasy  and 
tolerance  for  the  drug  as  may  be  seen  in  the  following:  P.  S.  Eoot^  reports 
a  case  of  poisoning  from  a  single  hypodermic  dose  of  hyoscine  hydrobromate  of 
/ioo  grain;  W.  A.  Carey,^  three  cases  from  a  dose  of  M^oo  grain;  L.  W. 
Morton,^  one  case  from  ^5  grain  hyoscine,  five  minutes  after  injection. 

On  the  other  hand  marked  tolerance  for  the  drug  is  shown  by  the  following 
instances:  During  active  treatment  of  one  of  H.  G.  Wagner's  cases,  after 
physiological  effects  had  been  obtained  by  the  usual  method,  %o  grain  of 
hyoscine  was  given  by  mistake  without  any  ill  effects,  W.  H.  H.  Githens-* 
reports  a  case  of  accidental  dose  by  mouth  of  %  grain  hyoscine  without  ill 
effects. 

A  Resume  of  the  Literature  on  the  Treatment  of  the  Drug  Habit  by 
Uyoscine  Hydrobromate. — The  first  to  have  successfully  and  openly  used  it, 
was  M.  K.  Lott^,  ^,  ',  who  reported  25  cases  of  the  morphine  habit  thus  treated 
in  1901,  and  again  in  1902"^  he  reported  34  cases.  J.  M.  Buchanan^  reported 
12  cases,  treated  by  hyoscine,  at  the  proceedings  of  the  American  Psychological 
Association  in  190:),  and  L.  Abramson»,  20  cases  of  the  drug  habit  treated  in 
this  way.  He  wrote  me,  tliat  before  giving  up  the  method  he  u?cd  it  in  100 
cases  with  no  deaths.  Sixty  of  the  one  hundred  remained  permanently  free 
from  the  use  of  drugs.     Forty  per  cent,  relapsed.    . 

R.  E.  Behringio,  11  reported  six  cases  of  the  morphine  habit  and  four 
alcoholic  addicts  successfully  treated.  He  considers  it  as  specific  in  the  morpliiue 
habit  as  antitoxin  is  for  diphtheria.  A.  W.  Eichardson^^^  one  case  of  the  mor- 
phine habit  treated  by  the  hyoscine  method;  J.  M.  Catchingsi^,  accurately 
and  in  detail,  15  cases  of  the  opium  habit  treated  with  hyoscine;   H.  G.  Wag- 


.jy8     TKEATMEiST  OF  JJRLei   AND  ALCOilOL  HABiilJiS   WJTJl  HYOSCIXE. 

nei'i'^,  5  cases  of  the  drug  habit  and  7  cases  of  the  liquor  habit.  The  latter 
t^o  authors  give  the  most  reliable  and  accurate  course  to  pursue.  I  prefer 
the  method  described  by  Wagner.  It  seems  to  me  the  less  dangerous  of  the 
two,  because  of  the  small  amoimt  oi'  hyoscine  necessary  in  a  given  case,  due  to  its 
combination  with  atropine  and  strychnine,  which  I  believe  are  somewhat  sup- 
portive and  therefore  safer.  Gatching's  method  of  a  demonstration  is  prac- 
tically the  same,  except  that  he  uses  hyoscine  alone  and  uncombined  with,  other 
drugs. 

The  most  remarkable  series  of  cases  treated  by  this  method,  but  not  yet 
reported,  I  have  learned  of  in  a  letter  from  C.  C.  Stockard.  He  has  treated  800 
cases  of  the  various  drug  habits  during  the  past  ten  years  by  the  hyoscine  method, 
but  of  late  uses  it  only  in  jiatients  who  sufl'e!'  too  much  pain  from  the  gradual 
withdrawal  of  the  morphine  which  he  finds  to  be  about  one  in  four,  or  25  per  cent, 
of  all  cases.  He  mentions  two  deaths  in  this  series,  one  from  pneumonia,  the 
second  caused  by  perforating  appendicitis.  Xo  deaths  occurred  in  cases  treated 
by  other  observers  mentioned. 

Oscar  Jennings,  of  Le  Yesinet,  France,  in  a  letter  writes,  that  his  first 
and  only  attempt  at  treatment  of  a  case  of  opium  habit  with  hyoscine  was 
in  1888.  He  was  unsuccessful;  consequently  he  considered  it  too  dangerous. 
After  hearing  of  its  success  in  America,  he  was  prompted  to  use  hyoscine  upon 
himself.  He  took  it  by  the  method  described  below  imtil  he  obtained  the 
physiological  etrects.  This  forced  him  to  conclude  that  the  drug  was  not  as 
dangerous  as  it  first  seemed. 

Method  Employed  with  lieport^  of  Cases. — In  the  drug  cases  the  method 
employed  has  been  the  same  as  that  described  by  Wagner,  i.e.,  hypodermic 
medication  of  from  48  to  72  hours'  duration.  The  alcoholic  cases  were  more 
favorable  subjects,  treated  at  their  homes  with  competent  attendants.  The 
drugs  were  given  by  mouth  during  the  first  eight  days,  just  enough  to  keep 
the  throat  dry  and  pupils  dilated,  as  for  example  %oo  gi'ain  to  %o  grain 
hyoscine — %oo  grain  atropine  and  %o  to  %o  grain  strychnine,  every  2  to  4 
hours.  During  the  ninth  and  tenth  days  the  In'podennie  was  used,  pushing 
the  treatment  to  the  stage  of  mild  delirium.  In  tlie  alcoholic  cases  the  delirium 
was  of  but  two  days'  duration.  Tlie  patients  were  males  without  abnormal 
physical  findings. 

I'en  cases  of  the  liquor  hahit  were  treated  by  this  method.  Four  have 
not  relapsed  to  date.  The  longest  period  of  total  abstinence  after  treatment 
is  three  yeai-s.  Treatment  for  this  case  ended  December  7,  1905.  The  other 
three  patiuiits  have  abstained,  one  for  six  months,  the  other  two  for  nine  months 
each.  Of  the  six  relapsed  cases  the  shortest  period  before  relapse  was  three 
months.  Not  one  of  these  returned  to  the  liquor  habit  because  of  the  craving 
for  drink,  but  simply  to  take  one  drink  socially  then  let  it  alone.  Thus  the 
desire  v;as  created  and  they  relapsed  within  four  to  ten  months  after  treatment. 

Ten  Morphine  Cases  Treated  hy  the  Hyoscine  Method. — For  the  privilege 
of  reporting  four  of  these  cases  I  am  indebted  to  Dr.  Wagner,  they  were  treated 
by  him  at  the  Cleveland  City  Hospital.     As  an  example  of  the  average  course, 


TREATME>iT  OF  DRIG  AND  ALCOHOL  HABITUES  WITH  HYOSCINE.    589 

a  detailed  report  of  one  case  will  be  given,  including  bedside  chart.     This 
case  is  interesting  from  a  siirgical  standpoint  as  well. 

Mr.  J.,  high-school  principal,  referred  to  me  by  Dr.  F.  C.  Herrick,  34 
years  old  had  been  addicted  to  the  use  of  morphine  for  eight  years,  beginning 
in  1899  when  it  was  administered  to  relieve  the  pain  of  gall-stone  disease. 
Family  history  was  negative.  Phj-sical  examination  was  negative  except 
moderate  anaemia  and  slight  tenderness  on  deep  pressure  over  the  gall-bladder. 
The  urine  was  acid,  specific  gravity  1024,  contained  no  sugar,  no  bile,  nor 
albumin.  The  morphine  taken  had  consisted  of  four  grains  per  dose  by  hypo- 
dermic four  times  daih%  making  sixteen  grains  every  24  hours.  An  initial 
dose  of  calomel  grains  3,  followed  by  Eochelle  salts  one  ounce,  was  given. 
Special  nurse  day  and  night  during  the  first  week.  Eegular  hospital  vigilance 
during  the  second  week.  Active  treatment  began  June  2,  1908,  at  4  p.  m., 
when  a  single  hypodermic  was  given,  consisting  of  hyoscine  hydrobromate, 
grain  ^200  '>  atropine,  grain  %oo  and  strychnine,  grain  ^oo?  in  distilled  water. 
This  was  repeated  every  1^4  hours  for  eight  doses.  Then  one-half  this  dose 
was  given  for  the  six  succeeding  periods  of  1'54  hours  each.  This  was  followed 
by  twelve  full  doses  at  V/o  hour  intervals  ending  the  active  treatment  with  two 
half  doses.  The  last  hypodermic  of  hyoscine  was  given  June  fifth  at  2.30  p.m. 
Altogether  during  the  active  treatment,  which  lasted  sixty-nine  hours,  ^ 
grain  hyoscine,  %  grain  strychnine  and  %4  grain  atropine  were  administered. 
A  copy  of  the  bedside  record  is  appended  giving  in  detail  the  treatment  and 
management.     (See  pages  592  and  593.) 

After  the  first  week  patients  as  a  rule  eat  heartily  and  sleep  normally;  the 
appetite  becomes  ravenous  usually  about  the  tenth  day.  Those  who  complain  of 
insomnia  may  for  one  or  two  nights,  after  first  four  days'  active  treatment,  be 
relieved  by  any  suitable  hypnotic :  trional,  grains  20,  or  chloral  and  bromides,  of 
each  grains  15,  for  one  or  two  doses  at  bed  time.  There  is  no  craving  for  the 
drug  nor  pain  nor  suffering  from  its  withdrawal  at  any  time  during  or  after 
treatment.  Occasionally  one  finds  a  patient  who  sleeps  most  of  the  time  during 
the  three  days  of  active  treatment.  These  should  not  be  pushed  to  the  stage 
of  mild  delirium  described  on  the  bedside  record.  This  delirium  referred  to, 
should  be  carefully  controlled  since  too  large  doses  at  this  time  will  create  a 
wild  almost  unmanageable  delirium  with  attempts  to  crawl  up  the  wall,  etc. 
This,  however,  can  l)e  controlled  at  any  time  when  the  patient  becomes  unman- 
ageable, by  giving  %.  grain  of  morphine,  which  will  not  in  any  way  interfere 
with  the  results  of  treatment. 

In  mild  delirium,  the  delusions  and  illusions  are  altogether  quite  pleasant, 
leaving  no  bad  effects.  In  this  patient,  who  had  been  a  soldier  in  the  Spanish 
War,  while  looking  intently  at  the  figures  on  the  wall  paper,  they  suddenly 
became  transformed  into  troops  of  marching  soldiers.  He  would  look  at  the 
chandelier  watching  turners*  and  acrobatic  performances. 

A  quite  common  illusion  is  mistaking  a  white  counterpane  for  black  broad- 
cloth which  the  patient  is  buying  for  his  wife  and  children  for  clothing.  Some- 
times the  sheet  is  torn  into  shreds  in  making  endless  yards  of  olntli  for  piiivhaso. 


590    TREATMENT  OF  DRUG  AND  ALCOHOL  HABITlES  WITH  HYOSCINE. 

A  smoker  will  reach  into  space  for  his  i^ipe  which,  when  he  is  about  to  grasp  it, 
suddenly  disappears. 

In  looking  out  of  the  window,  one  of  the  men  saw  a  tree  which  suddenly 
expanded  into  a  beautiful  park.  He  intended  to  walk  out  of  the  second  story 
window  into  the  park,  with  lakes  and  benches  scattered  here  and  there.  He 
was  easily  dissuaded  upon  being  asked  to  sit  down  on  this  bench  (chair  in  the 
room).  He  did  so  still  looking  out  into  the  tree  when  he  whispered  to  me  to 
watch  a  pair  of  lovers  on  yonder  bench.  He  said  at  first  they  were  sitting  far 
apart,  but  now  he  was  moving  closer  and  closer  with  his  arm  about  her  Vv'aist. 
Here  his  delusions  were  stopped  by  suggesting  that  he  was  looking  at  a  tree. 
"Only  a  tree?"  "Yes,  yes."  "Why  I  saw  them  a  minute  ago,  now  they  have 
vanished."  The  park  and  lovers  disappeared  as  suddenly  as  they  appeared. 
Others  will  walk  about  picking  up  rings,  etc.,  from  empty  space  and  hiding 
them  under  the  pillow. 

This  patient's  delirium  was  very  carefully  adjusted,  so  that  he  was  kept 
in  bed  most  of  the  time,  part  of  the  time  asleep  some  time  answering  his  wife 
or  talking  to  his  daughter.  Then  again  the  nurse's  white  apron  would  bring 
about  a  conversation  with  the  butcher. 

At  this  stage  too  much  hyoscine  will  make  them  wildly  delirious.  Walking 
about,  sometimes  jumping  upon  the  window  sill  or  table.  This  can  be  con- 
trolled by  34  gi'ain  morphine,  or  if  the  pulse  is  good  they  can  easily  be  led  about 
the  room  and  put  back  to  bed.  They  are  quite  amenable  to  suggestions  at 
this  time  and  if  watched,  they  will  without  the  dose  of  morphine  become 
quieter  and  more  tractable  within  an  hour  or  two.  The  effects  of  the  drug 
disappearing  entirely  within  6  to  24  hours  after  treatment  is  discontinued. 
During  this  stage  of  active  treatment,  sneezing  and  vomiting  occur  very 
commonly. 

Case  of  Opium  Poisoning  in  Baby  Three  Months  Old. — July  19,  1905,  I 
was  called  at  5  a.m.  to  see  a  boy  three  months  old.  Examination  showed  pin 
point  pupils  with  no  reaction  to  light,  lids  half  open;  respiration  four  to  six 
a  minute  and  irregular,  sometimes  completely  arrested  for  from  15  to  30 
seconds;  hands  and  lower  extremities  cold,  skin  and  mucous  membranes  cyanotic. 
The  evening  before,  the  child's  mother  borrowed  some  soothing  mixture  from 
an  accommodating  neighbor.  The  boy  seemed  in  severe  pain,  so  she  gave 
him  a  teaspoonful  every  little  while,  how  often  she  could  not  recall,  until  the 
child  was  sound  asleep.  He  slept  all  night.  Parents  tried  unsuccessfully  for 
an  hour  by  slapping,  shaking,  hot  and  cold  water  baths,  etc.,  to  rouse  him 
but  the  stupor  became  deeper.  Shortly  after  my  arrival,  a  hypodermic  injection, 
containing  strychnine  grain  Mooo,  hyoscine  grain  %ooo  and  atropine  gi-ain 
V-iooo,  was  given.  Two  more  doses  were  given  fifteen  minutes  apart.  Twenty 
minutes  after  the  third  dose  pupils  became  larger  with  flushed  checks.  Thirty 
minutes  later  breathing  was  twenty  times  a  minute.  At  this  time  teaspoonfuls 
of  water  were  swallowed.  The  same  medication  was  then  continued  by  mouth 
for  three  days  always  watching  ior  physiological  effects.  The  necessity  for 
continuing  treatment  for  three  days  was  shown  when  the  child  would  fall  into 
a  deep  sleep  if  the  interval  between  dosea  was  too  long,  especially  during  th® 


TREATMENT  OF  DRUG  AND  ALCOHOL  HABITUES  WITH  HYOSCIKE.    591 

first  48  hours.  Tins  seemed  to  show  that  the  effect  of  hyoscine  disappears  quite 
rapidly  but  that  morphine  is  eliminated  rather  slowly.  The  text-books,  I 
believe,  coincide  with  this  statement.  The  boy  is  at  present  living  and  in  good 
health ;  now  three  and  one-half  years  old. 

Conclusions. — 1.  The  hyoscine  treatment  will  eliminate  the  desire  of  drug 
and  alcohol  habitues  for  these  drugs,  thus  eliminating  the  element  which  pre- 
vents the  patients  abstaining  by  force  of  will  power. 

2.  That  having  lost  the  desire  they  do  very  well  without  intoxicants  or 
the  drugs  as  shown  by  the  increase  in  appetite,  gain  in  flesh  and  their  general 
improvement. 

3.  The  question  of  relapse  lies  entirely  in  the  sincerity  and  environment 
of  the  patient. 

4.  The  favorable  alcoholic  addicts  are  those  who  earnestly  desire  to  dis- 
continue the  use  of  intoxicants  and  are  willing  to  change  their  mode  of  living 
and  environment ;  but  who  cannot  until  relieved  of  the  craving  for  liquor. 

5.  Eelapse  in  both  drug  and  liquor  cases  is  not  due  to  a  desire  nor  suffer- 
ing after  the  treatment,  but  to  their  curiosity  to  test  the  necessity  of  total 
abstinence,  or  to  the  temptations  of  social  life. 

6.  That  a  single  dose  of  the  drug  or  drink  of  liquor,  even  after  one  year 
of  total  abstinence,  is  very  apt  to  start  the  craving  resulting  in  a  condition 
which  is  no  better  than  before  treatment. 

7.  This  method  may  prove  a  valuable  treatment  for  apparently  hopeless 
cases  of  opium  poisoning.  Interesting  experiments  along  this  line  might  be 
carried  out. 

8.  The  one  contraindication  for  this  treatment  is  the  presence  of  Bright's 
disease. 

9.  That  no  case  should  be  treated  unless  put  to  bed  and  watched  by  com- 
petent nurses  day  and  night  during  the  first  week. 

BiBLIOGBAPIIY. 

1  Therap.  Gazette,  Vol.  II,  p.  598,  1886. 
2Therap.  Gazette,  p.  358,  1889. 

3  Therap.  Gazette,  Vol.  V,  p.  94,  1889. 

4  Therap.  Gazette,  Vol.  VI,  p.  645,  1890. 

5  May   14,   1901.   Calvert,  Texas,  meeting  Brazos  Valley  Medical   Society. 

6  Texas  Medical  Journal,  Nov.,  1902. 

7  Therap.  Gazette,  Vol.  XXVI,  p.  91,  1902. 

8  Proceedings  of  Am.  Psycliolngical  Assn.,  Vol.  X,  p.  442,  1903. 

9  iS'ew  Orleans  Medical  and  Surgical  Journal,  Vol.  LVI,  p.  406. 

10  Occidental  Medical  Times,  San  Francisco,  Vol.  XVII,  p.  423,  Nov.,   1903. 

11  California  State  Medical  Journal,  San  Francisco,.  Vol.  Ill,  p.  211,  1905. 

12  Queen's  Medical  Quarterly,  Canada,  Kingston,  Vol.  I,  p.  73,  1903-4. 

13  Journal  Mississippi  Medical  Association,  Vicksburg,  Vol.  IX,  p.   1G3,  1904-5. 

14  Cleveland  Medical  Journal,  June,  1905. 


r)92    TREATMENT  OF  DRUG'   AND  ALCOHOL  HABITUES  WITH  HYOSCINE. 


Clinical  Chart. — Mr.  J.,  High  School  Principal. 


Date         Hour  \  Temp.  Pulse  Resp.     Medicine  and  Stlmulast         Urine      Stool 


Diet 


Remarks 


1S08     IP.  M.| 
June  2    12       I  98.6 


3 
J 
5 
G 

7 

7.30 

8 

9 

10 
11 
12 

A.  M. 
12.30 

1 

2 

2.30 

3 

4 

5 

6 

7 

7.30 

8 

9 

9.30 
10 

11 
12 
P.  M. 

1 

1.30 

2 

2.30 

3.30 

4 
5 

6 

6.30 


|20    ICalomel,      gr.      ilj. 
Rochelle  salts,  5J 


|70 
97.6  i76 
78 
78 


98.6 


June  4 


180 

I 
76 


101 


100.4 


8.30 
9 

10 

10.30 
11 

P.  M. 
12.30 
2 
I  2.30  [100.8  178 
13        1  178 

4  82 

I  4.30  I 

I  5        I  |80 


R  Hypo.  * 
B  Hypo. 

B  Hypo. 

R  Hypo. 
Pk  Hpyo. 
R     Hypo. 
B  Hypo. 


R  Hypo. 

Enoma     soap     aud 

water 
B  ^A  Hypo. 


3vj 


3v 


]  1 
I   1 


78 

R    Vz   Hypo 

80 

R  Vz  Hypo. 

78 

R  Vz  Hypo. 

88 

SO 

22 

B  ^i   Hypo. 

SO 

80 

B  Vz   Hypo. 

/8 

78 

18 

R  Vz  Hypo. 

86 

80 

R  Hypo. 

82 

1 
1 
6 

1 

78 

1 

6.30 

7 

iOO.7 

74 

24 

8 

76 

8.30 

9 

80 

10 

100.4 

74 

2fi 

10.30 

11 

86 

12 

SO 

1 

|A.  M. 

1 

|R  Hypo. 
IR  Hypo. 

R  Hypo. 

Enema 

R  Hypo. 
R  Hypo. 


Soft  diet 


Bread,     but- 
ter and  tea 


Water 


Water 
Water 


Cereal 


R  Hypo.  Hyoscine,  ^/ooo  gr. 

Strychnine,  1/200  gr. 

Atropine,   Vnoo  gr. 
Patient    in   bed 


Slept    '/i-hour 

Asleep 

Confused,  restless 

Nauseated 

Sleeping 

Sleeping 

Restless,    vomited 

Vomited,   restless 


Quiet 

Sleeping 

Sleeping 

Asleep 

Asleep 

Nauseated 

Nauseated 


Nauseated,    confused 
Mumbling 

Evacuation  large  and  hard 

Watery  bowel  evacuat'on 
Asleep 

Sneezing 
Vomited 


Busy  picking  up  imagin- 
ary objects 

Restless,     speech     discon- 
nected 

Forgetful 

Talking;   ideas     discon- 
nected 

Restless 

Nausea 

Sleeping 

Asleep 


Restless,   confusion 
Slept  %-hour 
Restless,  confused 


Awake  past  two  hours 
Busy     picking    up     and 
reaching   imaginary     ob- 
jects,   pipe,    cloth,    etc. 


Large,  hard  stool 

Watery  stool 

Picking  at  bed  clothes 


*  The  Composition  of  Hypo,  is  as  follows:    Atropine,  ^Jitt  gr.:    Hyoscine,  jjo  gr.;    Strych.  Sulph. 


TREATMENT  OF  DRUG  AND  ALCOHOL  HABITUES  WITH  HYOSCINE.    593 


Clinical  Chart.— (OoJitinufd.) 


Dati 


Hour     Tamp,  j  Pulse  Resp.     Medicine  and  Stimulant 


Utint 


Stool  1 


Diet 


Retraiks 


June  6 


June  7 


June  8 


12.30 

1 

2 

2.30 

3 

4 

100.4 

0 

6 

7.30 

8 

100.4 

9 

10 

11 

12 

P.  M. 

1 

2 

3 

4 

5 

0 

6 

7 

101.2 

8.30 

9.30 

11.45 

A.  M. 

2.30 

5 

6 

99.4 

7.30 

8., 30 

9 

10.30 

99 

12 

P.  M. 

3 

6 

99.4 

9 

11 

98. 4 

A.  M. 

2 

1  6 

7 

10.30 

12.30 

99 

P.  M. 

1 

2 

4 

5.30 

99 

O.JO 

|10 

|A.  M. 
I  6 


62 


24 


24 


22 


TJ  Vj  Hypo. 
Py  V2  Hypo. 
i>  V2  Hypo. 

R  M  Hypo. 


Enema. 
IR  1/2  Hypo. 


R  V2  Hypo. 

B  Hypo.discontin'd 


Citrate  Magnesium 


1 


Sponge  bath.shavod 


Alcohol   rub 


jSpouge    bath,  mas- 
sage 


|3j     Bromides, 
I    chloral 
3j    Bromides, 
chloral 


3vij     I    1 


I    1 


I    1 


Cereal, 
toast,    cof- 
fee 


Custard,   tea 


Milk-toast, 
:    pineapple, 
tea 


Cereal, 
toast,  cof- 
fee, bacon 


Restless,  talking 

Quiet,  but  awake 

Restless 

Awake,  quieter 

Restless,   wall-paper  looks 

to  him  like  marching 

soldiers 


Watery   stool 
Restless 


More  rational 
Vomited  small  amount 


I  Becoming  more  rational 
I  At  times  still  talking  non- 
sense 

I  Slept  1^^  hours 
Sleeping 
Sleeping 

Sleeping 

Asleep  most  of  the  time 

during  night 
Now  quite  rational 
Feels   tired    and   weak 


1      Milk,  5V 

Broth,     cus- 
1    tard 


1     Custard,  'Comfortable  all  afternoon 

bread,  tea   | 

I  Had  1  hour  of  sleep 


1     Cereal, 
I    toast,  tea 
'Milk,  jviij 


Chicken 

broth 
Chicken, 

potato, 

bread,  tea 
Milk,   5vJ 


Slept  1  hour 
Sleeping  2  to  4  A.  M 
Did  not  sleep  well  during 
night 


•■Ji-hour  sleep  this  P.   M. 


Regular  hospital  vigilance  during  second 
June  16  Discliarged  in  good  condition. 


Slept  well  through  night 
week  with  full  tray  and   nourishment   between  meals. 


594  -A.  CASE  OF  NEUROMA  OF  THE  ORBIT. 


A  CASE  OF  NEUROMA  OF  TPIE  ORSIT.* 

By  HOWARD  F.  HANSELL,  M.D., 
Professor  of  Opbtlialmology  in  JefTerson  Medical  College,  Etc. 

PHILADELPHIA. 

Under  the  general  head  "Xeuroma"  are  included  all  kinds  of  tumors 
Avhich  originate  in  or  on  a  nerve  trunk  and  which  are  composed,  at  least  in 
part,  of  nerve  tissue.  In  his  large  dictionary,  Gould  says  the  neuromata  are,  in 
most  cases,  really  fibromata  and  this  opinion  seems  to  be  borne  out  by  the 
remarkable  rarity  of  instances  of  true  neuroma  of  the  orbit  or  those  tumors, 
the  distinguishing  elements  of  which  are  nerve  fibers  hyperplastic  and  degen- 
erated. The  neuroma-like  tumors,  on  the  other  hand,  the  plexiform,  the 
fibrous,  the  myxoma,  ganglionic,  gliomatous  and  others,  contain  in  addition 
to  hyperplastic  nerve  fibers,  the  characteristic  structure  in  much  greater  pro- 
portion. The  great  variation  in  the  microscopic  elements  of  nerve  tumors  has 
led  to  some  confusion  among  writers  in  describiog  cases  under  their  observation. 
Parsons^  says,  "Simple  neuroma  of  the  orbit  has  been  seldom  described,  prob- 
ably owing  to  their  small  size  and  to  the  absence  of  sjanptoms,"  and  Parker^^  as 
a  result  of  his  search  through  literature,  "Cases  of  neuro-fibromata  (pseudo- 
neuromata,  solitary  neuromata)  of  the  orbit  are  extremely  rare,  there  being 
but  two  cases  on  record.  Of  these,  one  reported  by  Tertsch  involved  the 
lacrimal  branch  and  one  reported  by  Marchetti,  the  infraorbital  branch  of  the 
fifth  nerve."  Both  these  writers  are  quoted  by  Parsons.  Under  the  heading 
"Plexiform  Neuroma,"  Parsons  records  a  number  of  cases  of  modified  forms  of 
neuromata  of  the  appendages  of  the  eye  and  orbit.  Parker  quotes  Tertsch  in 
his  contention  of  the  extreme  rarity  of  neuro-fibromata  of  the  orbit:  "A 
solitary  neuroma  is  altogether  a  rare  tumor  and  its  location  in  the  orbit 
appears  at  least  a  curiosity."  Dr.  Edward  Jackson,  in  his  discussion  of  Dr. 
Parker's  paper,  well  expressed  the  situation  by  stating  that  the  term  neuro- 
fibroma has  been  used  so  loosely  that  its  significance  is  uncertain  and  indefinite. 
Dr.  Parker's  case  and  the  two  he  cited  should  probably  be  classed  as  true 
neuromas,  of  which  the  tumors  developed  on  the  ends  of  nerves  after  amputation 
of  a  limb  are  the  most  common  examples. 

It  is  difficult  to  explain  the  scarcity  of  reports  of  instances  of  neuroma  of 
the  orbit.  Surely  the  small  size  of  the  tumors  and  the  absence  of  symptoms  is 
an  inadequate  assumption.  If  neuroma  of  the  orbit  may  be  compared  with 
neuroma  after  amputation  of  a  limb,  and  I  think  the  comparison  is  a  proper 
one,  the  comparison  should  extend  beyond  the  histologic  characteristics  and 
should  include  the  symptoms.  It  is  well  known  that  neuroma  after  amputa- 
tion is  an  excessively  painful  affection.     Gross  in  the  second  volume  of  his 


•Ro.nrl  before   the   Section   on  Ophthalmology,   College  of   Physicians,   Philadelnhia 
Feb.  20,  1908.  '  ' 

1  "Pathology  of  the  Eye,"  Vol.  II. 

2  Trans.  Sect.  Ophthal.  American  Medical  Association,   1007. 


A  CASE  OF  NEUROMA  OF  THE  ORBIT.  S95 

surgery,  as  long  ago  as  1872,  wrote,  "The  tumor  which  sometimes  attains  th« 
size  of  a  hickory  nut  or  even  of  a  pullet's  egg  is  of  a  firm  dense  consistence  and 
is  composed  of  a  strong  fibrous  stroma  inlaid  with  hypertrophied  and  curiously 
interlaced  nervous  trunks  and  filaments.  It  is,  in  fact,  a  true  neuroma.  The 
accompanying  pain  is  exquisite  and  the  part  is  so  sensitive  as  to  be  intolerant 
of  the  slightest  touch."  Neuroma  of  the  ciliary  nerves  or  of  the  supraorbital 
branch  of  the  fifth  nerve  after  enucleation  of  the  ball  or  exenteration  of  the 
orbit  would  be  a  condition  analogous  to  that  of  the  sensitive  nerve  trunks  after 
amputation.  Bietti^  has  described  amputation  neuromata  of  the  ciliary  nerves 
after  opticociliary  neurotomy.  It  is  a  matter  for  surprise  that  other  cases 
following  other  operations  involving  section  of  the  nerves  have  not  been  recog- 
nized and  reported.  In  my  own  experience  I  do  not  recall  a  single  case  and  I 
am  sure  that  if  they  were  at  all  common  I  should  have  met  with  and 
remembered  them. 

Miss  IST.  J.  was  admitted  to  a  hospital  in  Providence,  E.  1.,  January,  190-i. 
(For  the  notes  relative  to  this  patient  before  she  consulted  me  I  am  indebted  to 
Dr.  Neill,  of  Providence.)  She  was  a  robust  and  an  apparently  healthy  girl. 
She  had  suffered  moderately  with  rheumatism  and  considerably  with  headache 
and  neuralgia.  One  week  before  admission  she  complained  of  severe  pain  in 
the  left  eye  and  the  left  side  of  the  head,  followed  by  adema  of  the  lids, 
exophthalmos,  destruction  of  vision  and  orbital  abscess.  Several  incisions 
were  made  into  the  orbit  and  necrosis  of  the  upper  outer  wall  discovered. 
The  incisions  gave  vent  to  a  serous  discharge  which  continued  up  to  her  admis- 
sion into  the  hospital.  Enucleation  was  performed  and  a  large  drain  inserted 
into  the  incision  in  the  supraorbital  region.  On  February  9th,  the  discharge 
had  ceased  and  the  patient  left  the  hospital.  Both  lids  were  firmly  bound 
down  by  adhesions.  Five  days  later  she  was  re-admitted,  complaining  of 
intense  pain  in  the  left  side  of  the  head  and  occiput,  nausea  and  vomiting. 
Under  ether  the  orbit  was  found  to  be  filled  with  dense  cicatricial  bands  and 
adhesions  and  the  soft  bone  on  the  roof  was  curetted  away.  Hamiorrhage  was 
very  free.  Gradually  the  sinus  became  closed  and  the  discharge  ceased. 
Curettement  again  became  necessary  in  June,  when  many  small  fragments  were 
removed  with  but  little  permanent  improvement.  In  January  she  was  again 
re-admitted.  Since  the  last  operation,  eighteen  months  ago,  she  has  had  con- 
stant pain  in  and  about  the  orbit.  The  lids  are  shrunken  and  the  cavity  of  the 
orbit  greatly  reduced  in  size.  Operations  to  restore  the  orbit  induced  ery- 
sipelatous inflammation  of  the  left  side  of  the  face  and  purulent  discharge  from 
the  orbit.  Under  treatment  the  S3'mptoms  subsided  and  she  was  discharged 
in  two  weeks.  On  March  2,  1907,  she  came  under  my  care,  stating  that  for  the 
past  year  she  had  had  frequent  and  intense  paroxysms  of  pain  which  were 
relieved  only  by  one-half  grain  of  morphia.  She  was  emaciated,  pale,  easily 
exhausted  and  mive  every  evidence  by  her  appearance  of  indescribable  suffering. 
The  soft  tissues  of  the  orbit  were  contracted  and  cicatricial.  Light  pressure 
against  the  roof  of  the  orbit  gave  rise  to  acute  pain  and  imparted  to  the  examin- 


3  Arch.  f.  Ophtb.,  XLIX,  1900. 


596  THE  ADRENALS  IN  SUDDEN  DEATH. 

ing  finger  the  sensation  of  a  small  node.  Dr.  J.  Chalmers  DaCosta  confirmed 
the  opinion  that  the  supraorbital  nerve  was  caught  in  the  scar  and  advised  its 
removal.  Under  ether  an  incision  was  made  in  the  upper  lid  and  the  tissues  of 
the  roof  of  the  orbit  separated.  The  nerve  was  readily  found  and  dissected 
out  thoroughly  from  the  orbital  margin  to  the  apex  of  the  orbit.  About  its 
center  was  an  oval  swelling  the  size  of  a  bean,  similar  in  color  and,  apparently,  in 
texture  to  the  nerve,  and  corresponding  in  position  to  the  sensitive  point.  No 
other  swellings  on  tlie  nerve  were  found.  The  patient  made  a  speedy  recovery. 
Until  August,  five  months  later,  she  was  entirely  relieved  of  pain.  Soreness, 
reflected  pain  and  sensitiveness  to  pressure  were  no  longer  felt.  She  had 
regained  her  health  and  had  added  thirty  pounds  to  her  weight.  From  August, 
1907,  to  Januarj',  1908,  she  had  recurrences  of  neuralgia,  every  week  or  two 
weeks,  of  moderate  severity  coming  on  without  assignable  cause  other  than 
changes  in  the  weather.  Believing  that  a  filament  of  a  sensitive  nerve  was 
entangled  in  the  cicatrix,  I  exsected  a  portion  of  the  cicatricial  tissue  at  the  roof 
of  the  orbit  and  transplanted  a  graft  of  skin  taken  from  the  inner  aspect  of  the 
thigh.  Healing  proceeded  without  interruption.  The  patient  has  had  no  pain 
up  to  the  present.  Only  a  month  has  elapsed  and  the  future  is  of  course 
uncertain. 

The  specimen  was  unfortunately  lost,  so  that  no  microscopic  examination  of 
the  tumor  was  made.  The  physical  features  and  the  symptoms  were  character- 
istic of  neuroma,  and,  while  microscopic  confirmation  of  the  clinical  diagnosis 
would  have  been  valuable,  the  nature  of  the  tumor  seems  to  be  fairly  well 
established. 


THE  ADRENALS  IN  SUDDEN  DEATH. 
By  CHARLES  E.  de  M.  SAJOUS,  M.D.,  LL.D., 

PHILADELPHIA. 

Notwithstanding  the  marked  attention  that  the  adrenals  have  received 
in  recent  years,  text-books  of  practice  give  the  disorders  of  these  organs  but 
scant  attention.  Practically  all  refer  only  to  their  main  syndrome,  Addison's 
disease,  thus  conveying  the  impression  that  this  morbid  process  represents 
the  whole  of  adrenal  pathology.  It  were  as  true  to  say  that  pulmonnry  tuber- 
culosis is  the  sole  disease  to  which  the  lungs  are  liable.  Close  observation  has 
clearly  shown  during  the  last  two  decades  that  the  adrenals  are  not  only,  as  are 
the  lungs,  the  seat  of  disorders — functional,  inflammatory,  degenerative,  hyper- 
trophic, infectious  and  neoplastic — quite  as  numerous  as  any  other  organ,  but 
that  owing  to  the  friability  of  their  cellular  elements,  and  their  intimate  relation- 
ship with  the  large  and  deep  arterial  trunks,  they  are  readily  destroyed  when  the 
arterial  tension  exceeds  a  certain  limit.  AW  disorders  of  the  adrenals  are  con- 
veniently said  to  be  rare;  nearer  the  truth  would  be  the  admission  that  they 
are  still  rarely  recognized.  This  assumes  special  importance  because  of  the  fact 
that  many  of  these  disorders  entail  prompt  and  often  sudden  death  either  as  a 
result  of  hsemorrhage  into  the  organ,  or  of  rupture  of  the  latter  and  hremorrhage 
into  the  peritoneal  cavity. 


THE  ADRENALS  IN  SUDDEN  DEATH.  597 

In  adults,  adrenal  hajmorrhage  or  '"'adrenal  apoplexy"  as  Arnaud  has  termed 
it,  occurs  most  frequently  in  subjects  between  twenty  and  thirty  years  of  age. 
The  attack  is  sudden,  as  a  rule,  or  it  may  be  preceded  by  a  period  of  great  lassi- 
tude or  asthenia.  In  most  instance?,  however,  the  s}Tnptoms  are  such  as  to 
suggest  acute  intoxication  or  infection.  There  is  very  severe  pain  either  in  the 
epigastrium,  the  abdomen  or  below  the  costal  margin,  soon  followed  in  most 
instances  by  incoercible  vomiting  and  diarrhoea,  very  weak  pulse,  a  rapid  fall 
of  the  blood-pressure  and  temperature,  cold  sweats,  coldness  of  the  extremities, 
and  lethal  coma.  In  some  cases  the  patient  passes  into  a  typhoid  state  with 
delirium,  and  occasionally,  convulsions,  the  skin  assuming  a  yellowish  or  brown- 
ish hue.  In  a  series  of  80  cases  collected  by  Arnaud  (1900)  death  occurred 
within  a  period  ranging  from  a  few  hours  to  three  days. 

In  the  infant,  especially  the  newborn,  death  occurs,  in  some  instances, 
without  appreciable  preliminary  symptom,  except  perhaps  a  hsemorrhagic  rash, 
or  purpura,  over  the  entire  body,  and  a  high  temperature.  As  a  rule,  however, 
there  are  besides,  diarrhoea  with  mela^na,  very  acute  abdominal  pain,  haiuia- 
temesis,  and  more  or  less  icterus,  all  soon  followed  by  collapse,  hypothermia, 
cyanosis,  lividity  and  death.  In  a  third  class  of  cases,  the  whole  morbid  process 
may  be  asthenic  from  the  start :  there  is  a  history  of  emaciation  with  increasing 
weakness,  a  feeble  and  rapid  pulse,  shallow  respiration  with,  perhaps,  bronchial 
rhonchi,  duskiness  of  the  face  and  even  cyanosis  and  hypothermia,  which  end 
promptly  in  collapse  and  death. 

With  the-  prevailing  view  that  the  adrenal  secretion  causes  a  rise  of  the 
blood-pressure  by  acting  directly  on  the  cardiac  and  vascular  muscles,  this 
pot  pourri  of  S}miptoms  cannot  be  explained,  many,  in  fact,  being  antagonistic. 
But  such  is  not  the  case,  when  my  owa  conception  of  the  functions  of  the 
adrenals  is  taken  into  account.  As  I  pointed  out  in  19031  the  adrenals  supply 
a  secretion  which,  on  reaching  the  lungs,  becomes  converted  into  the  con- 
stituent of  the  hasmoglobin  which  sustains  oxidation,  i.e.,  general  metabolism 
and  nutrition.  The  increase  of  blood-pressure  and  muscular  tone  that  Oliver 
and  Schafer  found  to  be  produced  by  adrenal  extracts  and  also  by  the  adrenal 
secretion,  are  but  secondary  results  of  these  functions  since  it  is  by  increasing 
metabolism  in  the  muscles  that  they  increase  their  tone.  As  this  applies  to 
the  musculature  of  the  heart  and  blood-vessels,  the  vigor  of  the  cardio-vascular 
contractions  and  the  general  blood-pressure  arc  correspondingly  increased. 

Important  also,  in  the  present  connection,  is  that  products  of  metabolism 
and  many  other  poisons,  as  shown  by  various  investigators,  cause  congestion  of 
tlie  adrenals  in  some  obscure  manner.  From  my  viewpoint  this  is  because 
these  various  toxics  excite  either  the  vasomotor  center  or  the  adrenal  center, 
or  both  these  co-ordinating  structures.  As  the  resulting  vascular  contraction 
forces  an  excess  of  blood  into  all  capillaries,  the  adrenals,  which  are  exceedingly 
rich  in  vascular  channels,  become  congested.     From  this  condition  to  ha^mor- 


1  "Internal  Secretions  and  the  Principles  of  Medicine,"  Vol.  T. 


598  '^'JIK  ADRENALS  IN  SUDDEN  DEATH. 

rhage  into  the  adrenals  or  rupture  of  these  organs  and  external  hsemorrhage 
there  is  but  a  step,  since,  as  already  stated,  the  adrenal  tissues  are  very  friable 
while  they  receive  their  blood  from  the  great  arierial  trunks  in  their  immediate 
neighborhood. 

The  morbid  processes  which  can  thus  bring  on  early  or  sudden  deatli 
through  adrenal  hamiorrliage  uuiy  be  divided  into  several  types: — 

Type  1.  Infaniile  Toxcemia.  An  infant  a  few  months  old  and  in  per/eet 
health,  suddenly  shows  high  fever  with  or  v/ithout  purpura.  After  a  few 
hours,  diarrhoea,  vomiting  and  abdominal  pain  appear,  followed  soon  after  by 
convulsions,  a  weak  and  rapid  pulse,  cyanosis  and  coldness  of  the  extremities. 
Death  takes  place  from  six  to  twenty-four  hours  alter  the  onset  of  the  s}Tnp- 
toms.  Loeper  and  Oppenheim,^  who  refer  to  a  number  of  such  cases  reported 
by  Talbot,  Claker  and  Bailey,  Andrewes  and  others,  state  in  this  connection 
that  "in  every  case  no  lesion  other  than  a  more  or  less  voluminous  lumnorrhage 
in  the  adrenals  was  to  be  foimd,"  while  the  blood  examined  daring  life  was 
found  to  contain,  in  several  instances,  the  streptococcus  pyogenes.  Andrewes^ 
considers  that  "we  have  clearly  to  do  with  an  infective  process" — a  conclusion 
amply  sustained  clinically  and  experimentally. 

Explained  in  the  light  of  my  own  views,  outlined  above,  the  bacterial 
toxins  or  other  toxics  that  happened  in  the  blood,  awakened  the  sthenic  stage 
of  the  morbid  process;  in  other  words,  they  excited  both  the  vasomotor  and 
adrenal  centers.  The  excess  of  adrenal  secretion  produced  caused  not  only 
increased  oxidation — thus  explaining  the  fever — but  also  a  rise  of  blood-pres- 
sure, and,  as  a  result,  such  marked  vascular  tension  that  the  capillaries  of  all 
organs  became  intensely  hypersemic.  The  skin  showed  this  by  haemorrhagic 
spots,  or  purpura  (accompanied  in  some  instances  by  hsematemesis  and  bloody 
stools)  ;  the  gastro-intestinal  canal  by  the  vomiting,  the  diarrhosa,  and  the 
abdominal  pain;  the  cerebro-spinal  system  by  the  convulsions.  The  adrenals, 
doubly  congested  as  it  were,  through  the  excess  of  arterial  blood  in  tliem 
incident  upon  supernormal  activity  and  the  blood  driven  into  them  by  the 
contracted  arteries,  stood  the  stress  for  a  time;  but  finally,  their  capillaries 
yielded,  flooding  the  glandular  parenclnmia.  This  inaugurated  the  asilienic 
stage,  the  functions  of  the  adrenals  being  paralyzed.  The  production  of  their 
secretion  ceasing,  the  cardiac  and  vascular  contractions  gradually  lost  their 
tone  and  the  pulse  became  weak  and  rapid;  oxygenation  being  also  prevented, 
cyanosis  and  coldness  of  the  surface  appeared  and  death  soon  followed. 


2  "Manuel    des    Maladies    dos    Reins    ct    des    Capsules    Surrenales."      By    Debovc. 
Arehard,  and  others,  1906. 

3  Pathological   Soeic-ty   Reports,    1898. 

(To  he  concluded  in  the  next  issue.) 


THE  EARLY  TREATMENT  OF  INSANITY.     CANCER.       699 


Editorial 


THE  EARLY  TREATMENT  OF  INSANITY. 

The  general  practitioner  is  very  generally  awakening  to  the  importance  of 
recognizing  the  earliest  indications  of  such  disorders  and  now  realizes  how 
much  depends  upon  him,  as  the  one  who  is  brought  most  directly  in  contact  with 
the  patient  in  this  stage.  It  is  also  known  that  early  removal  to  new  sur- 
roundings, and  under  the  supervision  of  experts,  will  give  those  afflicted  with 
nervous  troubles  the  greater  hope  of  permanent  recovery,  and  lessen  the  number 
who  will  require  to  be  certified  as  insane  and  maintained  at  asylums. 

The  Ontario  government  has  been  induced  to  give  special  attention  to  this 
subject.  It  appointed  a  commission  of  physicians  to  inquire  into  the  methods 
abroad,  and,  upon  this  recommendation,  are  to  erect  a  special  clinic  in  Toronto 
for  such  cases.  Patients  will  be  admitted  from  all  parts  of  the  province.  There 
will  be  public  and  private  wards,  outdoor  departments,  and  laboratories.  It  will 
be  equipped  with  all  modern  methods  of  examination  and  treatment.  Each 
department  under  the  charge  of  competent  heads.  Later,  it  is  intended  to 
extend  the  system  to  other  cities  of  the  province. 

H.  Beaumont  Ssiall,  M.D., 
Ottawa,  Ont. 


Cyclopaedia  of  Current  literature 


CANCER  IN  MAN  AND  ANIMALS.  All  the  clinical  and  pathologic  features 
The  liability  of  all  races  of  mankind  of  cancer  were  produced  in  animals  by 
and  of  all  vertebrates  to  cancer  has  been  cell  proliferation  from  a  few  cells  intro- 
established,  and  the  experimental  re-  duced.  It  is  now  agreed  that  infection 
production  of  carcinoma  and  sarcoma  plays  no  part  in  the  experimental  trans- 
has  become  a  routine  laboratory  pro-  ference  of  cancer ;  that  it  is  a  true  trans- 
cedure.  This  has  put  the  investigation  plantation  of  living  colls.  In  animals,  as 
of  cancer  on  a  sound  biologic  and  ex-  well  as  man,  cancer  is  associated  with 
perimental  basis,  and  rapid  progress  has  certain  periods  of  life,  being  frequent  as 
been  made  in  defining  the  nature  of  the  age  advances. 

disease.     It  is  found  that  cancer  is  as  In  studying  the  increase  of  cancer,  the 

frequent  in  India  as  in  England.     The  author  states  that  it  is  found  that  savage 

Hindoos  are  vegetarians,  but  the  disease  nations  are  not  suited  J'or  this  investiga- 

occurs  irrespective  of  vegetarian  diet.  It  tion  because  of  the  absence  of  reliable 

also  occurs  in  savage,  as  well  as  in  civi-  vital  statistics.    The  increase  in  the  num- 

lized  races ;  yet  there  is  no  indication  of  ber  of  deaths  from  cancer  in  any  country 

any  epidemic  character    of    the    disease  is  not  actual,  but  is  parallel  with  in- 

among   savage   races.     The   commission  creased  accuracy  in  vital  statistics.    Sta- 

has  shown  that  cancer  may    be    repro-  tistics   from   hospital   and   from   cancer 

duced    experimentally   by    innoculation.  censuses  nro  fallacious,  according  to  tha 


6UU 


CHOLERA,  Tii]':AT-MENT  OJb\ 


DIABETES  MELLITUS. 


writer,  owing  to  inaccurate  diagnosis 
and  other  causes.  There  is  an  increase 
in  the  number  of  recorded  cases,  but 
tliis  is  probably  not  a  real  increase,  but 
only  an  increase  of  records.  The  rela- 
tive incidence  of  cancer  on  different 
parts  of  the  body  shows  a  large  number 
invading  the  stomach;  among  females 
the  generative  and  mammary  organs  arc 
involved  in  two-fifths  of  fatal  cases,  and 
another  twQ-fiiths  involve  stomach,  liver, 
intestines  and  rectum.  In  man  they  are 
more  frequent  in  throat,  mouth,  stomach 
and  rectum.  This  may  be  due  to  chronic 
irritation  of  these  sites  from  difference 
in  habits.  The  sites  of  predilection  show 
the  existence  of  endogenous  factors 
aside  from  irritation,  that  is,  innate  pe- 
culiarities of  the  organs  involved.  The 
incidence  of  cancer  at  certain  sites  in 
different  races  is  due  to  habit,  and  de- 
termined by  external  irritation.  Any 
part  of  tlie  normal  covering  of  the  body 
may  acquire  cancerous  properties.  This 
has  an  indirect  significance  only. 

The  question  of  heredity  is  not  yet 
settled,  and  many  facts  are  opposed  to 
the  congenital  origin  of  cancers.  The 
cancer  cells  are  not  of  embr^'onic  nature, 
but  highly  specialized.  Cancer  has  no 
analogy  with  any  form  of  infective  dis- 
ease. In  the  laboratory  where  thousands 
of  mice  have  cancer  neither  they  nor  the 
laboratory  workers,  asserts  tlie  writer, 
have  ever  been  known  to  take  it.  In 
animals  tliere  is  no  evidence  of  produc- 
tion by  cancer  of  toxic  products.  Deatli 
is  not  due  to  these,  but  to  the  growth  of 
the  tumor  and  its  nutrition.  C3'itic 
changes  in  the  growth  of  the  cancer  ai'e 
shown.  Exacerbations  of  growth  occui', 
alternating  with  periods  of  slow  growth. 
Some  parts  grow  slowly,  others  rapidly. 
The  nature  of  immunity  in  cancer  is  not 
yet  fully  known.  E.  F.  Bashford  (Med- 
ical Eeeord,  September  4,  1909). 


CHOLERA,    TREATMENT    OP. 

The  great  value  of  a  large  injection 
of  morphine,  in  cholera,  immediately  the 
disease  is  suspected,  is  emphasized  by  the 
M'riter.  He  reports  a  number  of  cases  of 
bad  collapses,  in  all  of  which  from  2  to 
10  pints  of  saline  solution  v/ere  infused 
intravenously.  The  pulse  instead  of  be- 
ing quite  impalpable,  became  full,  strong 
and  quiet,  being  at  its  acme  by  the  time 
3  pints  had  been  infused,  whereas 
twenty  minutes  previously  the  heart  was 
beating  at  a  rate  of  from  140  to  170,  as 
recognized  by  the  stethoscope.  The  face 
became  fuller,  and  the  awful  sunken  look 
to  a  large  extent  disappeared.  Eestless- 
ness  became  less,  the  intelligence  be- 
came brighter,  the  skin  became  warm. 
The  author  suggests  that  the  poison  of 
cholera  attacks  principally,  or  perhaps 
only,  the  vasomotor  system,  that  the 
heart  is  not  at  fault,  that  the  abdominal 
veins  are  holding  most  of  the  blood  in 
the  body,  and  that  the  treatment  in  this 
condition  should  be  tliat  of  shock.  He 
further  noticed  in  a  number  of  eases 
that  if  persons  sleep  after  an  injection 
of  %  or  %  gi'ain  of  morphine  their 
chances  of  recovery  are  good;  that  mor- 
phine does  not  induce  sleep  in  those  pa- 
tients who  are  badly  collapsed,  but  only 
stops  the  diarrhoea  and  vomiting.  R.  W. 
Burkitt  (Journal  of  Tropical  Medicine 
and  Hygiene,  July  15,  1909). 

DIABETES  MELLITUS,  EFFECT  OF  CER- 
TAIN DRUGS  ON. 
The  primary  object  of  the  author's 
clinical  observations  was  to  ascertain  the 
effects  of  opium,  or  its  alkaloid  codein, 
on  various  symptoms  of  diabetes  mel- 
litus;  in  what  respect,  if  any,  the  crude 
drug  differed  from  the  alkaloid  in  ac- 
tion ;  and  whether  such  effects  varied 
with  the  dose  given.  For  this  purpose 
a  series  of  nine  cases  of  ordinary  dia- 


ENLARGEMENT  OF  THE  PROSTATE,  ETIOLOGY  OF. 


601 


betes  were  placed,  so  far  as  possible,  un- 
der similar  conditions.  Codein  was 
given  in  seven  cases,  always  in  the  form 
of  a  pill.  As  a  rule,  the  initial  dose 
was  1/4  grain,  thrice  daily,  which  was 
gradually  increased,  at  varying  inter- 
vals, by  ^/4  grain  to  the  dose,  or  by 
larger  amounts,  until  as  much  as  twelve 
grains  was  being  taken  daily.  On  the 
whole,  the  definite  result?  obtained  in 
these  cases  are  disappointing.  Possibly 
the  doses  given  were  altogether  too 
small.  This  does  not  seem  an  adequate 
explanation,  however,  as  in  more  than 
one  case  the  results  have  appeared  to  be- 
come less  favorable  with  increased  doses. 
Ontheotherhand,in  a  certain  small  num- 
ber of  cases  the  effects  of  gradually  in- 
creased doses  have  been  favorable,  even 
over  several  weeks.  It  may  be  said  that 
inasmuch  as  codein  will  quickly  lose  its 
first  sedative  effect,  it  can  only  be  of 
value  for  a  short  period. 

Opium,  either  in  the  form  of  pilula 
opii  or  of  pilula  saponis  comp.,  was  given 
in  six  cases.  In  three  of  these  it  was 
tried  before  any  other  drug,  while  in 
three  other  cases  it  was  given  to  patients 
who  had  previously  taken  codein,  in  order 
that  the  effects  of  the  two  alkaloids 
might  be  compared  in  the  same  individ- 
uals. The  initial  dose  given  varied 
from  1/5  to  1  grain,  thrice  daily,  and 
was  usually  increased  gradually,  in  one 
case  up  to  12  grains  daily.  In  spite  of 
the  fact  that  one  of  the  patients  be- 
came worse  and  died  while  under  treat- 
ment by  opium,  the  general  results  ob- 
tained with  it  were,  on  the  whole, 
rather  more  uniformly  successful  than 
those  obtained  with  codein.  In  three 
cases  codein  had  previously  been  tried, 
and  comparing  the  results,  one  sees  that 
opium  began  to  act  effectively  when  co- 
dein in  increasing  doses  had  ceased  to 


do  so.     A.  J.  Hall   (Quarterly  Journal 
of  Medicine,  July,  1909). 

ENLARGEMENT  OF  THE  PROSTATE,  ETI- 
OLOGY OF. 

Enlargement  of  the  prostate  is  the  re- 
sult of  a  chronic  inflammation,  the  in- 
flammatory foci  lying  around  the 
mouths  of  the  excretory  ducts  and  thus 
causing  stenosis  or  occlusion  of  these 
ducts  with  retention  of  the  catarrhal  se- 
cretion, dilatation  and  cystic  degenera- 
tion, the  process  and  results  similar  to 
those  of  retention  in  any  glandular  or- 
gan. The  chronic  prostatitis  in  ques- 
tion is  a  very  long  drawn  out  process, 
extending  over  years  and  decades,  and 
it  may  be  not  only  clinically  latent,  but 
the  naked  eye  may  be  unable  to  detect 
histologic  changes  in  the  gland.  The 
microscope,  however,  will  reveal  the 
signs  of  submucous  chronic  inflammation 
in  the  posterior  urethra,  and  of  catar- 
rhal proliferation  and  depquamatiou  of 
the  epithelium  in  the  follicular  pouches 
and  outlets  of  the  prostate.  Some  pros- 
tate? contain  less  glandular  substance 
than  others,  and  the  effect  of  the  inflam- 
mation is  felt  less  on  this  account. 

The  findings  reported  confirm  the  lack 
of  any  rational  basis  for  treatment  of 
enlargement  of  the  prostate  by  castra- 
tion or  severing  of  the  vas  deferens  or 
ligation  of  afferent  arteries — all  of 
which  are  now  abandoned.  But  the  ana- 
tomic findings  suggest  the  importance  of 
systematic  treatment  of  chronic  prosta- 
titis in  prophylaxis  of  hypertrophy  of  the 
organ.  This  is  the  task  of  the  general 
practitioner,  and  he  should  not  fail  to 
institute  a  three  or  four  weeks'  course 
of  massage  two  or  three  times  a  year  for 
several  years  after  subsidence  of  the 
acute  phase  of  prostatitis.  This  will 
counteract  the  stagnation  of  the  secre- 
tions   and    development    of    deposits   of 


602      EXOPHTHALMIC  GOITER  AND  DIABETES. 


ILEUS,  TREATilENT  OF. 


round  cells  at  diilerent  points,  while  it 
will  promote  the  circulation  through  the 
blood  vessels  and  lymphatics  and  favor 
absorption  of  inflammatory  infiltrates. 
Of  course,  after  fibrous  connective  tissue 
processes  have  developed,  massage  is  no 
longer  efiectual.  It  may  be  usefully  sup- 
plemented by  other  measures  to  promote 
absorption,  such  as  brine  and  mud  baths, 
etc.  Eothschild  (Berliner  klinische 
Wochenschrift,  July  5,  1909). 

EXOPHTHALMIC  GOITER  AND  DIABETES. 

x\ttention  was  drawn  by  the  writer  to 
the  relationship  between  the  thyroid 
gland  and  the  pancreas  by  a  group  of 
four  cases  which  came  under  his  obser- 
vation, in  which  exophthalmic  goiter 
was  accompanied  or  succeeded  by  a  se- 
vere form  of  diabetes.  One  patient  re- 
covered from  a  typical  attack  of 
exophthalmic  goiter,  which  was,  hoAvever, 
followed  by  a  severe  form  of  pancreatic 
diabetes,  to  which  she  succumbed.  Tlie 
disappearance  of  the  exophthalmic  goiter 
was  evidently  due  to  the  return  of  the 
thyroid  to  a  normal  condition,  and  is 
an  interesting  example  of  how  complete 
this  recovery  of  the  gland  may  be.  The 
diabetes  Vv-as  the  result  of  the  destruction 
of  the  islands  of  Langerhans.  When  a 
second  patient  first  came  under  observa- 
tion she  was  suffering  from  exophthalmic 
goiter  without  glycosuria,  whereas  three 
years  later  she  had  practically  recovered 
from  exophthalmic  goiter,  but  was  suf- 
fering from  a  severe  form  of  diabetes, 
A  third  patient  with  exophthalmic  goi- 
ter, who  apparently  recovered,  relapsed 
on  taking  tliyroid  tablets,  the  second  at- 
tack persisting  and  becoming  compli- 
cated by  the  development  of  composite 
diabetes.  The  fourth  case  illustrates 
the  development  of  diabetes  nearly 
eleven,  years  after  the  onset  of  exopli- 


thalmic  goiter.  In  all  these  cases,  one 
patient  being  a  man  and  three,  women, 
severe  diabetes  developed  at  a  variaole 
interval  after  the  disease  had  either  sub- 
sided or  decreased  considerably  by  the 
time  the  diabetes  had  declared  itself. 
G.  I?.  Murray  (Clinical  Journal,  July  28, 
1909). 

IIEUS,  TREATMENT  OF. 

As  a  result  of  experiments  with  ani- 
mals, to  determine  the  most  decisive 
factors  in  the  fatalities  from  ileus,  the 
writers  show  that  autointoxication  and 
reflex  action  are  comparatively  unim- 
portant factors.  The  disturbances  are 
the  result  of  interference  with  the  func- 
tioning of  the  intestines  and  with  the 
circulation  in  the  abdominal  cavity.  The 
heart  is  not  primarily  involved  with 
ileus  in  the  small  intestine,  unless  the 
clinical  picture  is  complicated  by  infec- 
tion. Otherwise,  in  animals,  as  in  man, 
the  normal  heart  continues  to  work  con- 
tinually and  powerfully  to  the  very  last. 
At  first  the  intestine  above  the  occlu- 
sion increases  in  size,  fills  up  with  in- 
testinal juice  in  nine  hours,  with  an 
amount  corresponding  to  the  total  quan- 
tity of  blood  in  the  animal.  All  the  in- 
testinal vessels  are  gorged  with  blood, 
and  the  intestine  above  the  obstruction 
is  in  extreme  peristaltic  excitement,  ac- 
companied by  exaggerated  secretion  of 
pancreatic  and  intestinal  juice  and  bile. 
These  views  emphasize  the  necessity  in 
ileus  for  measures  to  tranquilize  tlie  in- 
testine and  regidate  the  circulation. 
Opium  may  accomplish  the  former,  and 
saline  infusion  the  latter,  possibly  sup- 
plemented by  a  suprarenal  preparation. 
W.  Braun  and  H.  Bornttau  (Deutsche 
medizinische  Wochenschrift,  August  12, 
1909;  Journal  American  Medical  As- 
sociation, September  18,  1909). 


INFANTILE  AN.EMIA. 


LATENT  MALARIA,  DIAGNOSIS  OF. 


bOS 


INFANTILE  ANiEMIA,  PREVENTION  OF. 
The  writer  refers  to  the  anaemia 
without  ajDjjreciable  cause,  and  experi- 
ence has  convinced  him  that  these 
anaemic  infants  are  sujffering  from  lack 
of  iron.  Tliis  form  of  auicmia  is  more 
common  in  families  in  which  the  infants 
are  allowed  nothing  but  milk,  while  it 
is  rare  when  the  children  early  eat  at  the 
famil}^  table.  He  does  not  give  iron  di- 
rectly, but  during  or  after  the  third 
month  allows  once  a  day  a  little  meat 
broth  with  one-half  and  later  the 
whole  yolk  of  an  egg.  During  thi 
fourth  and  fifth  months  gruel  is  given 
once  or  twice  a  day,  made  of  zwieback, 
with  butter,  milk,  salt  and  sugar,  lo 
which  the  egg  yolk  is  added.  By  the 
sixth  or  ninth  month  he  gives  spinach; 
by  the  tenth  and  eleventh  month  a  lii- 
tie  meat.  When  the  child  is  a  year  old 
he  reduces  the  milk  to  a  pint  or  a  pint 
and  one-half  a  da}^,  and  accustoms  the 
child  to  a  mixed  diet.  By  this  n^ans, 
the  anaemia  is  prevented,  and  always 
cured  when  developed.  Infants  seem  to 
feel  the  need  of  iron  mostly  in  the 
fourth  month,  and  by  giving  them  in 
this  way  a  little  food  that  contains  iron, 
it  is  possible  to  keep  the  ha?moglobin  at 
100  per  cent.  The  children  take  this 
diet  without  disturbance.  Yolk  of  egg 
and  spiiiach  contain  22  and  35  mg.  iron 
in  100  Gin.  of  dry  substance,  while  cow's 
milk  contains  only  2.3  mg.  The  writer 
thinks  it  is  not  a  mere  coincidence  tliat 
none  of  the  children  given  iron  in  this 
way  has  ever  developed  rachitis.  Milk 
does  not  contain  enough  iron  for  the 
proper  development  of  the  infant,  and 
sooner  or  later  the  child  will  sufl'er, 
especially  about  the  fourth  or  sixth 
month,  at  which  time  a  little  mixed  food 
containing  iron  is  given  whether  the 
child  is  getting  breast  milk  or  is  bottle- 
fed.     J.  Katzenstein   (Miinehener  mcd- 


izinische  Wochenschrift,  August  10, 
1909;  Journal  American  Medical  Asso- 
ciation, September  18,  1909). 

IVY  POISONING. 

In  the  treatment  of  ivy  poisoning,  the 
writer  suggests  the  following  method: 
No  scratching;  no  ointments  in  the 
acute  stage;  no  bandages,  for  these  tend 
to  spread  the  poison  to  adjacent  sur- 
faces; if  any  protector  is  necessary,  it 
should  be  a  loosely  applied  dressing  of 
absorbent  cotton,  kept  moist  at  all  times 
and  changed  at  short  intervals ;  frequent 
and  copious  washings  with  lukcwarin 
v.-ater  and  an  unirritating  soap;  in  han- 
dling the  inflamed  surface  it  is  best  to 
wear  rubber  gloves;  after  the  parts  are 
washed,  a  2  to  4  per  cent,  warm  solution 
of  permanganate  of  potassium  should  be 
applied.  This  completely  neutralizes 
any  poison  with  which  it  comes  in  con- 
tact; the  strength  of  the  solution  and 
the  frequency  of  application  are  matters 
of  Judgment  vrith  the  physician  after 
the  acute  stage  is  past;  ointments  are 
permissible.  A.  W.  Baird  (Medical 
Eecord,  August  7,  1909). 

LATENT  MALARIA,  DIAGNOSIS  OF. 

Three  phases  of  latent  malaria  are 
distinguished  by  the  author,  the  first 
lasting  from  the  time  of  infection  until 
the  onset  of  fever;  the  second  is  the 
afebrile  stage  between  the  paroxysms,  and 
the  third  phase  begins  after  disappear- 
ance of  parasites  and  stippling  from  the 
blood.  The  first  phase  ordinarily  is 
short,  but  in  those  taking  prophylactic 
treatment  it  may  last  many  months,  and 
the  fever  may  not  come  at  all.  The 
symptoms  are  nervousness  and  digestive 
disturbances  associated  with  more  or  loss 
anaemia.  This  symptom  complex  was 
formerly  believed  to  be  a  manifestation 
of  acclimatization.     In  this   stage,   th« 


604 


OPHTHALMl  A    N  EON  AT(  )KU  ^  1 . 


PEKITOKITIS. 


red  cells  show  a  form  of  stippling  pecul- 
iar to  parasitic  diseases.  It  persists 
until  the  beginning  of  the  third  stage. 
Particularly  after  energetic  quinine 
treatment,  pigment  from  the  red  cells 
may  be  found  in  the  leucoc3'tes,  but  it 
is  seen  most  frequently  in  the  large  mono- 
nuclear basophile.  Special  stress  is  laid 
on  the  importance  of  urobilinuria  f^r 
the  diagnosis  of  latent  malaria  in  the 
tliird  phase.  It  may  begin  in  the  first 
phase,  and  in  the  later  stages  it  is  con- 
stant imtil  after  the  begmning  of  tho 
third  phase,  when  it  may  be  the  only 
sign  of  the  disease.  When  urobilinuria 
from  complicating  diseases  can  be  ruled 
out,  the  writer  believes  that,  following 
known  malarial  infection,  it  indicates 
the  persistance  of  degenerative  changes 
of  the  organs.  Plehn  (Miinchener  med- 
izinische  Wochenschrift,  August  24, 
1909;  Boston  Medical  and  Surgic?.l 
Journal,  September  33,  1909). 

OPHTHALMIA  NEONATORUM. 

As  the  result  of  an  investigation  by 
the  writer,  he  has  found  that  blindness 
due  to  the  infectious  diseases  sums  up 
to  a  total  of  62  cases,  or  20  por 
cent.,  due  to  scarlet  fever,  measles, 
mumps,  cerebrospinal  meningitis,  ty 
phoid,  smallpox  and  trachoma.  School 
inspection  is  the  greatest  safeguard 
against  all  of  these.  No  civilized  com- 
munity ought  to  expose  its  school  chil- 
dren to  the  ravages  of  the  infections, 
when  regular  and  systematic  examination 
of  all  children  at  school,  by  competent 
physicians,  will  lead  to  the  early  detec- 
tion of  a  contagious  disease  in  a  child. 
When  isolation  of  a  child  with  scarlet 
fever  or  measles  follows  at  once,  when  ?J\ 
the  other  children  in  that  family,  or  even 
those  living  under  the  same  roof,  are 
isolated  and  not  allowed  to  return  to 
school  until  the  danger  of  contagion  is 


past,  when  fumigation  of  the  schoolroom 
follows  every  time  infection  is  detected, 
just  to  that  degree  are  the  dangers  of 
an  epidemic  averted.  Twelve  cases 
(4.02  per  cent.)  were  due  to  near-sighted- 
ness, high  degrees  of  myopia.  This  con- 
dition can  likewise  be  ameliorated  by  the 
proper  lighting  of  schoolrooms,  seeing 
that  the  light  falls  from  the  proper  di- 
rection; the  character  of  the  type  used 
in  school  books,  and  the  proper  adjust- 
ment of  desks  and  chairs. 

Methyl  or  wood  alcohol  has  been  the 
cause  of  blindness  in  three  (possibly 
four  cases),  as  the  result  of  inhalation. 
Hundreds  have  died  from  drinking  It. 
Its  sale  should  be  made  a  felony,  since 
denatured  alcohol  (which  contains  but 
2  per  cent,  of  wood  alcohol)  can  be  used 
for  everything  for  wlrich  wood  alcohol  's 
now  used,  and  the  dangers  are  greatly 
minimized.  Lead  poison  caused  four 
cases  of  blindness.  These  two  causes  are 
responsible  for  2.62  per  cent,  of  cases  of 
blindness.  In  a  total  of  175  cases,  equal 
to  58.90  per  cent.,  the  causes  could 
justly  be  considered  as  preventable.  L. 
Strieker  (Ohio  State  Medical  Journal, 
August,  1909). 

PERITONITIS,     ADRENALIN-SALINE     IN^ 
FUSION  IN. 

Extensive  experimental  and  clinieil 
researches  are  reported  by  the  writer, 
which  demonstrate,  he  thinks,  that  the 
main  effect  of  the  infusion  is  due  to  the 
salt  solution,  and  that  this  is  more  prom- 
inent in  the  cases  in  which  the  patient 
has  just  lost  large  amounts  of  fluid. 
The  effect  of  the  adrenalin  is  so  transient 
that  it  can  be  of  little  use  in  peritonitis; 
its  chief  field  is  in  collapse,  transient  in 
its  nature,  as  in  general  ana3sthesia  and 
spinal  anassthesia;  in  shock  after  severe 
operations  and  injuries;  in  haemorrhage; 
and  possibly,  also  in  intoxications  and  in 


PNEUMONIA,  8TR0PHANTHIN  IN. 


RHEUMATISM  OF  THE  HEART.       (jOo 


threateuing  conditions  during  infectious 
diseases.  H.  Heincke  (Archiv  fiir  klin- 
ische  Chirurgie,  Bd.  xc,  lUn.  1,  1909). 

PNEUMONIA,  STROPHANTHIN  IN  001= 
LAPSE  IN. 
Five  cases  of  pneumonia  are  reported 
by  the  writer,  which  show  that  in  cer- 
tain cases  of  collapse,  due  to  cardiac 
weakness,  the  ph3^sician  has  in  strophan- 
thin  a  drug  which  will  act  promptly 
and  powerfully  and  enable  the  pa- 
tient to  rally,  and  the  heart  to  resume 
its  work.  The  large  amounts  of  urine 
which  have  been  passed  by  these  patients, 
which  are  much  greater  than  the  ord- 
inary diuresis  following  the  crisis  of  a 
pneumonia,  make  it  seem  that  the 
strophanthin  has  also  to  do  with  the  pro- 
duction of  what  Meltzer  has  called  the 
'life  giving  diuresis,"  by  means  of  which 
the  toxic  products  are  more  rapidly  elim- 
inated than  would  otherwise  be  the  case. 
When  a  patient  has  grown  weaker  and 
weaker  in  the  course  of  his  disease, 
whether  it  be  pneumonia  or  tjqihoid 
fever,  the  cardiac  stimulant  of  the 
strophanthin  will  apparently  have  little 
effect  upon  the  gradually  flagging  heart 
action.  A.  K.  Stone  (Boston  Medical 
and  Surgical  Journal,  August  19,  1909). 

RHEUMATISM  OF  THE  HEART. 

The  main  factor  in  the  production  of 
mitral  incompetence  early  in  rheuma- 
tism, is  a  loss  of  tone  in  the  mitral 
sphincter.  The  pathologic  reason  for 
such  loss  of  tone  is  the  development, 
especially  near  the  mitral  ring  and  near 
the  root  of  the  aorta,  of  inflammatory 
nodules.  In  such  nodules  toxins  would 
be  elaborated  (wliether  formic  acid  or 
others)  and  the  lymph  of  the  part  would 
contain  these  toxins.  Hence,  the  muscle 
fibers  of  the  mitral  sphincter  would  be 
bathed  in  toxins,  the  special  action,  of 


which  is  to  diminish  tonicity,  while  the 
rest  of  the  cardiac  muscle  would  be 
much  less  severely  poisoned  since  the 
toxins  must  be  absorbed  into  the  general 
circulation  in  order  to  reach  any  fibers 
that  are  not  in  close  proximity  to  the 
nodules.  Thus,  in  any  rheumatic  myo- 
carditis, an  early  loss  of  tone  in  the 
sphincter  of  the  mitral  valve  would  be 
expected  with  the  development  of  a  re- 
gurgitant murmur.  Modules  tend  also  to 
form  near  the  root  of  the  aorta;  but  the 
aorta  has  no  sphincter  and  so  no  change 
is  produced  during  an  attack  of  rheu- 
matic fever.  There  is  also  heard  at  the 
apex  a  murmur  diastolic  in  time,  soft  and 
blowing  in  character,  only  temporary, 
which  seems  to  have  nothing  to  do  with 
the  development  of  a  genuine  stenosis  of 
the  valve.  Death  in  a  first  attack  of 
rheumatism  is  very  uncommon,  apart 
from  hyperpyrexia,  but  a  fresh  attack 
may  fatally  affect  the  heart  that  is  al- 
ready damaged  by  valvular  disease  or 
pericardial  adhesions,  or  the  muscle  ^f 
which  has  previously  been  injured  by 
poisoning  or  inflammation.  The  lesions 
of  rheumatic  myocarditis  are  in  them- 
selves insufficient  to  lead  to  a  fatal  issue, 
and  the  main  factor  in  the  production  of 
a  fatal  cardiac  failure  seems  to  be  the 
action  of  the  toxin  on  the  muscle  cells. 
Affections  of  the  myocardium  in 
rlieumatism  may  be  divided  into  the  in- 
flammatory and  the  toxic.  Inflamma- 
tory lesions  cause  a  loss  of  tone  in  the 
muscle  which  surrounds  the  mitral 
valve,  allowing  of  mitral  regurgitation. 
Thus  an  apical  systolic  murmur  is  the 
sign  of  rheumatic  myocarditis,  and  is, 
indeed,  the  only  sign  of  inflammation  of 
the  heart,  apart  from  pericarditis.  In 
the  majority  of  cases  the  presence  of 
such  a  sy.'^tolic  bruit  is  diagnostic  of  myo- 
carditis, but  in  a  small  minority  a  re- 
gurgitant   murmur    may    result    from 


606 


SENILE  EPILEPSY. 


SUPRARENAL  INSUFFICIENCY. 


general  dilatation  witliout  any  inflam- 
mation. Poisoning  of  the  heart  muscle 
in  rheumatism  causes  a  general  dilata- 
tion of  the  heart,  and  sometimes  a  mitral 
diastolic  murmur.  Dilatation  may  or 
may  not  be  associated  with  inflammation 
of  the  myocardium,  but  the  diastolic 
murmur  may  be  taken  to  imply  an  ab- 
sence of  myocarditis  at  the  time  it  is 
heard.  So  far  as  the  immediate  welfare 
01  the  patient  is  concerned,  the  toxic 
action  of  rheumatism  is  more  important 
than  the  inflammatory,  since  it  is  to  the 
consequent  failure  of  tonicity  and  con- 
tractility that  death  during  an  attack  is 
due.  Myocarditis  is  probably  always  as- 
sociated with  endocarditis,  so  that  there 
is  danger  of  permanent  damage  to  a 
valve,  and  the  inflammation  in  the  muscle 
itself  may  lead  to  such  local  damage 
that  tone  is  never  regained,  leaving  i 
permanent  widening  of  the  orifice.  It  is 
probable  that  the  muscle  may  sometimes 
completely  recover  both  from  the  poison- 
ing and  the  inflammation,  but  in  other 
cases  the  muscles  never  again  become 
healthy.  A.  M.  Gossage  (Lancet,  August 
21,  1909). 

SENILE  EPILEPSY. 

The  pathology  of  the  various  forms  of 
syncopal,  vertiginous,  and  epileptiform 
seizures  which  occur  for  the  first  time  in 
advanced  life,  is  summarized  by  the  writer 
as  follows:  Idiopathic  epilepsy  never 
arises  for  the  first  time  in  advanced  life. 
At  least  nine-tenths  of  these  syncopal, 
vertiginous,  and  epileptiform  seizures 
are  circulatory  in  origin.  Senile  syncope 
is  generally  due  to  cardiac  failure  and 
low  blood-pressure.  Senile  vertigo  and 
similar  head  sensations  (postural  verti- 
go, interruptions  of  thought,  etc.)  are 
due  to  the  disturbances  of  the  regulator 
mechanism  of  the  arteries  in  different 
parts  of  the  body  owing  to  arterial  hy- 


permyotrophy  or  other  arterial  disease, 
not  necessarily  accompanied,  so  far  as 
his  observations  go,  by  any  notable  al- 
teration of  the  general  blood  pressure  or 
of  cardiac  increase  or  diminution.  Sen- 
ile epilepsy  (convulsive  attacks)  is  gen- 
erally due  to  increased  blood-pressure 
with  cardioarterial  hypermyotrophy.  All 
these  attacks  of  senile  syncope,  senile 
vertigo,  and  senile  epilepsy  merge  into 
and  are  associated  one  with  the  other; 
vertigo  may  occur  at  one  time,  convul- 
sions at  another,  and  the  same  patient 
may  in  the  end  die  from  syncope  (when 
the  heart  is  defeated.) 

The  treatment  of  epileptiforin  and 
other  like  seizures  occurring  for  the  first 
lime  in  advanced  life  follows  naturally 
from  the  preceding  remarks.  Having 
investigated  the  other  possible  causes, 
the  main  thing  is  to  concentrate  atten- 
tion on  the  circulation — examine  the 
hr'art,  the  arteries,  and  above  all  (from 
the  point  of  view  of  treatment)  the 
blood-pressure.  Then  we  must  be  guided 
by  what  we  find  to  administer  treatment 
to  raise  or  lower  blood-pressure,  and  to 
tone  or  steady  the  heart.  T.  D.  Savill 
(Lancet,  July  17,  1909). 

SUPRARENAL  INSUFFICIENCY. 

The  syndrome  of  suprarenal  insuffi- 
ciency may  be  slow  or  acute.  In  the 
chronic  form,  of  which  Addison's  dis- 
ease is  the  extreme  type  if  there  is  no 
bronzing,  it  can  be  rendered  manifest 
by  applying  a  mustard  plaster  which 
draws  the  pigment  to  the  surface.  The 
tuberculous  process  in  the  suprarenals 
in  this  disease  is  almost  always  primary, 
and  these  glands  are  rarely  affected  even 
with  advanced  tuberculosis  in  other  or- 
gans. Without  the  bronzing,  the  syn- 
drome suggests  pernicious  anaemia,  leu- 
kremia  or  latent  cancer,  especially  the 
weakness,    the    low  blood-pressure,  the 


TUBERCLE  BACILLUS  IN  THE  CIRCULATING  BLOOD. 


607 


loss  of  appetite,  the  constipation,  vomit- 
ing, anfemia,  and  progressive  emaciation. 

The  acute  form  may  simulate  a  ful- 
minating poisoning,  peritonitis,  menin- 
gitis, apoplectiform  coma,  etc.,  and  it 
may  be  suspected  when  the  febrile  and 
other  phenomena  of  an  infectious  dis- 
ease are  suddenly  supplanted  by  signs  of 
depression,  small,  unstable  pulse,  sub- 
normal temperature  and  arterial  ten- 
sion. The  writer  is  convinced  that  the 
"white  line''  is  pathognomonic  of  su- 
prarenal  insufficiency  and  it  may  prove 
very  instructive  in  cases  of  sudden  death 
from  this  cause  in  which  circumstances 
indicate  possible  poisoning  or  violence. 
Besides  trauma,  an  operation  or  even  a 
pregnancy  may  bring  on  this  acute  in- 
sufficiency on  the  part  of  the  supra- 
renals. 

Treatment  should  aim  to  prevent  the 
development  of  the  acute  phase  or  ex- 
acerbations in  persons  already  affected 
with  the  chronic  form.  They  should 
avoid  exertions  and  contact  with  per- 
sons suffering  from  infectious  diseases 
and  should  refrain  from  toxic  drugs,  es- 
pecially from  arsenic,  which  is  a  violent 
poison  in  cases  of  suprarenal  insuffi- 
ciency, and  they  should  not  permit  any 
surgical  operations  unless  for  vital 
necessity.  On  the  other  hand  they  will 
derive  benefit  from  phosphates  and 
especially  from  lecithin.  Antisyphilitic 
treatment  should  be  instituted  if  there 
is  a  possibility  of  a  syphilitic  origin,  but 
the  mercury  and  iodid  must  be  managed 
with  great  care  as  they  are  liable  to 
prove  poisonous  for  the  suprarenal  cap- 
sule. Suprarenal  organotherapy  is  use- 
ful both  for  differentiation  and  cure, 
and  the  author  has  witnessed  the  entire 
subsidence  of  the  Addison  syndrome,  in- 
cluding the  disappearance  of  the  "white 
line"  under  the  influence  of  suprarenal 
medication.  Fresh  glands  from  young 
calves  may  be  used,  the  patient  ingest- 


ing from  1.5  to  2  Cm.  a  day  up  to  5 
Gm.,  or  the  dry  extract  can  be  taken. 
This  is  kept  up  for  ten  or  twelve  days, 
then  suspended  for  two  or  three,  and 
then  recommenced.  As  a  rule  the  ex- 
tract of  the  whole  gland  is  to  be  pre- 
ferred, but  the  writer  sometimes  uses 
adrenalin.  He  found  this  particularly 
useful  in  infectious  diseases  when  he 
suspected  suprarenal  involvement.  Signs 
of  cardiovascular  weakness  subside  un- 
der the  influence  of  the  adrenalin,  and 
the  vi'hite  line  vanishes  and  reappears 
parallel  with  the  fluctuations  of  the 
pulse,  which  is  regarded  as  substantial 
proof  of  its  pathognomonic  character. 
The  usual  dose  is  0.001  Gm.  a  day,  but 
up  to  0.006  may  be  given  fractional  in 
six  doses,  and  this  maybe  kept  up  for  two 
months.  The  white  line  is  the  opposite 
of  the  "red  line"  of  meningitis.  The 
flnger  is  drawn  lightly  along  the  skin  of 
the  abdomen ;  in  a  few  seconds  the  path 
of  the  finger  shows  up  as  a  white  stripe 
growing  more  and  more  distinct  and 
remaining  stationary  for  three  or  four 
minutes  and  then  disappearing.  E.  Ser- 
gent  (Presse  medicale,  July  10,  1909; 
Journal  American  Medical  Association, 
August  14,  1909). 

TUBERCLE  BACILLUS  IN  THE  CIRCULAT- 
ING BLOOD. 

As  a  result  of  his  studies,  the  author 
believes  that  tubercle  bacilli  can  be  dem- 
onstrated in  the  blood  in  every  case  where 
there  is  an  active  tuberculous  process; 
also,  that  they  are  present  in  the  blood  of 
many  apparently  healthy  persons,  ready 
to  produce  tuberculosis  as  soon  as  lowered 
resistance  from  any  cause  gives  them  a 
chance.  He  also  believes  that  the  bacilli 
are  transmitted  from  mother  to  child 
through  the  placenta.  R.  C.  Rosenber- 
ger  (iS'ew  York  Medical  Journal,  June 
19,  1909). 


(308  BOOK  REVIEWS. 


5ool<  Reviews 


Essentials  of  Lahoratory  Diagxosts.  Dcsignt'd  for  Sti!(lent>i  and  Practilioners.  By  Friiiicis 
Ashley  Fauglit,  M.D.,  Director  of  the  Laboratory  of  the  Department  of  Clinical  Medicine 
and  Assistant  to  the  Professor  of  Clinical  Medicine,  Medico-Chinirgical  College,  etc.,  etc., 
Philadelphia,  Pa.  Containing  an  Indican  Scale  in  Colors,  six  Full-page  Plates  and 
JS'umerous  Engravings  in  the  Text.  Net,  $1.50.  Philadelphia:  F.  A.  Davis  Company, 
Publishers,   1909. 

In  this  age  of  scientific  research,  much  has  been  written  on  the  various  laboratory 
methods  and  their  value  in  the  corroboration  of  the  clinical  diagnosis.  To  the  busy  prac- 
titioner who  makes  an  efl'ort  to  keep  abreast  of  the  advancement  of  medical  science  by  the 
application  of  these  methods  in  a  small  laboratory  of  his  own,  the  saving  of  time  is  neces- 
sarily a  matter  of  vital  importance,  and  it  is  for  this  reason  that  we  feel  the  book  under 
review  will  receive  a  wide  circulation.  The  author  has  not  made  an  effort  to  displace  any 
of  the  excellent  text-books,  "but  rather  to  supplement  them,  by  pointing  out  to  the  busy 
student  and  practitioner  simple  and  reliable  methods  by  which  he  may  obtain  the  information 
desired,  without  unnecessary  expenditure  of  valuable  time  upon  difficult,  tedious  or  untried 
methods."  The  definitions  are  clear  and  concise,  and  the  subject  headings  are  well  selected. 
The  text  briefly  considers  the  handling,  of  the  microscope.  The  examination  of  the  sputum 
and  the  blood,  and  the  determination  of  the  opsonic  index,  the  blood  pressure,  and  the 
coagulation  time  receive  careful  attention.  Blood  and  animal  parasites,  the  determination  of 
the  functions  of  the  stomach,  the  examination  of  the  faeces,  the  urine,  the  cerebrospinal 
fluid,  the  body  Uuids,  and  the  human  milk  are  succinctly  described.  The  various  bacteriologic 
methods  are  considered  in  a  chapter  by  themselves.  The  appendix  contains  much  informa- 
tion of  importance  and  includes  forms  for  the  report  of  the  ditierent  examinations,  the 
clinical  term.s  to  be  used,  and  the  apparatus  and  the  chemical  agents  for  the  iiuuieroas  tests, 
and  tlie  list  of  stains  vvaich  are  commonly  resorted  to. — R.  B.  S. 

Surgery:  Its  Principles  and  Practice.  Volume  iV.  Whole  Work  in  Five  \'olumes.  By 
Sixty-six  Eminent  Suigeuns.  Edited  by  \V.  W.  Keen,  M.D.,  LL.D.,  Hon.  F.R.C.S.,  Eng. 
and  Edin.,  Emeritus  Professor  of  the  Principles  ol  Surgery  and  of  Clinical  Surgery, 
Jefferson  Medical  College,  Phila.  Octavo  of  1194  Pages,  with  5G2  Te.xt  illustrations 
and  Nine  Colored  Plates.  Philadelphia  and  London:  VV.  B.  Saunders  Company,  PJ08. 
Per  Volume:      Cloth,  $7.00,  net;   Half  Morocco,  $8.00,  net. 

The  present  volume,  the  fourth  of  the  series,  is  equal  to  its  predecessors,  both  in  mat- 
ter and  make-up.  The  paper  is  splendid  and  the  illustraiions  clear  and  sharp.  As  to  the 
text  itself,  the  names  of  the  authors  and  the  departments  treated  by  each  offer  sullieient 
guarantee;  but  a  perusal  of  the  work  soon  indicates  tluit  no  expectation,  however  san- 
guine, has  failed  to  be  fuHilled.  The  I'oniribulors  to  the  present  volume  and  the  subjects 
undertaken  by  them  are  as  follows:  "Hernia,'  William  B.  Coley;  "Siirg^My  of  tue  iiectum 
and  Anus,"  Robert  Abbe;  "Examination  of  the  L'rine  in  Relaiion  to  SurgLal  .Measures," 
David  L.  Edsall;  "Surgery  of  the  Kidney,  the  I  refer,  and  the  Suprarenal  Gland,"  Joseph 
Ransohofl';  "Surgery  of  the  Bladder,"  Bransford  Lewis;  "Stone  in  the  Bladder,"  Arthur 
Tracy  Cabot;  "Surgery  of  tlie  Prostate,"  Hugh  H.  Young;  "Surgery  of  the  Penis  and 
Urethra,"  Orville  Ilorwitz;  "Surgery  of  the  Scrotum,  Testicle,  Spermatic  Cord,  and  Seminal 
Vesicles,"  Arthur  Dean  Bevan;  "Surgery  of  the  Intestines,  but  Excluding  the  Appendix, 
the  Rectum  and  the  Anus,  and  Surgery  of  the  Omentum  and  Mesentery,"  Weller  Van  Hook 
and  Allen  B.  Kanavel ;  "Surgery  of  the  App.ndix  Vermiformis."  John  B.  Murphy;  "Surgery 
of  the  Ear,"  Edward  Bradford  Dcneh ;  "Surgery  of  the  Eye."  George  E.  de  Schweinltz; 
"Military  Surgery,"  General  Robert  M.  O'Reilly;  "Naval  Surgery,"  Surgeon-General  P.  M. 
Rixcy;  "Tropical  Surgery."  Walter  D.  Mc(Jaw;  "The  Influence  of  Race,  Sex.  and  Age  in 
Surgical  Affections,"  W  illiam  L.  Rodman. 


ONTHLY    Cyclopedia 

AND 

EDicAL   Bulletin 


Published  the  Last  of  Each  Month 


Medical  Bulletin  Section 


Vol.  II.  PHILADELPHIA,  OCTOBER,  1909.  No.  10. 


Clinical  Lecture 


EPITHEUOMA.^ 


By  JOHN   V.   SHOEMAKER,   M.D.,   LL.D., 

Professor  of  Materia  Medica,  Therapeutics,  Clinical  Medicine,  and  Diseases  of  the  Skin, 
in  the  Medico-Chirurgical  College  and  Hospital  of  Philadelphia, 

PHILADELPHIA. 

Gentlemen:  Mrs.  A.  G.;  aged  54  years;  nativity.  United  States;  ex- 
hibits a  wart-like  growth  on  her  forehead,  which,  at  the  present  time,  is  in 
appearance  somewhat  obscure.  However,  her  history  will  help  us  to  arrive 
at  a  definite  and  positive  diagnosis. 

Family  History.— Rev  parents  are  both  dead.  The  father,  aged  72,  died  of 
paralysis,  and  the  mother,  aged  66,  of  cancer  of  the  breast.  She  has  two  sisters 
in  good  health.  Another  sister,  older  than  herself,  died  two  years  ago  of 
cancer  of  the  uterus.  Her  two  brothers,  both  younger,  are  in  good  health. 
She  has  no  knowledge  of  her  grandparents,  except  tbat  they  all  died  at  a 
matured  age. 

Previous  Personal  History. — During  her  childhood  days  she  had  measles 
and  diphtheria.  At  the  age  of  twenty-three  she  had  pneumonia  and  typhoid 
fever  at  the  age  of  twenty-five. 

Social  History. — She  was  married  at  twenty  years  of  age  and  is  the 
mother  of  three  daughters  and  four  sons,  all  of  whom  are  in  good  health.  Her 
habits  have  always  been  very  good. 

Present  Illness. — About  four  months  ago  there  appeared  on  her  forehead 
where  now  the  present  growth  exists,  a  small  hard  papule  which  was  neither 
painful  nor  did  it  show  a  tendency  to  suppurate.  She  was  little  concerned 
about  it  until  six  months  ago  when  she  noticed  a  comparative  increase  in  size 

•Delivered  in  the  Clinieol  Amphitheatre  of  the  Medico-Chirurgical  Hospital. 
5  (C09) 


610 


epithelio:ma. 


and  also  slight  pain  at  intervals.  There  is  at  present  a  small  zone  of  infiltra- 
tion surrounding  the  growth.  On  close  inspection  there  is  slight  desquamation 
and  shows  a  tendency  to  slough. 

Diagnosis. — This,  I  believe  to  be  an  epithelioma  in  its  incipient  stage,  and 
my  belief  is  influenced  greatly  by  the  family  history.  The  history  of  the  onset, 
its  development  and  appearance  are  all  very  suggestive  of  a  beginning 
epithelioma. 

Groat  care  should  be  taken  in  diagnosing  an  epithelioma  since  it  may  be 
confounded  with  the  lesions  of  syphilis,  lupus  vulgaris,  ordinary  wart,  con- 
dylomata and  seborrhoea  sicca.  The  diagnosis  is  easy  in  the  advanced  stage 
but  in  some  cases  it  is  very  difficult  to  decide  whether  a  wart-like  growth  is 
the  initial  lesion  of  epithelioma  or  an  ordinary  wart.  As  a  rule  warts  that  de- 
velop after  thirty  years  of  age  are  suspicious  and  should  be  removed.  The 
differential  diagnosis  is  shown  in  the  following  tables : — 

Syphilis    (hard  chancre). 

1.  History  of  infection. 

2.  Evolution  rapid. 

3.  No  pain. 

Tertiary  Syphilitic  Ulcer. 


Epithelioma  {paprile). 
No  history  of  infection. 
Evolution  slow. 
Lancinating  pain. 

Epitheliomatous  Ulcer. 
Lesions  single. 
Secretion  is  blood  streaked. 
Surrounded  by  a  well-marked  zone  of  in- 
filtration. 
Long  duration. 


5.  Yields  only  to  destruction. 

Epithelioma   {papillary ) . 

1.  Lesion  painful. 

2.  Lesions  usually  single. 

3.  No  history  of  infection. 

4.  No  concomitant  signs. 

5.  Occurs  in  advanced  age. 

Epithelioma. 

1.  Develops  in  middle  and  advanced  life. 

2.  Lesions  single. 

3.  Course  more  rapid. 

4.  Ulcer  deep. 

5.  Lancinating  pain. 

6.  Secretion   blood-streaked  and  viscid. 


Edges    and     base 
pearly  border. 


hard,     characteristic 


L  Lesions  multiple. 

2.  Secretion  is  foetid,  yellow,  and  abundant. 

3.  Zone  of  infiltration  is  either  absent  or 

insignificant. 

4.  Short  duration. 

5.  Heals  under  the  use  of  the  iodides  and 

mercury. 

Condylomata. 

1.  Lesion  not  painful. 

2.  Lesions   usually   multiple. 

3.  History  of   infection. 

4.  Concomitant  signs  of  syphilis. 

5.  Usually  occurs  in  youth  and  middle  age. 

Lupus  Vulgaris. 

1.  Develops  usually  before  puberty. 

2.  Lesions  multiple. 

3.  Course   slow. 

4.  Ulcer  superficial. 

5.  Pain  absent. 

6.  Secretion    abundant,    yellow,    and   puri- 

forra. 

7.  Edges  and  base  soft. 


Pathology. — Microscopically,  the  process  consists  of  a  proliferation  of 
epithelial  cells  growing  downward  into  the  corium  of  tbe  interpapillary  projec- 
tions of  the  rete  mucosum.  The  downward  growth  and  continuous  multiplica- 
tion of  epithelial  cells  forms  an  unusual  length  of  the  interpsipillary  processes, 
which  project  down  into  the  corium  like  the  fingers  of  a  glove.  These  finger- 
like  processes  continue  to  multiply  and  increase  in  size.     Then  they  divide  into 


EPITHELIOMA.  611 

branches,  which  unite  with  one  another  to  form  a  framework  of  epithelial  tis- 
sue. The  cells  of  which  they  are  composed  become  pressed  together  and  form 
onion-like  bodies,  the  so-called  cell-nests  or  globes.  In  other  instances  they 
form  club-shaped  masses.  This  rapid  cell-growth  requires  increased  nutrition, 
hence  the  blood-vessels  become  enlarged;  wandering  cells  and  lymphoid  cor- 
puscles fill  up  the  lymphoid  spaces  and  the  skin  becomes  infiltrated  with  serum. 
Finally  the  pressure  of  the  cell-masses  gives  rise  to  irritation  and  inflammation. 

The  second  stage  of  the  disease  is  marked  by  degeneration  and  ulceration. 
When  the  ulceration  advances  rapidly  and  extends  to  the  deepr  tissues,  the 
neighboring  lymphatics  soon  become  affected  and  through  them  the  involve- 
ment of  the  entire  system  takes  place.  However,  when  the  ulceration  is  super- 
ficial, the  patient's  health  is  not  much  affected.  Muscular  tissue  and  paren- 
chymatous organs  undergo  fatty  degeneration  and  the  composition  of  the 
blood  is  altered,  followed  by  the  production  of  toxic  products  in  the  tissues. 
The  albumin  is  increased  irrespective  of  the  nature  and  amount  of  the  food 
consumed  and  there  is  decrease  in  the  alkalinity  of  the  blood.  This  is  followed 
by  the  excessive  formation  of  urea  which,  nevertheless,  is  imperfectly  eliminated, 
and  some  cases  have  been  reported  in  which  the  excretion  of  urea  had  entirely 
ceased. 

Etiology. — The  etiology  of  this  affection  is  obscure.  The  disease  is 
brought  about  in  some  cases  from  long-continued  pressure  or  other  mechanical 
irritation.     Any  locally  irritated  tissue  may  be  the  starting  point. 

Many  theories  have  been  advanced  to  explain  the  cause  of  this  growth, 
but  none  have,  as  yet,  been  established.  In  a  majority  of  cases  it  is  attributed  to 
irritation  either  by  contact  with  paraffin  or  by  the  irritation  of  soot  in  the  folds 
of  the  scrotum,  thus  producing  chimney-sweepers'  cancer.  Epithelioma  of  the 
tongue  and  lip  has  been  produced  by  the  irritation  of  a  short  clay  pipe  or  a 
broken  tooth.  Epithelioma  has  also  occurred  in  cases  where  there  was  no  irri- 
tation. Old  scars,  pre-existing  warts,  nasvi  and  sebaceous  cysts  frequently 
undergo  degeneration  without  an  apparent  cause  and  become  the  seat  of 
epithelioma.  As  a  rule  this  affection  is  not  inherited,  but  in  this  patient's 
family  there  is  a  predisposition  to  cancer.  A  theory  has  been  advanced  that 
cancer  is  of  parasitic  origin  and  cases  have  been  reported  where  the  disease 
has  been  transmitted  from  one  individual  to  another,  and  some  experiments 
have  demonstrated  that  cancer  may  at  least  be  transmitted  from  one  animal 
to  another  of  the  same  species.  Epithelioma  occurs  in  middle  life  and  more 
frequently  in  men  than  in  women. 

Treatment. — In  this  particular  case  I  believe  immediate  excision  is  the 
very  best  treatment.  There  is  very  little  involvement  of  the  surrounding  tis- 
sue, consequently  the  wound  can  be  allowed  to  heal  by  first  intention.  Of  course 
after  excision  the  wound  should  receive  a  number  of  x-ray  treatments.  Some 
patients  always  shun  the  surgeon's  knife  and  in  such  cases  a  caustic  may  be 
empWed.  In  beginning  superficial  epithelioma  I  have  found  tlie  emulsion 
made  from  the  Abrus  precatorius  bean  most  useful  to  destroy  the  growth. 
The  emulsion  should  be  fresh  and  carefully  made.  Great  care  slioukl  be 
exercised  in  its  application  so  that  not  too  much  of  it  is  brought  in  contact 


612  A  STUDY  OF  COxN TEMPORARY  WORKMEN'S  COMPENSATION. 

with  healthy  skin.  The  slough,  however,  is  soon  lollov/ed  by  healthy  granula- 
tion and  repair  of  the  destroyed  tissues. 

The  Abrus  precatorius  bean  belongs  to  the  leguminous  family  and  is  a 
native  of  India,  but  also  grows  in  other  tropical  countries.  It  is  small,  nearly 
round,  of  a  bright  red  color,  with  a  black  spot  at  the  hiliini.  The  poisonous 
constituents  are  a  globulin  and  an  albumose,  the  action  of  which  closely 
resembles  that  of  toxins  of  bacterial  origin.  No  alkaloid  is  present  in  the 
bean. 

The  therapeutic  action  of  Abrus  is  that  of  a  strong  escharotic,  and  it  is 
often  used  with  beneficial  results  in  the  treatment  of  trachoma,  chronic 
metritis  and  chronic  suppurative  otitis.  Either  the  powdered  drug  may  be 
applied  by  means  of  a  camel's  hair  brush  or  an  infusion  may  be  made  by 
triturating  three  beans  in  a  mortar  with  an  ounce  of  cold  water,  to  which  is 
added  an  ounce  of  hot  water.  When  cold  the  solution  is  filtered,  the  resulting 
filtrate,  containing  the  globulin  and  albumose,  if  introduced  into  the  eye  is  highly 
irritating  and  sets  up  a  purulent  inflammation.  Its  therapeutic  success  in 
epithelioma,  trachoma,  etc.,  depends  largely  upon  the  method  of  application. 
Good  results  are  sure  to  follow  if  cautiously  used  in  order  to  prevent  excessive 
reaction. 

Prognosis. — There  is  no  glandular  involvement  in  this  patient,  conse- 
quently I  believe  that  immediate  excision  and  x-ray  will  arrest  all  further 
progress. 


Orlmnal  Articles 


A  STUDY  OF  CONTEMPORARY  WORKMEN'S  COMPENSATION.* 
Bt  w.  h.  allport,  m.d. 

First   Paper. 

The  writer  makes  no  claim  to  having  prepared  these  papers  from  a  purely 
medical  standpoint;  in  fact,  most  of  the  aspects  of  the  conditions  discussed  in 
the  following  pages  are  altogether  legal.  None  the  less  a  knowledge  of  those 
conditions  which  inevitably  arise  in  consequence  of  industrial  injuries,  and  the 
methods  which  the  world  at  large  is  adopting  to  cope  with  them,  is  of  grave 
importance  to  the  physician  who  would  keep  in  touch  with  the  society  in  which 
he  lives.  Such  knowledge  properly  employed  is  bound  to  give  him,  not  only 
keener  zest  for  correct  and  observant  practice,  but  also  a  broader  sense  of  hia 

•  The  synoiiymoua  terms  WorJcma7i  and  Employe  are  here  used  in  the  sense  de- 
fined by  the  English  Workmen's  Compensation  Act  of  1906,  q.v.  post. 

The  term  Compensation  is  used  in  the  sense  implied  in  the  same  Act;  i.e.,  a 
recompense,  or  solatiuin,  for  disablement,  and  not  a  wage  for  service. 


A  STUDY  OF  CONTEMPORARY  WORK^klEN'S  COJUPENSATION.  613 

duties  towards  both  the  patient  and  the  corporation  he  may  happen  to  be 
serving.  Furthermore,  there  is  no  great  doubt  but  that  we  are  on  the  ere  of 
most  important  legislative  action — both  State  and  Federal — in  these  matters, 
which  will  touch  tlie  medical  profession  at  many  vital  points. 

The  reason,  therefore,  for  the  presentation  of  such  a  subject  by  a  medical 
man  in  a  medical  journal  is  sufficiently  obvious,  and  does  not  require  further 
comment  or  excuse. 

Syllabus. 

Attention  is  invited — but  not  necessarily  in  the  order  laid  down  in  the 
syllabus — to  the  following  aspects  of  the  subject: — 

1.  The  development  and  some  of  the  changing  features  of  contemporary 
law,  in  80  far  as  the  same  relates  to  injuries  to  workmen. 

2.  Certain  common-law  doctrines  by  the  use  of  which  a  large  body  of 
otherwise  humane  and  intelligent  lawyers — usually  actually  or  prospectively 
in  the  employ  of  corporations — still  thinks  the  ends  of  justice  are  best  attained. 
Certain  weak  points  in  these  same  ancient  but  still  operative  doctrines,  where 
many  of  the  best  modern  lawyers  think  change  is  impending  and  highly 
desirable. 

3.  The  two  methods  by  which  these  changes  are  evolving  themselves: — 
a.  The  Fjuropean  or  constructive  method,  based  on  the  principle  of  a 

scientific  plan  of  advance  through  positive  betterment  of  the  modus  vivendi 
between  employers  and  workmen; 

6.  The  American  or  destructive  method,  based  on  the  principle  of  pro- 
hibitive enactments,  levelled  only  at  the  most  flagrant  encroachments  which  the 
employer  has  been  heretofore  enabled  to  make  upon  the  personal  rights  of  the 
individual  workman,  under  cover  of  the  common  law. 

4.  The  English  Laws. 

5.  The  German  and  Continental  Laws. 

6.  The  United  States  Federal  Laws. 

7.  State  Laws  of  the  United  States. 

8.  The  forces  operating  toward  and  against  the  enactment  of  workmen's 
compensation  laws  in  the  United  States. 

9.  Probable  methods  by  which  such  laws  will  eventually  reach  the  statute 
books. 

I 

It  must  be  quite  apparent,  even  to  the  casual  observer,  that  the  conditions 
of  life  and  law  affecting  the  relation  of  master  and  servant  have  changed  during 
the  last  generation  through  no  uncertain  tendency,  and  more  than  by  a  natural 
and  gradual  progression.  This  progression  per  saltern  has  been  due  especially 
to  the  substitution  for  the  slow  labor  of  water  and  of  the  hand,  of  rapidly  moving 
machinery  driven  either  by  steam  or  electricity;  and  generating  destructive 
as  well  as  constructive  energies  of  enormous  power,  often  capable  of  transmission 
over  paths  and  distances  not  contemplated  at  their  point  of  origin. 

To  satisfactorily  adjust  tlie  problems  produced  by  these  new  and  terrible 
potentials — owned  and  at  the  service  of  employers,  and  under  control  largely 


614  A  STtTDY  OF  CONTEMPORARY  WORKJMEN'S  COMPENSATION. 

of  employes — we  find  that  not  only  has  statutory  law  been  specialized  and  com- 
plicated, but  many  of  the  so-called  fundamental  principles  of  common  law  are 
no  longer  found  to  meet  present  day  exigencies.  Certain  of  those  patriarchal 
axioms  by  which  courts  are  wont  to  season  the  law  are  rapidly  finding  their 
way  into  the  scrap  heap,  because  they  do  not  contain  enough  of  the  leaven  of 
justice  to  keep  them  wholesome  under  modem  conditions. 

Many  examples  of  this  process  of  evolution  will  readily  occur:  Thus, 
the  old  adage,  that  "he  who  handles  machinery  must  take  the  consequences" — 
volenti  non  fit  injuria — has  given  way  to  safety  appliance  acts,  factory  laws,  shop 
inspectors,  employes'  minimum  age  limits,  and  other  positive  methods  of 
enforcing  protection  of  those  who  earn  their  livelihood  as  operators  of  machinery. 

The  old  "Common  Employment"  or  "Fellow  Servant"  doctrine^  has  be- 
come worn  so  threadbare  by  seventy  years  of  common-law  service  in  the  interest 
of  corporate  masters,  that  even  the  myopic  legal  eye  has  begun  to  see  that  the 
cloak  is  too  meager  and  too  full  of  holes  to  longer  shelter  the  overgrown  modern 
corporation  against  the  claim  of  the  employe  injured  through  no  carelessness 
of  his  own.  Many  lawyers  are  even  disrespectful  enough  to  affirm  that  Abinger's 
decision,  and  Shaw's  American  application  of  it,  were  villainously  and  per- 
niciously bad  law  from  the  start.  We  may  concede,  perhaps,  that  such  judge- 
made  law  may  have  done  very  well  to  defend  masters  against  house  servants,  or 
to  meet  those  primitive  conditions  where  every  employe  saw  and  was  seen  by 
every  other,  and  all  worked  under  the  direct  eye  of  the  master;  but  it  can 
hardly  convey  exact  justice  to  the  family  of  the  dead  engineer,  who  is  killed 
through  a  faulty  train  order  issued  by  a  dispatcher  a  hundred  miles  away. 

The  time-honored  doctrines  of  "Assumed  Eisk"  and  "Contributory  Negli- 
gence" come  also  well  within  this  list  of  obsolescent  formulae,  which  a  long 
suffering  public  is  commencing  to  recognize  as  not  comprehensive  or  humane 
enough  to  the  employe  to  meet  the  demands  of  modern  justice. 

In  place  of  these  and  many  other  outgrown  fetishes  and  forms  of  ancestor 
worship,  which  passed  as  common  law  among  the  lawyers  of  early  and  semi- 
agricultural  days,  we  are  coming  to  see  that  vastly  broader  and  more  humane 
principles  must  underlie  our  complicated  modern  life,  if  law  is  still  to  be  the 
embodiment  of  justice. 

A  truer  conception  of  law  than  any  laid  down  in  the  medioaval  and  evasive 
doctrines  of  fellow  servant  and  contributory  negligence,  is  to  be  found  in 
the  theory  that  all  corporate  and  public,  and  many  private,  rights  flow  from 
and  are  farmed  out  for  the  benefit  of  the  community.  If  a  corporation  or 
manufacturer  thus  becomes  merely  a  public  agent,  then  the  injured  employe, 
whoHO  disability  will  eventually  make  him  or  his  family  a  public  burden,  should 
— unless  grossly  and  individually  responsible  for  his  injury — be  entitled  to 
recompense,  and  the  community  should  bear  the  charge  through  an  addition 
made  to  the  original  cost  of  the  product  turned  out  by  its  agent.  "If  a 
corporation  has  no  recourse  but  to  replace  a  wrecked  engine,  why  not  reimburse 

1  First  laid  down  by  Lord  Abiiiger  in  1837  in  his  decision  in  the  Priestley  case, 
and  restated  in  1842  by  Chief  Justice  Shaw,  of  Massachusetts,  in  the  Farwell  vs.  Fitch- 
burg  R,  R.  case. 


A  STUDY  OF  CONTEMPOEARY  WORKMEN'S  COMPENSATION.  615 

also  tlie  injured  engineer  and  charge  both  items  off  to  maintenance  P"^  These 
charges  in  turn  must  be  balanced  later  on  by  a  slightly  higher  tariff  collected 
from  the  community.^  As  we  shall  come  to  see  in  our  examination  of  the  laws 
of  those  European  countries  where  tliis  system  is  actually  in  force,  such  a 
method  breeds  no  litigation,  debases  no  workman,  and,  by  virtue  of  its  wide 
apportiomnent,  the  charge  is  absorbed  unconsciously  by  those  who  eventually 
have  to  bear  it. 

None  of  these  far-reaching  social  principles  have  ever  received  even  the 
scantiest  recognition  from  the  eye  of  the  common — or  judge-made — law,  which 
has  never  looked — when  it  looked  at  all — in  any  direction  other  than 
backward  and  inward. 

The  best  that  the  common  law  has  ever  done  has  been  to  recognize  the 
ruthless  rapidity  and  strength  of  the  modem  machine,  by  no  longer  exacting 
of  employe,  passenger,  bystander,  or  wayfarer  more  than  the  ordinary  efforts 
of  the  instinct  of  self-preservation  when  brought  in  contact  with  such  appliances. 
Even  these  efforts  are  often  conceded  to  be  feeble  and  unavailing,  and  the  law 
very  properly  exacts  from  the  corporate  interest,  as  a  price  which  it  pays  for 
rights  of  way,  better  power,  increased  production,  and  higher  speed,  a  pledge  of 
safety  and  protection  for  those  who  approach  its  property.  The  owner  or 
operator  of  "ways,  works,  or  machinery" — who  is,  after  all,  as  we  have  seen,  but 
the  agent  of  the  public — shall  so  safeguard  them  that  no  properly  instructed 
or  right-minded  person — whether  employe,  passenger,  or  bystander — shall  be 
injured  on  or  by  them  except  through  his  own  wilful  and  voluntary  act.  Any 
employer  or  proprietor  not  furnishing  such  protection  is  guilty — under  the 
common  law — of  Negligence. 

"By  negligence  is  meant,  in  law,  the  failure  to  exercise  that  degree  of 
care  which  the  law  requires  for  the  protection  of  those  interests  of  other 
persons  which  may  be  injuriously  affected  by  the  want  of  such  care." — Cen- 
tury Dictionary. 

"By  negligence  is  meant,  in  law,  the  omission  to  do  something  which 
a  reasonable  man,  guided  by  those  considerations  which  ordinarily  regulate 
the  conduct  of  human  affairs,  would  do,  or  doing  something  which  a 
prudent  and  reasonable  man  would  not  do." — American  Law  Dictionary. 
Claims  made  under  the  common  law  by  an  injured  workman  seeking 
redress  in  American  courts  from  an  employer,  are  usually  based  on  some  form 
of  negligence  of  the  latter's  duty  to  fulfil  this  pledge  of  safety  to  his  employe. 


2  J.  W.  Lewis,  Atlantic  Monthly,  January,  1909. 

3  From  President  Roosevelt's  message  of  December  4,  1906.  referring  to  the  Em- 
ployers' Liability  Act  of  1900.  "It  was  a  marked  step  in  advance  to  get  tlie  recognition 
of  Employers'  Liability  on  the  statute  books,  but  the  law  did  not  go  far  enougli. 
*  *  *  The  inevitable  sacrifice  of  life  though  reducible  to  a  minimum,  cannot  be 
eliminated.  *  *  *  It  is  a  great  social  injustice  to  compel  the  employe,  or  rather 
his  family,  to  bear  the  entire  burden  of  .such  sacrifice,  when  the  injury  is  often  the  direct 
result  of  the  legitimate  risk  of  trade.  Such  risks  and  burdens  should  be  placed  where 
they  belong — on  the  cost  of  the  completed  article,  through  the  medium  of  an  assess- 
ment against  the  employer.     Trade  risks  should  not  be  borne  by  the  workmen." 


616  ^  STUDY  OF  COA' TEMPORARY  WORKMEN'S  COAIPENSATION. 

It  might  seem  at  a  casual  glance  that  it  would  be  easy  to  recover  compen- 
sation on  such  a  plea.  But  the  common  law  has  always  refused  to  recognize 
any  of  the  broader  responsibilities  which  the  manufacturer  and  his  product  owe 
to  the  workman,  and  insists  that  all  negligence  shall  be  traced  to  and  charged 
only  against  its  exact  source. 

Note. — Statistics  vary  as  to  the  responsible  source  of  industrial  accidents  and 
their  attendant  injuries.  Most  American  articles  and  statistics  on  this  subject  are 
based  on  foreign  sources,  since  the  laws  of  few  American  states  have  reached  even  the 
preliminary  stage  where  employers  are  obliged  to  furnish  casualty  information  to  insur- 
ance boards  or  labor  commissioners.  A  recent  American  -writer  states  that  about  20 
per  cent,  of  these  accidents  are  due  to  negligence  of  the  employer;  30  per  cent,  to 
negligence  of  the  workmen;  and  50  per  cent,  to  unavoidable  causes.  These  latter  con- 
stitute a  class  of  legitimate  risqucs  professionel.  Another  writer  (Warner,  "Green 
Bag,"  1906),  probably  deriving  his  statistical  information  from  the  same  source,  cites 
the  New  York  Labor  Commissioner's  Report  of  1889,  to  show  that  in  Austria  75  to  SO 
per  cent,  of  injuries  are  due  to  the  last  mentioned  cause,  and  not  to  any  avoidable 
negligence.  In  Austria,  only  one  per  cent,  of  accidents  are  now  assignable  to  employers' 
negligence,  as  against  20  per  cent,  in  Germany,  12  per  cent,  in  England,  and  an  unknown 
but  probably  extremely  high  percentage  in  the  United  States. 

These  are  late  statistics.  Prior  to  the  date  when  the  last  very  stringent  Austrian 
laws  of  1902  went  into  effect,  the  percentage  of  unavoidable  accidents  out  of  the  total 
was  much  less — 50  to  55  per  cent. 

Under  a  mutual  scheme  of  accident  insurance,  started  in  1897  by  the  South 
Metropolitan  Gas  Company  of  London,  the  number  of  accidents  per  thousand  showed, 
during  the  ensuing  ten  years,  a  steady  decrease  of  about  5  per  thousand  per  year,  or 
from  82  per  thousand  in  1897  to  37  per  thousand  in  1906.  Tliis  remarkable  decrease  in 
the  percentage  of  accidents  was  due  to  two  causes:  first,  an  effort  by  the  company  to 
give  the  employes  better  protection,  and  second,  the  organization  of  the  employes  of  the 
various  stations  of  the  company  into  separate  branches,  with  their  own  assessments  and 
statistics.  Improvement  in  the  statistics  for  any  branch  resulted  iu  the  reduction  of 
the  assessment  against  the  members  of  that  branch.  As  will  be  seen  later  on  in  the  dis- 
cussion of  German  laws,  this  detail  was  borrowed  from  a  similar  system  established 
among  groups  of  German  employers. 

Tliese  statistics,  if  correct,  show  conclusively  when  compared,  that  both  employers 
and  employes  are  led  to  eliminate  their  own  percentage  of  avoidable  accidents  when 
brought  face  to  face  with  the  fear  of  financial  loss  or  criminal  prosecution. 

And  80  the  employer  responds  with  various  counter-pleas — tu  quoque — 
unless  a  statute  expressly  forbids  them — some  just,  some  unjust,  and  all  legal — 
which  enable  him  to  shake  off  his  pursuer  by  proving  either:  that  tlie  negligence 
was  not  his;  or  had  been  contracted  for;  or  was  overshadowed  by  a  more 
proximate  negligence  on  the  part  of  the  injured  plaintiff;  or  that  the  latter 
knew  beforehand  of  the  negligence  and  assumed  the  risk  of  iujury  through  it 
by  remaining  in  the  service. 

Various  phases  of  the  doctrine  of  negligence,  with  its  Pandora's  box  of 
troubles  for  the  employer,  the  worlanan  and  the  public,  will  be  discussed  more 
in  detail  when  considering  the  American  aspects  of  workmen's  compensation. 

The  evolution  of  the  English  laws  relating  to  industrial  accidents  furnishes 
at  this  point  an  instructive  study  for  those  interested  in  recent  efforts  to 
galvanize  life  into  the  comrnon-law  medisevalism  of  American  courts. 


A  STUDY  OF  COJS' TEMPORARY  W0R]OIEN'S  COMPENSATION.  617 

n 

Workmen's  Compensation  for  Industrial  Accidents  in  England. 

Under  the  common  law,  which,  in  England,  governed  without  restriction 
in  these  cases  until  1880,  the  employer  was  liable  to  the  employe  for  injuries 
resulting  from  breach  of  duty,  on  the  part  of  either  the  employer,  or  of  any  one 
authorized  to  act  for  him,  even  though  the  employer  was  unaware  of  the 
specific  act  of  negligence. 

Thus,  negligence  became — very  properly,  according  to  the  notions  of  early 
days — the  basis  of  the  action,  but  unfortunately  it  also  became  the  basis  of  the 
defense,  and  the  English  worlcman  was  usually  effectually  barred  from  recovery 
by  one  of  the  following  pleas,  drawn  from  the  abundant  stock  of  English 
judge-made  laws : 

1.  A  plea  by  which  the  burden  of  responsibility  was  shifted  to  the 
shoulders  of  a  neglectful  fellow  servant — the  "Common  Employment 
Doctrine,"  based  on  the  decision  of  Lord  Abinger  in  the  "butcher's  boy" 
or  Priestley  case  of  1837. 

2.  The  ancient  doctrine  of  "Contributory  ISTegligence,"  a  plea  by 
which  the  burden  was  shifted  to  the  shoulders  of  the  injured  party  him- 
self, provided  he  had  contributed  to  the  accident  by  the  smallest  measure 
of  negligence. 

3.  The  still  older  doctrine  of  "Assumption  of  Eisk,"  with  its  corollary 
— volenti  non  fit  injuria.  "Shortly,  the  servant  must  have  been  willing 
to  encounter  the  risk,  and  at  his  own  expense  to  bear  the  consequence."'* 
Also,  if  he  had  not  wished  to  assume  the  risk  of  the  known  negligence  of 
his  employer,  he  could  have  quit  his  service. 

Thus  the  employe,  though  injured  through  no  fault  of  his  ovra,  was  left, 
to  use  a  somewhat  homely  expression,  to  hold  the  empty  bag,  and  the  employer 
took  all  the  profits  of  his  perilous  labor.  It  may  be  observed,  in  passing,  that 
the  law  in  many  of  those  American  State  Courts  where  common-law  practice 
still  governs,  has  never  advanced  beyond  this  stage. 

To  remedy  this  outrageously  oppressive  attitude  of  the  English  courts 
towards  the  workman,  Gladstone,  in  1880,  secured  the  passage  of  the  Employer's 
Liability  Act.  This  act  was  modeled  after  the  Prussian  Act  of  1838,  which  was 
originally  designed  to  protect  railroad  employes  only,  but  which  was  expanded 
and  incorporated  into  the  German  Imperial  Code  of  1871.  The  Gladstone  Act 
had  all  of  the  vices  of  its  protot3^e  of  1838,  without  any  of  the  safeguards 
added  either  in  the  German  Code  of  1871,  or  in  those  later  German  laws  which 
followed  shortly  after  the  Gladstone  Act.  Whilst  this  Act  specifically  abolished 
the  tripod  of  common  law  defense  just  mentioned,  it  was  still  based  on  negli- 
gence, and  threw  upon  the  employe  the  heavy  and  difficult  burden  of  proving 
the  same.  In  addition,  no  provision  was  made  to  prevent  the  forestalling  of 
claims  by  contract,  and  employers  were  soon  informed  by  their  legal  advisers 
that  they  could  evade  their  obligations  under  the  Act,  by  contracting  ^vith 
employes  to  renounce  all  those  rights  which  the  Act  intended  to  confer  upon 

4  Roberts  &  Wallace,  Employers'  Liability,  p.  105,  4th  Edition,  English. 


618  A  STUDY  OF  CONTEMPORARY  WORIOvIEN'S  COMPENSATION. 

them.  Such  contracts  are  still  valid  in  many  American  States;  all  railroad 
emplo)'e8  sign  them  on  entering  service,  and  the  document  passes  among  this 
class  of  our  working  men  under  the  often  prophetic  title  of  "death  warrant." 

Had  Gladstone  been  more  familiar  with  the  inevitable  socialistic  trend  of 
German  thouglit,  and  with  the  legitimate  imperial  efforts  to  guide  and 
counteract  that  tendency,  he  would  have  detected  the  rising  movement  which 
culminated  in  the  great  series  of  German  laws  of  1881-1890.  Even  in  his  own 
country  this  movement  was  rapidly  ripening,  and  he  need  not  have  left  it  to 
Joseph  Chamberlain  to  enunciate  to  the  English-speaking  world  those  far-reach- 
ing principles  which  first  had  authoritative  pul)lic  utterance  in  the  Kaisei"^s 
speeches  before  the  Eeichstag  from  1881  to  1884. 

Note. — A  few  extracts,  freely  translated  from  two  of  the  speeches  of  the  Emperor, 
are  interesting  in  this  connection,  as  showing  the  broad  spirit  of  intelligent  statesman- 
ship which  animated  this  best  and  wisest  of  German  rulers. 

"I  have  already  expressed  to  you  mjf  belief  that  the  remedy  for  social  evils  does 
not  lie  in  the  direction  of  a  repression  of  the  social-democratic  movement,  but  is  to  be 
sought  more  justly  in  the  enactment  of  mutually  satisfactory  measures,  which  will  tend  to 
the  advancement  of  the  welfare  of  the  workman.  We  hold  it  to  be  our  imperial  duty 
to  ask  the  Reichstag  again  to  lay  more  closely  to  their  heart  this  undertaking,  and 
feel  that  God  will  have  blessed  our  reign  more  signally  if  we  could  leave  behind  us  the 
consciousness  that  we  have  given  to  the  humbler  dwellers  in  the  Fatherland,  a  greater 
security  and  independence  of  circumstances,  through  tlie  enactment  of  laws  tending  to 
remedy  the  situation  of  those  who  are  legitimately  in  need  of  assistance.  In  our  efl'orts 
directed  towards  this  purpose  we  are  certain  of  the  agreement  of  all  the  federated  states, 
and  hope  confidently  for  the  support  of  the  Reichstag,  without  consideration  of  individual 
or  party  difl'ercnces.  To  find  the  right  ways  and  means  for  this  provision  is  perhaps 
difficult,  but  it  is  also  one  of  the  highest  of  our  common  duties,  resting  as  it  does,  beyond 
the  domain  of  the  civil  law,  and  on  the  traditional  foundation  of  the  Christian  life  of 
our  people.  It  is  believed  that  a  solution  of  this  problem — which  the  power  of  tlie 
Executive  alone  is  not  sufficient  to  achieve — tcill  be  secured  by  bringing  the  varied 
aolivitics  of  our  national  life  together  into  the  form  of  incorporated  asfiociations  of 
industrial  units  under  the  state  protection  and  control.  I'A-en  by  this  means,  however, 
it  does  not  seem  to  be  possible  to  reach  the  end  of  our  desire  withoiit  making  use  of 
those  methods  which  it  is  within  your  privilege  alone  to  employ;  but  our  imperial 
duties  impel  us  to  neglect  no  agency  at  our  disposal  to  further  the  betterment  of  the 
position  of  the  workman,  and  the  peace  and  contentment  of  the  working  classes,  as 
long  as  God  gives  to  us,  also,  the  strength  to  work." 

It  was  not  until  1893,  that  Chamberlain  took  the  position,  in  advocating 
a  Workmen's  Compensation  Act,  that  many  industrial  accidents  were  altogether 
unavoidable  either  by  employer  or  employe;  that  they  were  phenomena 
inherent  to  industry;  and  that  their  expense  should  justly  be  charged  against 
the  only  factor  in  the  balance  sheet  entitled  to  bear  it — the  cost  of  the  finished 
product.  To  Asquith,  however,  was  attributed  some  years  later  the  apothegm 
that  "the  blood  of  the  workman  is  part  of  the  cost  of  the  product."  These 
utterances,  as  already  noted,  were  foreshadowed  a  decade  before  in  the  Kaiser's 
speeches  from  the  throne,  and  in  the  subsequent  discussions  on  the  floor  of  the 
Eeichstag. 

Although  violently  opposed  by  the  large  manufacturing  interests,  the 
measure  of  1893  failed  of  enactment,  not  because  of  this  novel  position  taken  by 


A  STUDY  OF  C0:NTEMP0RARY  WORiaiEN'S  COMPENSATION.  619 

Cbamberlain  and  Asquith,  but  because  the  radical  element  in  tlie  Commons  very 
justly  refused  to  accept  an  emasculating  clause,  inserted  in  the  House  of  Lords, 
permitting  employers  to  nullify  the  Act  by  contracting  with  employers  to 
renounce  any  rights  which  its  provisions  might  secure  to  them.  Thus,  final 
legislation  was  postponed  until  1897,  when,  a  Tory  government  with  Joseph 
Chamberlain  in  the  lead,  enacted  the  first  experimental  Workman's  Compensa- 
tion Act — the  most  radical  and  yet  the  most  conservative  industrial  law  ever 
passed  in  England.  This  Act  reached  a  certain  limited  number  of  especially 
dangerous  industries,  and  under  it  seven  million  employes  secured  relief. 

Such  experimental  legislation  was  planned  broadly  on  the  lines  of  the 
German  law  of  188-i-5,  and  was  followed  shortly,  as  in  Germany,  by  the  appoint- 
ment of  a  commission  to  inquire  into  the  results  of  its  operation.  A  brief 
survey  of  the  commission's  report  shows  that  although  the  imposition  of  dis- 
ability pensions  threatened  the  employers  with  a  constantly  increasing  burden ; 
and  although  the  enforcement  of  the  act  terminated  their  willingness  to  con- 
tribute to  any  previously  existing  mutual  insurance  scheme,  there  was  very 
little,  if  any,  increase  in  the  cost  of  the  finished  product.  On  the  other  hand, 
it  diminished  very  materially  the  quantity  of  litigation  and  its  cost  to  both 
parties,  and  led,  on  the  whole,  to  a  much  more  friendly  status  between  employer 
and  employe. 

This  report,  and  the  statistics  which  were  collected  after  several  years' 
operation  of  the  Act  of  1897,  served  in  a  large  measure  to  stimulate  further 
legislative  efi'ort  towards  a  more  comprehensive  English  law,  which  would 
not  only  simplify  and  embrace  previous  enactments,  but  which  would  give  to  all 
workmen  the  rights  which,  under  the  law  of  1897,  were  enjoyed  by  only  one- 
half  of  their  number.  But  it  is  more  than  likely  that  this  final  effort,  which 
saw  its  successful  consummation  in  the  recent  Act  of  1906,  was  the  direct  result 
of  a  study  by  Asquith  and  other  English  statesmen,  of  the  Imperial  Industrial 
Code  of  Germany,  of  1900,  which  represents  the  ultimate  and  most  far-reaching 
effort  of  the  Eeichstag. 

It  is  to  be  noted,  however,  that  whilst  the  results  sought  by  both  laws  are 
practically  identical,  the  English  method  of  approaching  their  industrial 
problems  differs  radically  from  that  pursued  by  continental  governments. 
There  is  a  manifest  effort  in  the  English  law  to  adhere  to  the  older  structural 
forms  of  administration,  and  it  bears  less  evidence  of  that  tendency  to  radical 
reconstruction  which  might  lay  it  open  to  the  charge  either  of  paternalism  or 
socialism.  In  these  and  the  following  ways  does  the  English  law  of  1906 
approach  i?iore  nearly  to  a  realization  of  those  methods  by  which  we,  in  this 
country  will,  in  the  near  future,  modify  or  reconstruct  our  own  system  of  deal- 
ing with  industrial  casualties. 

For  example,  compulsory  insurance  has  no  place  in  the  Asquith  Act  of 
1906,  because  a  system  of  Friendly  Societies,  under  supervision  of  a  Ecgistrar's 
office,  was  firmly  implanted  in  Great  Britain  even  before  the  passage  of  the 
Gladstone  Act.  These  societies  have  been  found  to  suppdy  satisfactory  working 
men's  insurance,  especially  when  employers  make  voluntary  contributions  to 
the  society.     Again,  both  the  Chamberlain  and  Asquith  Acts  are  left  to  work 


620  A  STUDY  OF  CONTEMPORAHY  WORKJklEN'S  COMPENSATION. 

themselves  out  automatically  on  their  own  merits,  with  no  especial  machinery 
devised  for  the  purpose  of  carrying  out  their  provisions,  other  than  that  of  the 
trade  committees  and  county  courts  already  in  existence.  These  fimctions  of 
trade  committees  and  county  courts  have  been  expanded  by  the  Act,  so  that 
the  processes  of  settlement  by  arbitration  through  committees  are  more  definitely 
legalized.  Should  no  committee  exist,  either  both  parties  to  the  controversy, 
or,  the  county  courts,  are  empowered  by  agreement  to  appoint  arbitrators,  paid 
by  the  Treasury,  to  decide  claims  for  compensation  brought  under  the  Acts. 
In  the  event  of  agreement  failing,  either  party  to  the  controversy  may  request 
the  judge  of  the  county  court  to  proceed  as  arbitrator,  in  accordance  with  the 
usual  rules  of  liis  court.  Shoxild  the  court  prefer  not  to  serve,  he  is  authorized 
to  appoint  an  arbitrator  in  his  stead.  The  Secretary  of  State  appoints  and 
pays  medical  referees,  and  the  right  of  appeal  from  the  decision  of  such  referees 
is  gi'aiited  in  specified  cases.  Trial  by  jury  is  therefore  abolislied  in  cases 
adjudicated  under  the  provisions  of  these  Acts.  Should  the  employe  elect, 
the  way  is  still  open  to  proceed  against  his  employer  by  civil  suit  under  the 
common  law,  or  under  the  Gladstone  Act  of  1880. 

It  will  thus  be  seen  that  the  Workmen's  Compensation  Act  of  190(5,  is 
intended  to  supplement  rather  than  to  supplant  the  already  existing  legal 
machinery.  In  the  practical  test,  however,  both  workmen  and  employers  have 
come  rapidly  to  a  favorable  opinion  of  the  later  laws,  which  embrace  in  their 
operation  over  thirteen  million  individuals,  or  the  entire  working  population 
of  the  United  Kingdom.  Out  of  3,065  deaths  through  trade  accidents  in 
1904,-''  only  524  were  made  the  basis  of  proceedings  in  the  county  courts;  the 
remainder  were  settled  by  committees  or  arbitrators  under  the  tenns  of  the 
Chamberlaiii  Act.  Twelve  suits  were  brought  for  damages  under  the  Employ- 
ers' Liability  Act  of  1880;  the  remainder  were  claims  for  compensation  under 
the  Workmen's  Compensation  Act.  Out  of  4,333  personal  injury  claims  only 
598  were  brought  before  the  county  courts. 

It  is  at  present  too  early  to  furnish  statistics  of  the  operation  of  the 
Act  of  1906.Q 

III. 

Since  the  Workmen's  Compensation  Act  of  1906  is  the  latest  word  in 
English  law  on  this  subject,  and  may  be  supposed  to  represent  the  best  which 
Anglo-Saxon  industrial  evolution  can  yet  accomplish  for  the  workman,  the  fol- 
lowing brief  generalized  summary  of  its  more  important  provisions  is  offered : 
(See  also  the  previous  section  for  the  details  of  arbitration  or  other  legal 
proceedings). 

5  In  Great  Britain  tliore  are  reported  annually  about  18,000  trade  accidents. 

6  Recent  statistics  show  that  the  total  number  of  judges  for  civil  cases  in  England 
and  Wales  is  92,  for  a  population  of  32,000,000.  As  illustrating  the  enormous  excess 
of  civil  processes  in  this  country,  a  late  report  shows  that  there  are  in  Illinois,  for  a 
total  population  of  about  5,000,000,  216  judges,  besides  justices  of  the  peace  and  federal 
judges — a  veritable  legal  debauch.  These  figures  demonstrate,  more  loudly  than  any 
argument,  the  crying  necessity  for  some  radical  change  in  the  adjudication  of  those 
industrial  claims  which  now  come  before  American  civil  courts  and  juries. 


A  STUDY  OF  CONTEMPORAHY  W0RIO.IEN'S  COMPENSAllON.  621 

Any  workman  sustaining  an  injury  or  contracting  certain  diseases 
in  consequence  of  employment  may  demand  compensation  from  his  em- 
ployer imder  this  Act. 

But,  should  he  choose,  he  may  proceed — if  the  employer  has  been 
guilty  of  personal  or  wilful  negligence — by  civil  suit  under  the  common 
law,  or  under  the  Gladstone  Act;  and  should  he  lose  his  civil  suit  he  may 
still  seek  compensation  under  this  Act  of  1906. 

The  Act  does  not  bar  proceedings  against  employers  to  assess  fines 
for  violation  of  other  laws.  (In  this  respect  the  Act  bears  a  strong  re- 
semblance to  the  laws  of  many  continental  countries.) 

Ample  provision  is  also  made  for  the  adjustment  of  compensation, 
either  by  previous  agreement,  by  arbitration,  or  by  the  stipulations  of 
certain  approved  Friendly  Societies.  Any  employer  and  his  employes 
may  agree  on  an  independent  scheme  of  insurance,  but  such  scheme  must 
have  the  periodical  approval  of  the  Eegistrar  of  Friendly  Societies. 

Arbitrators  are  appointed  by  the  county  couiis;  medical  referees  are 
appointed  by  the  Secretary  of  State.  Their  fees  are  paid  out  of  a  fund 
provided  by  a  separate  Act  of  Parliament. 

Contracts  to  relinquish  claims  for  prospective  personal  injury  are 
void. 

Unless  the  employe  is  seriously  injured,  or  dead,  he  or  his  heirs  can- 
not recover  for  injuries  due  to  wilful  or  flagrant  misconduct. 

Employers  must  make  returns  to  the  Secretary  of  State  of  all  accidents 
and  the  compensations  allowed  therefore. 

Under  certain  conditions  the  formation  of  Trade  Groups  among  em- 
ployers, similar  to  those  existing  in  Germany,  is  optional,  and  may  even 
become  obligatory. 

The  plaintiff's  attorney — if  one  is  employed — has  no  lien  on  the 
amount  recovered,  and  the  county  court  under  whose  jurisdiction  the 
arbitration  takes  place,  decides  his  fee. 

"Workman"  means  any  person  working  continuously  in  the  service 
of  an  employer,  whether  by  way  of  manual  or  clerical  work,  or  otherwise, 
provided  he  earns  less  than  £250  yearly.  Only  those  performing  manual 
labor  are  included  if  their  earnings  are  over  £250,  and  casual  employes, 
police  officers,  out-workers,  and  resident  members  of  the  employer's  family 
are  excluded. 

An  examination  by  a  medical  representative  of  the  employer  is  a  sine 
qua  non  in  all  cases  occurring  under  this  Act.  The  examination  may  be 
repeated,  if  necessary,  at  proper  intervals. 

No  compensation  for  less  thari  one  week's  disability. 

In  case  of  death  through  accident,  the  dependants  of  the  workman 
receive  not  less  than  £150  or  more  than  £300,  the  amoimt  paid  being 
estimated  on  the  basis  of  three  years'  average  wage. 

In  case  of  total  or  partial  disability  the  work-man  receives  up  to  50  per 
cent,  of  his  average  weekly  earning  capacity,  but  not  to  exceed  one  pound 
per  week. 


622  MEDICO-LEGAL. 

The  amount  to  be  paid  for  partial  disability  is  decided  by  the  arbitra- 
tor, after  taking  the  opinion  of  the  medical  referee  and  other  qualified 
experts.  Provision  is  made  for  provision  of  payments  on  request  of  either 
of  the  interested  parties. 

Where  a  weekly  pa3anent  has  been  continued  for  six  months  or  more, 
the  employer  may  elect  to  cancel  the  same  by  pa3Tnent  of  a  lump  sum 
yielding  an  income — if  invested  in  the  National  Debt  through  the  Post 
Office  Savings  Bank — equal  to  75  per  cent,  of  the  annual  value  of  the 
weekly  payment.  This  is  optional  with  the  employer.  Tlie  investment 
of  such  lump  sum  is  optional  with  the  court. 

The  entire  burden  of  these  payments  falls  on  the  employer,  although 
the  emi)lo3^e  may  increase  the  payments  by  approved  insurance,  and  the 
employer  may  protect  himself  by  the  same  method. 

In  case  of  insolvency,  claims  for  compensation  for  personal  injury 
have  a  first  lien  on  the  assets. 

All  death  and  annuity  pajonents  are  made  to,  and  handled  by  the 
county  courts,  and  the  courts  are  empowered  to  administer  and  invest 
these  funds  in  such  manner  as  they  see  fit  in  the  National  Debt  or  the 
Post  Office  Bank. 

Ample  provision  is  made  for  the  enforcement  of  all  the  stipulations 
of  this  Act,  and  for  preference  of  pension  claim  in  case  of  insolvency  of 
the  employer. 

Thus  the  English  law  follows  the  majority  of  continental  laws  in  placing 
the  burden — regardless  of  culpability  for  the  accident — altogether  upon  the  cost 
of  the  product,  via  the  employer.  The  German  law,  as  will  be  seen  in  a  sub- 
sequent article,  recognizes  the  necessity  for  a  more  equitable  distribution  of 
the  burden,  and  charges  a  certain  portion  of  the  ex-pense  for  the  care  of  those 
injured  against  the  sickness  insurance  fund,  to  wliich  the  employe  contributes. 
Under  certain  conditions  the  State  also  contributes  a  percentage  to  these  funds, 
on  the  theory  that  the  State  is  thus  relieved  of  an  otherwise  necessary  charge. 


MEDICO-LEGAL. 

By  E.  S.  McKEE.  M.D., 

CINCINNATI. 
INTERNATIONAL  MEDICAL  ETHICS. 


Boas,  of  Berlin,  has  made  a  suggestion  which  to  us  seems  wise  and  prac- 
ticable, viz.:  that  at  the  oncoming  International  IMedical  Congress  at  Budapest 
this  subject  be  brought  up  for  discussion.  After  the  question  had  been  thor- 
oughly discussed  it  would  then  be  proper  to  appoint  a  committee  to  consider 
the  subject  further,  and  draw  up  a  code  and  submit  it  to  the  leading  societies  of 
the  various  countries  who  could  either  accept,  amend  or  refuse.  The  com- 
mittee could  be  continued  until  a  code  could  be  produced  acceptable  to  all 


MEDICO-LEGAL.  G23 

countries,  and  after  such  a  code  had  been  obtained  it  would  be  held  to  regulate 
the  relation  of  foreign  medical  practitioners  to  one  another.  The  moment  is 
opportune  for  this  work.  Professor  Boas's  first  and  second  contributions  on 
this  subject  are  published  in  Berliner  Aertzehorrespondenz,  1907,  No.  37  and 
Berliner  KUnische  Wochenschrift^  1908,  No.  52. 

LEGAL  INQUIRY  IN  DEATH  FOLLOWING  OPERATION. 

Probably  the  first  legal  inquiry  of  this  kind  in  Scotland  occurred  in 
Aberdeen,  in  February  last.  The  facts  in  the  case  are  that  a  child  who  had  just 
been  operated  on  in  the  Eoyal  Infirmary,  after  the  administration  of  the  anaes- 
thetic had  ceased,  though  still  under  its  influence,  became  sick,  and  died  from 
asphyxiation,  being  unable  to  vomit  up  some  solid  matter  with  which  his 
stomach  was  charged.  The  testimony  was  that  the  proper  instructions  had 
been  given  as  to  food  before  the  operation,  but  the  mother  said  that  she  had 
received  no  special  instructions  as  to  his  feeding,  and  that  the  boy's  dinner, 
which  he  received  two  hours  before  the  operation,  had  consisted  of  beef.  She 
further  stated  that  the  nurse  did  not  ask  her  what  food  the  boy  had  taken 
that  day,  neither  did  the  house  surgeon  or  the  surgeon.  The  surgeons  stated  in 
their  evidence  that  they  did  not  inquire  as  to  what  food  the  child  had  taken. 
The  house  surgeon  testified  that  he  administered  the  anncsthetic,  A.C.E. ;  the 
child  took  it  well.  The  operation  was  quite  simple,  lasting  about  eight  or  ten 
minutes  and  was  very  successful.  About  four  minutes  after  the  cessation  of 
the  administration  of  the  anaesthetic  the  doctor  noticed  that  the  child  was 
doing  badly,  showing  signs  as  if  he  would  vomit.  Eestoratives  were  applied 
and  he  recovered.  This  occurred  a  second,  and  a  third,  time  and  artificial 
respiration  was  resorted  to  and  the  boy's  throat  cleared  out.  Eventually,  how- 
ever, the  symptoms  of  asphyxia  were  so  marked  that  the  operation  of  tracheo- 
tomy was  performed  and  the  boy  vomited  solid  beef,  and  the  surgeon  took  solid 
beef  from  his  throat  and  from  below  the  wound.  The  court  in  addressing 
the  jury  said  that  this  was  a  case  dilTcrent  from  the  usual  class  of  cases  in  con- 
nection with  the  inquiries  under  "The  Fatal  Inquiry  Act."  There  was  no 
fatal  accident  in  the  case,  and  the  reason  why  the  inquiry  was  held  was  that  the 
Lord  Advocate  may  order  an  inquiry  into  any  case  where  death  has  occurred 
under  circumstances  into  which  he  thinks  it  necessary  that  there  should  be 
some  investigation.  Having  reviewed  the  evidence  the  court  concluded  :  "There 
has  been  nothing  disclosed  which  in  any  way  reflects  on  the  management  of 
the  infirmary.  It  is  essential,  of  course,  that  an  institution  of  this  kind,  within 
whose  walls  a  great  and  noble  work  is  being  performed,  should  carry  with  it 
the  confidence  of  the  public  at  large,  and  I  can  only  desire  to  say  that  there 
has  been  nothing  in  this  case  suggestive  that  there  was  any  carelessness  in  the 
way  in  which  the  operation  was  performed,  or  that  reflected  on  the  nuinagomont 
of  the  infirmary  in  any  way."  This  decision  is  especially  grateful  to  our  British 
confreres,  in  view  of  the  stnnd  taken  by  one  of  the  coroners  of  London  on 
holding  inquests  on  deaths  following  operations. 


624  MEDICO-LEGAL. 

MEDICAL  EXPERT  TESTIMONY. 

This  hackneyed  subject  is  probably  going  to  be  improved  in  tlie  near 
future,  New  York  Supreme  Court  Justice  Clearwater,  chairman  of  the  com- 
mittee of  the  New  York  State  Bar  Association,  appointed  to  consider  the  regu- 
lation and  introduction  of  medical  expert  testimony,  has  given  a  concise  state- 
ment of  the  matter  in  the  North  American  Review. 

The  first  of  the  many  existing  evils  named  by  Judge  Cleanvater  is  the 
lack  of  a  standard  as  to  expertness.  He  mentions  other  evils  as  the  giving  of 
partisan  evidence,  contradictory  evidence  of  physicians  in  equally  good  stand- 
ing; unprincipled  self-styled  experts;  trial  judges  who  are  incompetent  to 
pass  on  the  ability  of  experts  or  validity  of  their  opinions ;  payment  of  witnesses 
by  the  litigant  and  consequently  the  employment  of  the  best  experts  by  the 
litigant  with  the  longest  purse;  the  contemptuous  treatment  some  experts 
have  had  at  the  hands  of  unscrupulous  lawyers,  and  most  of  all  trial  judges  who 
have  sought  to  draw  attention  to  themselves  by  their  manner  of  admitting 
evidence  of  bad  quality.  In  order  that  the  ends  of  truth  and  justice  may 
prevail  "the  expert  witness  should  be  free  from  embarrassment,  should  have 
no  clients  to  save  and  no  partisan  opinions  or  interests.  He  should  speak 
judicially  as  an  exponent  of  the  science  of  medicine,  with  full  knowledge  of 
the  highest  authorities  and  of  the  most  recent  investigations  dealiug  with  his 
subject."  "Scientific  opinion,"  says  Judge  Clearwater,  "to  be  of  controlling 
value,  can  be  given  only  under  conditions  of  mental  repose;  a  condition 
seldom  found  in  the  witness  box.  The  ordinary  witness  testifies  to  facts,  the 
expert  to  opinions.  The  expert  should  not  form  his  judgment  from  the 
evidence  of  witnesses  and  should  not  draw  inferences  from  their  statements. 
While  the  hypothetical  question  seems  involved  the  method  pursued  is  scientific 
and  calculated  to  eliminate  the  element  of  error  so  far  as  it  is  possible  to  do  so. 
As  far  back  as  1533,  Henry  VIII  of  England,  in  his  published  Code,  gave 
power  to  appoint  expert  physicians  and  surgeons  for  the  examination  of  injured 
patients  before  the  court."  Medical  expert  testimony  long  has  been  a  necessary, 
and  always  will  be  an  important,  factor  in  the  administration  of  justice.  The 
medical  profession  can  not  do  better  than  to  get  and  read  the  paper  of  Judge 
Clearwater. 

AxciENT  Legal  Regulations  of  Medical  Schools. 

The  TJDiversity  of  Salerno  has  been  the  object  of  study  recently  by  Dean 
Walsh,  of  Fordham  University,  of  New  York.  He  found  there  legal  require- 
ments for  and  of  the  medical  student  and  practitioner  which  were  equal  to  and, 
in  fact,  better  than  what  we  now  have  gained  with  such  effort.  Eobert  Eitter 
von  Topley,  the  well  known  Viennese  historian  of  medicine,  has  only  recently 
published  this  law  in  its  entirety.  The  most  important  of  these  is  the  famous 
law  of  Frederick  II,  king  of  the  two  Sicilies,  who  afterward  became  Emperor 
of  Germany.  The  student  was  obliged  to  follow  three  years'  preliminary  study 
at  a  university,  study  medicine  five  years  and  then  practice  for  one  year  imder 
the  direction  of  a  physician  before  beginning  for  himself.  If  he  expects  to 
practice  surgery,  he  must  study  anatomy  a  year  in  addition  to  this.     He  must 


MEDICO-LEGAL.  625 

exercise  great  care  in  regard  to  the  drugs  he  uses  and  see  that  the  druggist 
supplies  them  in  their  purity.  Regulations  are  added  for  the  druggist,  con- 
stituting the  first  pure  food  law.  Frederick  opened  the  law  with  a  paragraph 
declaring  his  interest  in  the  health  of  his  subjects  and  how  much  that  is 
dependent  on  the  proper  education  of  the  physician.  On  account  of  the  serious 
damage  which  might  result  from  inexperienced  physicians  he  required  that 
each  one  should  pass  a  public  examination  before  a  teacher  of  medicine  in  the 
University  of  Salerno  and  should  have  a  certificate  not  only  from  him,  but  also 
from  a  civil  ofiBcial,  which  declared  his  trustworthiness  of  character  and  suffi- 
ciency of  knowledge.  Violation  of  this  law  to  be  punished  by  confiscation  of 
goods  and  a  year  in  prison.  Every  physician  was  required  to  take  oath  that 
when  it  came  to  his  knowledge  that  any  apothecary  had  for  sale  drugs  less 
than  the  normal  strength  he  should  report  the  matter  to  the  court.  There  is 
scarcely  a  feature  of  our  modern  regulation  of  the  practice  of  medicine  and 
medical  education  that  is  not  contained  in  this  law  of  the  early  part  of  the 
thirteenth  century. 

Eegulation"  of  Peostitdtiojt. 

Frederick  Clift,  M.D.,  of  Provo,  Utah,  ia  a  paper  on  the  "Social  Evil," 
published  in  the  Denver  Medical  Times,  for  August,  1909,  discusses  the  ques- 
tion of  regulation  as  follows.  He  found  that  the  system  of  regulation  had  been 
thoroughly  tried  in  Europe  and  in  many  American  cities.  Everywhere  it  has 
been  tried  there  has  been  a  marked  decrease  in  sexual  diseases,  not  only  among 
sinners,  but  of  still  greater  importance,  among  their  victims.  The  chief  objec- 
tion to  religionists  to  regulation  is  that  it  recognizes  and  affords  security  for 
debauchery.  Those  who  support  regulation  or  license  claim  that  all  diseases 
of  a  contagious  nature,  regardless  of  causation,  are  a  menace  to  the  health  of 
the  people  at  large  and  should,  therefore,  be  brought  under  the  regulation  of 
quarantine.  To  those  who  know,  such  as  physicians,  how  much  damnation  is 
being  stored  up  in  this  world  for  the  innocent,  whether  religionist,  infidel, 
atheist  or  agnostic,  there  is  much  to  be  said  for  this  contention,  but  the  argu- 
ments pro  and  con  would  extend  beyond  the  limits  of  this  paper.  Suffice  it  to 
say,  once  confined  to  certain  districts,  under  efficient  police  restraint,  the  pros- 
titute can  primarily  be  restricted  from  her  worst  effect  upon  the  community: 
that  of  corrupting  the  youth  of  both  sexes.  In  view  of  the  known  and  positive 
dangers  to  which  the  innocent  are  exposed,  I  urge  the  religionists  or  moralists 
and  the  sanitarian  to  make  peace  and  come  together.  Let  them  agree  to  some 
plan  for  the  betterment  of  our  fellow  citizens  and  neighbors,  of  our  sons  and 
daughters — our  own  flesh  and  blood. 

Privileged  Communication  and  the  Accomplice  of  Crime. 

How  far  does  a  physician's  devotion  to  professional  secrecy  render  him 
an  accomplice  to  crime  is  a  matter  of  moment.  The  physician's  course  in  this 
matter  is  often  a  decidedly  hard  one  to  decide.  For  instance,  where  a  servant 
girl  or  nurse  is  afflicted  with  venereal  disease  and  refuses  to  quit  her  job  on 
the  advice  or  command  of  her  physician.  Worse  still  is  the  instance  of  the 
e 


626  AMERICAN  PROCTOLOGIC  SOCIETY  ABSTRACTS. 

diseased  man  or  woman  who  refuses  to  defer  or  quit  altogether  the  matrimonial 
arrangements.  Hard  indeed,  is  it  when  as  has  been  the  ease  in  some  instances, 
well  known,  this  professional  secrecy  affects  the  safety  of  the  physician's  own 
household.  Professional  secrecy  does  not  require  a  physician  to  allow  his 
patient  to  infect  others  with  the  measles  or  mumps.  Why  should  he  allow 
the  patient  with  gonorrhoea  or  syphilis  any  greater  rights.  The  man  who 
visits  a  house  of  prostitution  is,  in  many  cities  and  States,  protected  from 
infection.  Shall  innocent  wives  and  children  not  be  allowed  the  same  protec- 
tion? We  find  a  conflict  between  the  physician's  duty  to  his  patient  and  the 
community  in  those  instances  where  persons  have  responsible  positions,  where 
many  lives,  or  health,  or  morals,  depend  on  persons  pliysically  unfit.  For 
instance,  the  color-blind  railroad  watchman;  or  the  one  subject  to  sudden  death, 
or  syncope,  from  heart  disease,  or  epilepsy,  or  conditions  causing  possible  or 
recurrent  incapacity.  There  is  a  growing  sentiment  that  a  community  has  the 
inalienable  right  to  protect  itself.  Cities  of  refuge  have  long  since  failed  to 
protect  the  criminal;  why  should  questions  of  professional  secrecy  when  other 
lives  or  the  State  at  large  are  endangered?  Privileged  communications  as 
regards  physicians  have  recently  been  very  greatly  modified  with  regard  to 
certain  contagious  diseases  and  it  is  but  a  step  to  further  this  to  other  con- 
tagious diseases.  A  good  means  of  differentiating  is  whether  we  are  aiding  in 
the  punishment  of  a  crime  already  committed,  or  to  avert  the  commitment  of 
one  against  innocent  persons.  The  question  is  very  ably  discussed,  editorially, 
by  the  iVcw  Yorh  Medical  Times  for  August,  1909. 


AMERICAN  PROCTOLOGIC  SOCIETY  ABSTRACTS. 
Reported  by  LEWIS  H.  ADLER,  Jr.,  M.D., 

PHILADELPHIA. 

(Continued  from  September  Issue.) 

"Prdritds  Ani,  Its  Etiology  and  Treatment."  T.  Chittenden  Hill, 
M.D.,  of  Boston,  Mass.,  said  that  he  was  convinced  that  pruritus  ani  was 
practically  always  caused  by  some  local  lesions  of  the  pelvic  colon  or  rectum, 
which  produced  an  unnatural  moisture  about  the  anal  region. 

He  said  the  most  common  sources  of  irritation,  in  the  order  of  their 
frequenc}',  were  as  follows:  (1)  Superficial  ulcerations  and  abrasions  of  the 
anal  canal.  This  lesion  he  found  in  about  75  per  cent,  of  all  cases  and 
attributed  the  frequency  of  its  occurrence  to  tlie  method  of  fusion  of  the 
proctodeimi  with  the  blind  end  of  the  bowel.  (2)  Eectitis  and  sigmoiditis, 
which  are  the  sequelae  of  habitual  constipation,  often  bring  about  a  pruritus, 
since  the  passage  of  flatus  allows  a  small  quantity  of  mucus  to  escape.  (3) 
Hypertrophied  anal  papilliE  and  inflammation  of  the  crypts  of  Morgagni  are 
more  often  the  cause  of  pruritus  ani  than  is  generally  admitted.  (4)  Small 
polyps  of  the  anal  canal,  protruding  internal  piles,  prolapse  of  the  rectum 


AJIERICAN  PROCTOLOGIC  SOCIETY  ABSTRACTS.  627 

and  anal  fissure,  do  occasionally  produce  itching  about  the  anus,  but  it  is 
exceptional  to  find  tbeni  the  sole  cause  of  chronic  pruritus  ani. 

He  stated  that  in  order  to  attain  permanent  results,  it  was  essential  that 
the  treatment  be  directed  to  the  removal  of  the  exciting  causes.  At  the  same 
time  the  sisin  in  the  immediate  vicinity  of  the  anus  should  receive  appropriate 
treatment  since  it  is  nearly  always  in  a  state  of  acute  inflammation  from 
scratching,  or  so  much  infiltrated  and  thickened  as  to  require  stimulating 
applications:  nitrate  of  silver  and  ointments,  in  order  to  bring  about  a  return 
of  a  normal  epidermis. 

"A  CONSIDERATIO^r  OF  THE  PROPHYLAXIS  AND  TREATMENT  OF  CICATRICIAL 

Eectal  Stricture/'  by  Alois  B.  Graham,  A.M.,  M.D.,  Indianapolis,  Ind. 
Opinions  were  based  upon  the  results  obtained  in  the  treatment  of  fifty-five 
cases.  He  stated  that  prophylaxis  implies  a  careful  rectal  examination;  a 
careful  rectal  examination  implies  an  early  diagnosis;  an  early  diagnosis 
implies  correct  treatment,  and  correct  treatment  implies  the  prevention  of  a 
stricture. 

When  cicatricial  rectal  stricture  is  diagnosed,  surgical  intervention  is 
indicated.  In  cases  where  there  is  no  danger  of  infection,  excision  should  be 
the  choice  of  all  the  surgical  measures  at  our  command.  If  successful,  its 
results  are  ideal  because  of  the  fact  that  it  effects  a  cure  by  the  complete 
removal  of  the  stricture.  In  cases  where  it  is  not  safe  to  practice  the  excision 
method  (and  there  are  many  such  cases),  complete  posterior  proctotomy  or 
colostomy,  either  alone  or  combined,  should  be  performed.  While  neither  of 
these  surgical  measures  have  effected  an  authentic  cure,  yet  they  undoubtedly 
can  and  have  effected  a  sjonptomatic  cure.  Gradual  dilatation  should  be 
employed  only  in  cases  of  small  annular  stricture.  The  excision  method 
needs  no  defense  as  its  results  are  all  that  could  be  desired.  As  for  the  other 
surgical  methods,  the  writer  was  not  at  all  pessimistic  as  to  the  results  which  can 
be  obtained,  if  they  are  followed  by  correct  and  systematic  after-treatment. 

'The  Use  of  Spinal  Anesthesia  in  Rectal  Surgery/'  by  Collier  F. 
Martin,  M.D.,  Philadelphia,  Pa.,  who  reported  87  cases  in  which  tropacocaine 
and  stovaine  were  employed.  The  technic  was  given  in  detail.  The  method 
is  not  recommended  where  the  hips  of  the  patient  have  to  be  elevated. 

Of  the  87  cases,  57  were  either  frankly  tubercular  or  the  condition  was 
suspected,  16  were  alcoholics,  4  had  anaemia  with  from  35  per  cent,  to  60  per 
cent,  of  haemoglobin,  2  had  sepsis,  2  cachexia,  2  were  suffering  from  general 
debility  and  old  age,  3  had  cardiac  complications  and  1  refused  to  take  ether. 

The  conditions  operated  upon  were  as  follows:  abscess  and  fistuhc,  54; 
haemorrhoids,  21;  rectal  stricture,  2;  sacral  sinus,  1;  fissure  with  fistula,  2; 
gangrenous  cellulitis,  2;  anal  condylomata,  2;  rectal  carcinoma  (perineal 
excision),  2;  and  Ball's  operation  for  pruritus  ani,  1. 

The  only  complications  observed  were  headache  18  times,  coming  on  from 
1  to  3  daj's  after  operation.  Only  three  cases  had  severe  headache  lasting  over 
one  or  two  days.  A  few  cases  complained  of  some  stiffness  of  the  back  of  the 
neck  and  shoulders.     One  patient  developed  a  temporary  oculo-motor  paljy 


628  AIvIERICAN  PROCTOLOGIC  SOCIETY  ABSTRACTS. 

which  recovered  under  treatment.  In  two  cases,  spinal  fluid  was  not  obtained 
because  of  the  difficulty  in  inserting  the  needle  with  spinal  deformity  present. 

Spinal  ana'stliesia  was  selected  in  cases  with  pulmonary  tuberculosis  to  avoid 
the  congestion  following  the  use  of  ether.  x\lcoholics  were  also  found  easier 
to  manage  than  when  ether  was  used. 

Under  spinal  anesthesia,  the  sphincters  are  completely  relaxed,  there  is  no 
muscular  spasm,  and  there  is  an  entire  absence  of  the  venous  engorgement  and 
swelling  of  the  tissues  so  often  seen  while  the  patient  is  under  ether.  Bleed- 
ing is  not  as  profuse  and  is  more  easily  controlled,  since  all  parts  of  the  rectal 
cavity  are  as  accessible  as  their  anatomy  will  permit.  The  complete  mus- 
cular relaxation  reduces  the  traumatism  to  the  tissues. 

Spinal  ana3sthesia  is  at  its  best  when  used  in  operations  about  the  rectum 
and  genito-urinary  tract.  Careful  selection  of  cases,  drugs  of  uniform  strength 
and  purit}'-,  and  a  careful  technic  will  do  much  to  re-establish  the  confidence  of 
the  surgeon  in  this  method  of  producing  anesthesia. 

''Yaqin^i.  A-nxjs  in  the  Adult,  With  Eeport  of  Two  Cases/'  by  Louis 
J.  Hirschman,  M.D.,  Detroit,  Mich.  Dr.  Hirschman  reported  two  cases  of 
imperforate  anus  with  the  anomalous  opening  occurring  in  the  lower  part  of  the 
vagina,  both  occurring  in  adults.  He  successfully  operated  in  both  case*, 
restoring  the  anal  outlet  to  its  normal  position  with  a  good  functional  result 
in  both  cases.  His  first  case  was  aged  25,  unmarried,  and  until  a  few  months 
before  examination  did  not  know  that  she  was  anatomically  difiierent  from 
other  young  women.  She  was  brought  up  by  a  maiden  aunt  who,  while 
realizing  that  her  charge  was  not  normal,  felt  that  as  long  as  she  was  having 
regular  bowel  movements,  she  would  put  off  any  operative  interference  until 
later  in  life. 

The  operation  in  this  case  consisted  in  closing  the  vaginal  anal  orifice 
after  dissecting  the  rectum  free  from  the  vaginal  septum.  There  being 
present  an  infantile  sphincter  muscle  at  the  nonnal  anal  site,  an  incision  was 
made  through  the  center  of  this,  and  by  blunt  dissection  the  tissues  between  it 
and  the  blind  end  of  tlie  rectum  were  separated.  The  rectum  was  then  pulled 
down,  opened  and  sutured  to  the  integument.  The  perineum  was  not  split 
open  nor  was  the  sphincter  divided.     A  good  functional  result  followed. 

His  second  case  was  also  unmarried,  23  years  of  age.  The  case  was  very 
similar  to  Case  I  except  that  there  was  an  over-development  of  the  sphincter 
vaginae  which  gave  her  good  fsecal  control.  There  was  present  in  this  case  a 
small  fistula  connecting  the  anus  and  vulva  but  not  commimicating  with  the 
rectum.  In  this  case  the  perineum  was  split  and  the  fistula  dissected  out. 
The  vaginal  anus  was  dissected  free  and  brought  down  to  the  normal  anal  site 
in  a  manner  similar  to  that  pursued  in  Case  I.  The  perineum  was  then 
repaired  as  in  an  ordinary  perineorrhaphy.  The  functional  result  in  this  case 
was  also  good.  The  author  concludes  from  his  experience  with  these  two 
cases,  and  realizing  the  very  high  mortality  from  operations  for  imperforate 
anus  in  infants,  that  where  there  is  some  abnormal  outlet  for  the  fasces 
present,  it  is  far  better  to  allow  patients  to  go  on  in  their  abnormal  condition 


AMERICAN  PROCTOLOGIC  SOCIETY  ABSTRACTS.  629 

until  they  grow  old  and  strong  enough  for  surgical  interference  and  the  cor- 
rection of  nature's  failure. 

"Fistula  in  the  Postekior  Anal  Commissure/'  by  J.  Coles  Brick, 
M.D.,  Philadelphia,  Pa.,  who  stated  that  the  anatomy  of  the  posterior  anal 
commissure  is  of  such  peculiar  arrangement  that  ulcers  or  fistulas,  in  this 
region  frequently  do  not  granulate  in  a  proper  manner. 

The  greater  part  of  the  external  sphincter  muscle  arises  from,  the  coccyx, 
and,  after  forming  the  ano-coccygeal  body  of  Symington,  passes  around  the 
anus,  forming  a  Y-shaped  or  triangular  cul-de-sac  at  the  posterior  anal  com- 
missure, making  this  the  weakest  part  of  the  anal  circumference.  The  levator 
aui  muscle  is  separated  from  the  coccygeous  muscle  by  a  cellular  interspace, 
rendering  possible  an  easy  extension  of  pyogenic  organisms. 

In  ulcerations  or  small  fistulas  in  the  posterior  anal  commisi?ure,  it  is 
the  writer's  custom  to  make  a  triangular  incision  with  the  apex  toward  the 
anus,  rather  than  an  antero-posterior  cut.  In  cases  of  fissure  in  this  com- 
missure, two  incisions,  one-eighth  of  an  inch  deep,  are  made  down  into  the 
sphincter  muscle  on  each  side  of  the  fissure,  all  fibrous  tissue  being  removed 
from  the  fissure  itself. 

The  physiological  action  is,  that,  during  defecation,  the  lateral  fibers  of 
the  sphincter  forming  the  triangular  space  are  at  rest,  due  to  their  division; 
thus  saving  distention  of  this  space,  and  consequently  no  interference  with 
healing. 

"Modified  Technic  in  Eesection  op  the  Eectum  "  by  J.  Eawson 
Pennington,  M.D.,  Chicago,  111.  Numerous  illustrations  were  shown  by  the 
author,  intended  to  serve  as  demonstrations  designed  and  employed  by  him- 
self and  Dr.  Gronnerud  in  resection  of  the  rectum  in  a  special  case.  The 
growth  for  which  the  method  was  employed  extended  upward  from  the  upward 
border  of  the  levator  ani  muscle  for  about  two  and  one-half  inches. 

A  perineorrhaphy  was  first  done,  splitting  the  recto-vaginal  septum  back  to 
Douglas's  cul-de-sac.  The  rectum  was  then  dissected  from  its  lateral  and 
posterior  connections  upward  until  it  could  be  pulled  downward  far  enough 
to  effect  an  end-to-end  anastomosis,  when  the  section,  including  tlie  growth, 
was  removed. 

The  incision  was  closed  with  buried  catgut  sutures,  and  silkworm-gut  for 
the  skin.  The  posterior  vaginal  flap  covering  up,  as  it  did,  the  operating 
field,  prevents  the  urine,  vaginal  and  uterine  secretions,  from  coming  in  con- 
tact with  the  wound. 

"Abdominal  Massage  in  the  Treatment  op  Chronic  Constipation, 
etc.,  by  T.  L.  Hazzard,  M.D.,  M.S.,  Pittsburgh,  Pa.  The  writer  referred  to  the 
fact  that  general  massage  had  been  practiced  from  very  ancient  times  until 
the  present  for  the  relief  of  fatigue  and  for  the  purpose  of  increasing  the 
flow  of  fluids  in  the  blood-vessels,  the  lymph  spaces  aud  juice  canals,  by  which 
more  perfect  elimination  of  waste  is  obtained  and  better  assimilation  brought 
about.    Two  conditions  whicli,  in  his  opinion  the  relief  of,  will  do  away  with 


630  AJ^IERICAN  PROCTOLOGIC  SOCIETY  ABSTRACTS. 

two-thirds  of  the  slight  ailments  as  well  as  of  some  of  the  more  serious  ones. 
He  began  massage  for  the  relief  of  chronic  constipation  and  was  much 
surprised  to  find  the  far  reaching,  adventitious  effects  produced.  Among 
others,  for  example,  that  the  chalky  deposit  in  the  joints  in  articular  rheuma- 
tism under  careful,  patient,  persistent  manual  therapeutics,  as  applied  to 
the  bowels,  will  entirely  disappear  more  often  than  not. 

Mentioned  no  particular  method,  saying  that  any  good  text-book  would 
give  the  technic  sufficiently  well.  This  manipulation  is  recommended  not 
only  for  chronic  constipation,  but  also  for  the  relief  of  coprostasis  for  which 
operation  it  is  very  frequently  done. 

Alter  indicating  more  of  the  benefits  and  some  of  the  dangers  of  the 
method,  the  writer  said  that,  if  this  treatment  called  for  more  time  than  the 
physician  or  surgeon  could  spare,  it  had  better  be  left  off  altogether,  although 
the  patient  would  surely  lose  a  very  great  benefit.  The  paper  closed  with  the 
remark  that  doubters  as  to  the  very  great  advantages  which  will  accrue  to 
the  sick,  in  many,  many  ailments,  have  but  to  practice  careful  and  intelligent 
massage  to  be  convinced. 

"Tubercular  Fistula  with  Extensive  iNriLTRATicisr  with  Specimen" 
Exhibited/'  by  Samuel  T.  Earle,  M.D.,  Baltimore,  Md.,  who  reported  a  case  of 
tubercular  ischio-rectal  fistula,  which,  on  the  skin  surface,  resembled  an  acute 
inflammatory  condition  ready  to  break  down,  yet  when  opened,  it  proved  to  be 
a  dense  mass  of  fibrous  tissue  v/ith  only  a  few  tracts  of  necrotic  tissue  running 
through  it. 

The  patient  was  a  policeman,  age  forty-five;  robust  and  of  a  ruddy  color; 
weighing  180  pounds;  no  cough,  no  history  of  pulmonary  trouble.  Patient 
admitted  to  hospital,  December  29,  1906. 

The  left  buttock  was  very  much  swollen  and  inflamed;  there  were  several 
fistulous  openings  on  its  surface,  which  could  not  be  followed  far  beneath  the 
skin,  and  there  was  one  of  them  that  opened  just  to  the  right  of  the  anterior  com- 
missure into  the  anal  canal.  Upon  laying  open  the  buttock  between  two  of 
the  openings,  there  was  exposed  a  mass  of  white  fibrous  tissue  that  seemed  to 
be  encapsulated,  except  at  points  which  apparently  were  necrotic,  which  was 
adherent  to  the  subcutaneous  tissue.  Supposing  it  to  be  a  tumor,  which  had 
broken  down  in  places,  an  incision  was  made,  on  either  side  near  each  lateral 
border,  for  the  purpose  of  removing  it,  which  was  done.  The  mass  measured 
6x3x2  inches. 

It  ran  down  to  and  some  went  between  the  muscles  of  the  buttock,  and  in 
one  or  two  instances  involved  the  same.  The  tract  from  the  inner  margin  of 
the  mass  to  the  opening  in  the  anal  canal  was  tlien  laid  open  and  packed  with 
gauze.  The  cavity  left  was  so  large  that  sutures  were  introduced  to  draw  the 
edges  partially  together,  tmd  to  hold  in  the  packing.  These  were  supplemented 
by  adhesive  strips. 

After  the  mass  was  removed,  it  was  found  to  be  composed  principally  of 
fat,  with  here  and  there  a  sinus  which  was  surrounded  by  dense  fibrous  tissue 
from  one-quarter  to  one-half,  inch  thick,  and  there  were  found  several  large 


PERSONAL  OBSERVATIONS  OF  A  CASE  OF  PARALYSIS  AGITANS.       631 

larva,  supposedly  of  flies,  deep  down  in  the  sinuses  of  the  growth.  The  taper- 
ing, tail-like  process,  that  extended  over  the  trochanter  major,  was  composed 
principally  of  muscle. 

Upon  microscopical  examination,  the  growth  proved  to  he  tubercular. 
The  patient  made  a  slow  but  complete  recovery.  The  large  cavity  filled  in 
completely.     The  patient  is  now  perfectly  well  and  robust. 


PERSONAL  OBSERVATIONS  OF  A  CASE  OF  PARALYSIS  AGITAl^IS  (SHAKING 
PALSY)  PARKINSON'S  DISEASE,  WITH  MULTIPLE  COMPLICATIONS. 

By  T.  G.  STEPHENS,  M.D.,  Ph.D.- 

The  patient's  name  is  Jeremiah  Thomas,  101st  Illinois  Vol.  Inf.,  IT.  S.  A., 
pension  claim  No.  89,5G5;  enlisted  August,  1863;  discharged  1865;  a  victim  of 
paralysis  agitans.  The  disease  made  its  appearance  soon  after  being  shot 
through  the  left  thigh  and  exposure  to  cold  during  a  campaign  through  Georgia 
in  time  of  the  Civil  War,  186-.  The  march  of  the  disease  and  its  complications 
have  been  very  slow.  Nothing  of  a  hereditary  or  neurotic  taint  can  be  deter- 
mined from  his  ascendants  or  decendants.  At  the  age  of  twenty-one  years  he 
enlisted  in  the  army,  was  five  feet  eleven  inches  in  height,  stood  erect;  is  now 
five  feet  two  inches,  semiflexed;  weighed  on  an  average  until  the  last  twelve 
months  185  pounds;  has  lost  twenty  pounds.  Rosenthal  says  among  the  causes 
of  paralysis  agitans  we  may  mention  debilitating  diseases  and  the  prolonged 
action  of  cold,  mental  shocks,  fright,  which  during  the  first  ten  years  of  life 
may  in  predisposed  individuals  cause  paralysis  agitans  (shaking  palsy)  at  a  more 
advanced  age.  The  disease  represents  the  most  severe  form  of  tremor,  and  was 
first  discovered  by  Dr.  Parkinson,  an  English  author,  in  an  essay  on  shaking 
palsy  in  1817,  describing  the  disease  under  the  name  of  shaking  palsy,  belonging 
in  the  group  of  affections  characterized  by  tremor  rather  than  among  the 
paralytic  affections.  The  gravity  of  this  results  from  its  intensity  and  from  its 
continuous  progress,  extension,  and  termination  in  general  paralysis.  It  has  no 
anatomical  characters  as  yet  discovered.  From  clinical  histories  belongs  under 
the  category  of  disseminated  sclerosis.  Paralysis  is  a  classic  word  and  compre- 
hends adjectively  several  varieties,  a  case  of  which  is  mentioned  in  antiquity. 
Jeroboam,  King  of  the  Ten  Tribes,  976  B.C.,  had  paralysis  of  one  hand. 

The  different  varieties  of  tremor  are  produced  by  different  cau.^es  and  have 
different  characteristics,  a.  In  senile  trembling  not  alone  the  limbs  but  espe- 
cially the  head  is  agitated  by  constant  trembling  movements;  furthermore,  the 
former  is  not  accompanied  by  neuralgic  pains.  We  have  the  characteristic 
muHculnr  stiff'ness,  the  deformity  of  the  hands,  or  the  tendency  to  movements 
of  propulsion  or  recoil. 

fe.  Alcoholic  tremor  is  characterized  by  the  excited  condition  of  the  patient 
by  delirium ;  is  presented  with  all  kinds  of  imaginary  visions,  and  by  the 
dissemination  of  the  tremor  under  the  influence  of  stimulants. 


632       PERSONAL  OBSERVATIONS  OF  A  CASE  OF  PARALYSIS  AGITAl^S. 

c.  Mercurial  tremor  is  almost  always  preceded  by  salivation,  ulceration  in 
the  throat,  swelling  of  the  gums,  foetid  breath,  diarrhoea,  loss  of  appetite,  and 
exhaustion. 

d.  Lead  tremor  is  characterized  by  the  previous  occurrence  of  lead  colic, 
arthralgius,  the  condition  of  the  mouth,  muscular  paresis,  and  partial  abolition 
of  electro-muscular  contractility  in  the  extensors  of  the  arms. 

e.  The  tremor  of  the  opium  eaters  is  accompanied  by  the  following  symp- 
toms: livid  color  of  the  face,  dull  expression  of  the  eyes,  markedly  contracted 
pupils,  considerable  emaciation,  obstinate  constipation,  loss  of  appetite,  tendency 
to  vertigo  and  gloomy  forebodings. 

The  prognosis  of  paralysis  agitans  is  unfavorable.  Strumpell  says  recovery 
has  never  been  observed.  Men  are  more  prone  to  shaking  palsy  than  women. 
It  does  not  often  occur  until  after  forty  years,  but  cases  have  been  reported  in 
which  the  disease  appeared  about  the  twentieth  year.  Drawing  near  as  we  now 
are  to  the  details  of  our  subject,  paralysis  agitans,  we  will  make  mention  of 
several  of  its  complications  in  the  present  case. 

1.  The  first  complication  was  ischiatic  neuralgia,  coming  on  with  a  mild 
prodromata,  and  slowly  increasing  in  intensity  with  remissions,  followed  fre- 
quently by  long  intermissions  for  years,  and  meteorology;  seemed  to  have  a 
predilection  for  the  sciatic  nerve.  This  was  the  condition  until  about  sis  years 
ago  when  the  disease  became  more  intense  and  continuous. 

2.  During  the  time  of  the  War  of  the  Kebellion  in  America  he  contracted 
measles,  leaving,  as  a  sequelae,  catarrhal  pneumonia,  which  still  persists,  with 
dyspnoea,  cough  and  copious  expectoration.  Eecently  I  sent  a  specimen  of  the 
sputum  to  the  bacteriologist  of  the  State  Board  of  Health  for  examination, 
who  reported  tubercle  bacilli,  negative. 

3.  For  a  number  of  years  the  soldier  has  been  suffering  from  chronic  cystitis. 
I  will  now  give  a  full  and  correct  analysis  of  his  urine: 

Report  on  the  Examination  of  Urine. 

Physical — Amount  in  24  hours,  1476  c.c.  Appearance:  Cloudy.  Color: 
Amber.  Sediment:  Much;  brown.  Specific  Gravity:  1,034.  Mucus:  Much. 
Odor:  Ammoniacal.     Total  Solids:   118.83  Gm. 

Chemical — Reaction:  135  degrees  acid.  Urea:  36.9  Gm.  in  24  hours. 
Uric  Acid:  1.4  Gm.  Phosphates:  3.G  Gm.  Chlorides:  15.8  Gm.  Indican: 
Much;  red.     Albumin:   0.012  per  cent. 

^Microscopical — Epithelia:  Many.  Vesical  ureter.  Pus:  Many.  Casts: 
None. 

We  now  pass  to  the  motor  functions.  The  muscles  of  the  limbs,  trunk, 
and  most  frequently  of  the  neck,  are  rigid,  and  he  experiences  in  them  a  sensa- 
tion of  cramp ;  his  voluntary  are  stiff  and  slow.  If  tonic  tension  predominates 
and  the  flexors  of  the  neck  and  trunk  are  inclined  forwards  in  the  vertical  posi- 
tion the  upper  limbs  assume  a  semiflexed  position.  The  thumb  is  adducted  and 
directed  towards  the  palm  of  the  hand,  the  movements  of  the  phalangeal  and 
carpal  articulations  are  markedly  interfered  with  and  the  patient  is  unable  to 


PELLAGRA. 


633 


carry  his  hand  backwards.  In  walking, 
the  body  inclines  towards  the  hemi- 
paretic  side.  He  now  has  flexion  of  the 
first  phalanges,  forcible  flexion  of  the 
second  phalanges  and  slight  flexion  of 
the  third.  The  gait  precipitate  and 
uncertain.  Savage  and  Sagas  have 
mentioned  as  a  pathogenic  sign  tendency 
to  rim  and  fall  forwards  and  backwards, 
which  is  true  in  the  present  case  for  the 
last  fourteen  years  necessitating  me- 
chanical assistance  and  is  caused  by  an 
efiort  which  the  patient  makes  to  main- 
tain his  center  of  gravity  in  the  base;  is 
unable  to  feed  himself;  has  frequent 
and  severe  attacks  of  gastralgia;  has 
pains  in  his  left  side  and  left  eye,  the 
vision  of  which  is  very  imperfect. 

As  to  the  treatment  since  the  pa- 
tient came  under  my  observation  over  a 
decade  ago,  it  has  been  palliative  and 
hygienic :  For  the  sciatica,  aspirin ;  for 
the  dyspnoea,  glonoin;  for  the  cough, 
heroin;  for  the  cystitis,  arbutin  and 
hyoscine  hydrobromate.  His  tremor  has 
always  been  so  strong  and  general,  that 

we  have  not  been  able  to  use  the  methodical  mode  for  his  gastralgia- 
occasional  dose  of  morph.  sulph.  hypodennatically. 


-an 


Editorial 


PELLAGRA, 

Recently  earnest  thought  and  consideration  has  been  given  to  pellagra. 
Our  brief  experience  with  this  disease  in  this  country  has  not  brought  out  all 
the  exact  information  concerning  it. 

Pellagra  is  an  endemic,  constitutional  affection,  characterized  by  severe 
gastro-intestinal  and  nervous  disturbances  and  accompanied  by  cutaneous 
symptoms.  The  disease  has  occurred  most  commonly  in  Lombnrdy,  the  south 
of  France  and  Spain,  especially  among  the  poorer  classes  in  tlio  country  dis- 
tricts where  the  meal  of  maize  is  largely  used.  A  study  of  the  disease  in  the 
United  States  has  thus  far  shown  that  it  is  widely  distributed  throughout  the 
south  and  is  present  in  some  localities  in  the  north.  The  disease  makes  its 
appearance  upon  the  skin,  and  any  portion  of  it  may  be  involved.     The  face. 


634  PELLAGRA. 

neck,  arms,  shoulders  and  legs,  all  of  which,  among  certain  classes  in  the 
countries  where  it  is  prevalent,  are  hahitiially  unprotected  from  the  sun  suffer 
most  severely.  Among  other  predisposing  factors  are:  insufEcient  food, 
unsanitary  surroundings,  worry,  mental  depression  and  alcoholism.  It  begins 
almost  as  an  erythema  in  the  spring  of  the  year.  The  epidermis  becomes  pain- 
ful, and  may  peel  off  m  large  patches.  Vesicles  and  bullre  may  also  fonn. 
There  is  very  little  fever.  In  the  cases  in  which  there  is  most  extensive 
erythema,  grave  constitutional  disturbances  are  observed  such  as  hallucina- 
tions, convulsions,  hypertrophy  of  the  nails  and  foetid  breath.  The  mental 
involvement  is  considered  serious  and  these  cases  are  usually  regarded  as  the 
most  hopeless. 

Dr.  C.  H.  Laviuder  of  the  United  States  Health  and  Marine  Hospital 
Service  has  recently  published  a  review  of  the  subject  in  the  Public  Health 
reports  of  September  10,  1909.  He  states  that  tlie  prognosis  must  invariably 
be  considered  grave,  as  complete  recovery  can  seldom  be  assured.  Since  un- 
hygienic surroimdings  play  a  part  in  the  causation  of  this  affection,  it  is 
easily  seen  why  prophjdaxis  should  play  an  important  part  in  the  treatment 
of  this  disease.  Reliable  statistics  on  the  subject  in  the  United  States  are 
practically  limited  to  asylum  cases  and  give  a  mortality  of  G7  per  cent.  It 
must  be  borne  in  mind,  however,  that  asylum  cases  are  undoubtedly  the  more 
advanced  and  hopeless  and  for  that  reason  will  give  a  mortality  much  above 
the  average.  Lombroso  gives  statistics  of  hospital  cases  in  Italy  in  1883  and 
in  1884,  showing  a  mortality  of  13  per  cent.,  whei-eas  Wollenberg  gives  Italian 
statistics  for  1905  showing  a  mortality  of  a  little  over  4  per  cent.  The  disease 
resembles  tuberculosis,  both  in  that  it  is  an  insidious  and  chronic  condition, 
and  that  much  depends  upon  early  diagnosis  and  treatment,  prognosis  of  early 
cases  being  far  better  than  advanced  ones.  The  importance  of  this  is  apparent 
when  it  is  considered  that  the  disease  is  an  autointoxication;  it  is  probably 
associated  with  diseased  corn  products  used  as  food.  On  this  account  maize 
should  be  given  very  cautiously. 

In  Italy  laws  have  been  passed  regulating  the  use  and  storing  of  corn  and 
its  derivatives,  institutions  have  been  established  for  the  care  and  treatment  of 
pellagra,  improved  agricultural  methods  are  encouraged,  and  assistance  is  given 
to  the  sick  in  many  ways  by  the  government. 

Concerning  the  medical  treatment  of  the  disease,  we  must  certainly  admit 
that  we  have  no  specifics.  Lombroso  recommends  a  liberal  diet,  including 
meats  especially,  but  points  out  tliat  this  alone  is  insufficient.  In  some  cases 
he  uses  baths  and  cold  douches,  believing  them  to  be  of  benefit  in  certain 
cases  with  nerve  and  skin  manifestations.  He  also  thinks  that  arsenic  is  a 
valuable  remedy  and  that  it  acts  in  a  certain  sense  as  an  antidote  for  the 
toxins  of  the  spoiled  maize,  to  which  he  attributes  the  disease.  Sodium 
chloride  is  also  of  service. 

Some  authors  have  reported  good  results  from  the  use  of  the  newer 
arsenical  preparations  of  atoxyl  and  soamin.  Transfusion  of  blood  from 
cured  cases  to  the  sick  has  been  tried  and  may  later  on  prove  its  value  more 
definitely. 


ADRENALIN  IN  TABETIC  CRISES. 


CALCIUM  SALTS  IN  EPILEPSY.      635 


Jlateria  Jledica  and  Therapeutics 


ADRENALIN  IN  TABETIC  CRISES. 
Dr.  Eoelimer  has  employed  adrenalin 
with  good  results  in  five  cases  of  tabetic 
crises.  In  three  of  these  the  crises  were 
of  gastric  nature,  in  one  case  a  rectal 
crisis,  and  in  tlie  fifth  case  a  laryngeal 
crisis  with  a  gastric  complication.  The 
dose  in  the  gastric  crises  consisted  of 
from  four  to  six  drops  of  a  one-per-cent. 
adrenalin  solution  in  20  cubic  centi- 
meters of  water,  which  was  administered 
per  03.  In  the  rectal  crisis,  after  a  pre- 
vious irrigation  of  the  rectum,  from  three 
to  five  drops  in  20  to  40  cubic  centuneters 
of  water  was  administered  per  rectum. 
These  doses  were  given  three  times  a 
day.  Under  the  influence  of  this  medi- 
cation Eoehmer  observed  the  disappear- 
ance of  pain,  nausea,  and  vomiting  in 
four  of  his  five  cases.  This  action  set  in 
after  fifteen  to  thirty  minutes  and  con- 
tinued for  several  hours.  After  the  ad- 
ministration of  adrenalin  three  times  a 
da)',  the  attack  ceased  entirely.  In  the 
fifth  case  there  was  also  a  mitigation  of 
all  the  S3T3iptoms,  but  the  person  under 
treatment  became  impatient  and  de- 
manded an  injection  of  morphine,  with 
the  action  of  which  he  was  familiar. 
(Semaine  Medicale,  1909,  No.  2,  p.  20.) 


ARTHRITIS,  SEVERE,  TREATMENT  OF. 

Dr.  A.  Schawlow  speaks  highly  of  the 
beneficial  efi'ects  of  sulphur  waters,  in 
combination  with  massage,  g}'mnastics, 
stasis  and  electricity,  in  the  treatment  of 
the  chronic  forms.  Acute  articular  rheu- 
matism is  usually  cured  l)y  thirty  batlis, 
though  the  same  number  of  baths  and 
more,  taken  at  home  may  liave  no  effect. 
In  arthritis  deformans  and  clironic  ar- 
ticular   rheumatism,    the    treatment    is 


naturally  extended  over  a  longer  period, 
though  the  good  efi'ects  do  not  admit  of 
dispute. 

The  third  group  includes  chronic 
progressive  arthritis,  a  much  more  seri- 
ous disease,  which  is  not  influenced  by 
the  salicylates  and  which  progressively 
affects  all  the  joints  and  is  often  fatal. 
In  certain  respects  it  resembles  the 
gonorrhoeic  form,  but  no  specific  germs 
have  yet  been  discovered.  The  gouty 
joint  affections  are  included  by  the 
author  in  a  fourth  group. 

Fibrolysin  injections,  especially  in  the 
more  chronic,  progressive  type,  have 
been  found  a  most  valuable  adjuvant  in 
the  treatment,  and  have  brought  about 
remarkable  results  when  all  the  other 
measures  failed.  As  a  rule,  30  injections 
of  2.3  cubic  centimeters  each  were  given, 
one  daily,  into  the  gluteal  muscles.  Im- 
provement was  generally  noticed  only 
after  the  twentieth  injection.  No  after- 
effects were  observed,  except  in  a  few 
cases  a  slight  diarrhoea.  Even  patients 
with  valvular  disease  and  lung  trouble 
stood  the  injections  remarkably  well. 
The  swelling  of  the  joints  disappears,  the 
active  and  passive  mobility  returns,  and 
a  most  marked  change  in  the  general  con- 
dition can  be  noticed.  Fibrolysin  acts  as 
a  lymphagogue,  increases  the  hyperemia 
and  stimulates  chemotaxis.  As  a  conse- 
quence the  firm  connective  tissue  will  l^e 
softened.  (Deutsch.  med.  Woch.,  IDOi^), 
No.  14.) 


CALCIUM    SALTS   IN   EPILEPSY. 

Dr.  A.  P.  Ohhnacher,  Detroit,  has 
hitherto  refrained  from  publishing  his 
remarkable    success    following   his    first 


636 


C-lXTHAMDfJS  IN  NEPHRITIS. 


choline:  in  aneaial  tissues. 


trial  of  the  calcium  salts  in  epilepsy,  but 
now  since  Littlejohn  {Lancet,  May  15, 
1909,  p.  1382)  has  reported  results  with 
tlie  same  agent,  he  vashes  to  supplement 
it  with  his  case.  It  was  a  child  four 
years  and  four  months  old,  with  no 
heredity  of  epilepsy,  in  whom  the  disease 
had  begim  and  continued  from  a  month 
after  his  third  birthday.  When  first  seen 
he  was  having  from  o-i  to  73  attacks  a 
month  and  his  mental  growth  had  appar- 
ently stopped. 

The  grand  mal  attacks  as  seen  by  Ohl- 
macher  were  very  severe  but  never  became 
the  typical  full  status  epilepticus.  The 
child  had  frequent  nosebleed  follow  these 
attacks  and  its  nurse  asserted  that  she 
could  detect  the  odor  of  blood  on  the 
breath  during  convulsions  and  prior  to 
the  appearance  of  actual  ha3morrhage. 
At  the  time  Ohlmacher  had  been  working 
on  therapeutic  immunization  where  the 
problem  of  blood  coagulability  presented 
itself,  and  he  had  employed  Wright's 
method  of  measuring  the  time  of  blood 
coagulation  and  of  using  calcium  salts  to 
fortify  a  defective  coagulability.  Ac- 
cordingly, when  his  attention  was  called 
to  the  haem.orrhages,  he  made  a  blood- 
clotting  test  and  finding  that  it  was  slow 
in  clotting,  he  began  giving  calcium  lac- 
tate in  doses  of  seven  to  ten  grains  dis- 
solved in  hot  water  and  added  to  the 
milk  three  times  a  day.  This  medication 
has  been  continued  from  this  first  begin- 
ning, on  June  2,  1907,  with  no  change, 
except  occasionally  reducing  to  one  r\v 
two  doses  daily,  to  the  present  time. 
The  coagulation  time  was  soon  reduced 
to  normal  and  since  the  cessation  of  the 
epilepsy,  three  months  after  commencing 
the  calcium  lactate,  the  child  has  had 
occasionally  nasal  haemorrhages  appar- 
ently related  to  periods  of  lowered  coag- 
ul:^bilit5\  At  the  time  he  began  the 
medicine  McCallum's  obseiTation  on  cal- 


cium metabolism  as  related  to  para- 
thyroid intoxication  and  to  tetany  had 
not  been  published,  nor  had  Carle's  paper 
on  calcium  chloride  in  therapeutics  ap- 
peared. Incomplete  observations  on  sev- 
eral additional  cases  similarly  treated 
tend  to  confirm  the  favorable  results  with 
the  first  case.  (Journal  American  Medi- 
cal Association,  August  14th.) 


CANTHAEIDES   IH  ACUTE  NEPHRITIS. 

Dr.  E.  Lancereaux  has  employed  this 
remedy  in  acute  parencm-matous  nephri- 
tis with  oliguria  and  anuria  respectively. 
To  children  he  administers  one  drop ;  to 
adults  five  to  six  drops  of  the  tincture  of 
cantharides  in  a  slimy  vehicle  (about  200 
grams  of  gum  mixture).  He  obtained 
rapid  increase  in  the  amount  of  urine, 
disappearance  of  cedema  and  very  rapid 
cure. 

The  name  of  this  distinguished  clini- 
cian may  encourage  the  cautious  adop- 
tion of  this  medication.  (Bull,  med., 
No.  13,  1909.) 

CHOLINE  IIT  ANIMAL  TISSUES  ASTD 

FLUIDS. 
Drs.  Mott  and  Halliburton  and  others 
have  identified  choline  as  a  substance  to 
be  found  in  increased  quantities  in  the 
blood  or  cerebrospinal  fluid  in  animals 
or  patients  with  degenerative  processes 
going  on  in  their  nervous  systems.  W. 
Webster  (Bio-Chemical  Jouraal,  Lon- 
don, 1909,  IV.,  p.  117)  points  out  the 
various  errors  on  which  these  and  similar 
statements  are  based,  and  shows  that 
with  our  present  methods  of  chemical 
analysis  there  is  little  hope  of  detecting 
the  very  minute  quantities — small  frac- 
tions of  a  milligram — of  choline  that 
might  be  set  free  from  degenerating 
nervous  tissue,  and  so  get  into  the  circu- 
lating blood  of  man  or  of  animals,  in 


CREOSOTE  1^  PULAIONARY  TUBERCULOSIS. 


DIGIPURATUM. 


637 


disease  of  or  after  operations  on  the 
nervous  system.  He  finds  that  no  cho- 
line can  be  detected  in  normal  blood 
provided  that  the  lecithin  in  it  is  pre- 
vented from  decomposing;  it  may  be 
noted  that  Kaufmann  in  1S08  could  iso- 
late no  choline  from  a  liter  of  cerebro- 
gpinal  fluid  collected  from  various  pa- 
tients vrith  nervous  disease.  Webster 
further  finds  that  the  amounts  of  cho- 
line or  of  potassium  salts  that  might  be 
set  free  into  the  circulation  by  even 
sudden  processes  of  degeneration  in  the 
nervous  system  would  be  too  small  for 
detection;  and  that  the  micro-chemical 
reactions  given  for  choline  occur  irregu- 
larly but  equally  freely  by  both  nor- 
mal and  pathological  cerebrospmal 
fluid,  while  it  is  doubtful  whether  any  of 
the  micro-chemical  tests  in  use  are 
specific  for  choline.  (The  British  Medi- 
cal Journal,  July  31,  1909.) 


CREOSOTE  IN  PULMONARY 
TTJBERCTJIOSIS. 

Dr.  Beverly  Eobinson  states  that  beech- 
wood  creosote,  internally  and  by  in- 
halation is  valuable  in  pulmonary  tuber- 
culosis. Internally  the  best  formula  is : 
Beechwood  creosote  (Merck's),  6  drops; 
glycerine,  1  ounce;  rye  whiskey,  2 
ounces;  dose  one  dessertspoonful  every 
two,  three  or  four  hours,  best  diluted 
with  a  little  water. 

The  best  formula  for  inhalation  is: 
Equal  parts  of  beechwood  creosote 
(Merck's),  alcohol,  and  spirit  of  chloro- 
form. Use  10  drops  on  the  sponge  of  a 
perforated  zinc  inhaler.  Repeat  a  few 
drops  as  required.  The  inhaler  should 
be  used  frequently;  at  first  for  a  few 
moments  each  time ;  later  (after  a  week 
or  more)  it  may  be  used  half  an  hour  or 
an  hour  at  a  time.  Finally,  it  may  be 
used  almost    continuously    during    the 

day  and  frequently  all  night,  without  in- 


terfering with  sleep.  Occasionally  it  is 
necessary  to  lessen  the  proportion  of 
creosote,  in  the  inhaling  formula  at 
least,  for  a  while  and  until  the  patient 
is  accustomed  to  the  use  of  the  inhaler. 
Creosote  should  always  be  given  in  so- 
lution. The  author  states  that  patients 
following  out  his  plan  will  be  relieved 
of  their  unpleasant  symptoms.  It  will 
help  cure  a  large  number  and  will  hurt 
none.  It  is  the  best  adjunct  to  fresh 
air,  sunlight,  good  food  and  rest. 
(American    Journal  Clinical    Medicine, 

July,  1909.)         

DIGIPURATUM  ON  THE  CIRCULATORY 
SYSTEM. 

Dr.  J.  Szinnyei  tested  the  action  of 
digipuratum  thoroughly  in  30  cases,  and 
concludes  that  it  is  an  absolutely  reliable 
preparation  of  digitalis.  It  is  indicated 
in  every  decompensation,  where  there  is 
yet  time  for  oral  medication,  owing  to  the 
fact  that  it  is  uniform  in  action  and  con- 
tains both  digitalin  and  digitoxin,  but  is 
free  from  digitonin.  In  11  cases  where 
digipuratum  was  used,  free  diuresis  set 
in  on  the  second  day;  in  four  cases  the 
amount  of  fluid  excreted  exceeded  that 
ingested  on  the  first  day.  In  three  cases 
the  free  flow  of  urine  began  on  the  third, 
in  two  cases  on  the  fourth  day,  and  in 
one  case  each  on  the  fifth,  sixth  and 
seventh  day. 

By  carefully  comparing  the  pulse  fre- 
quency with  the  diuresis,  it  may  be 
noticed  that  occasionally  the  pulse  will 
slow  down  as  early  as  the  second  or  third 
day,  whereas  the  amount  of  urine, 
though  larger  than  on  the  preceding  day, 
will  not  yet  correspond  to  the  amount  of 
fluid  introduced.  It  seems  tlint  this  ob- 
servation will  give  valuable  information 
as  to  the  condition  of  the  heart  muscle. 
The  slowing  of  the  pulse  and  the  onset  of 
a  free  flow  of  urine  are  simultaneous  if 
the  heart  muscle  is  still  in  good  condition, 


638 


DRY  HEAT  IN  GYNECOLOGY. 


HYPOPHYSIS  EXTRACT. 


while  with  a  weak  myocardium  the  fre- 
quenc}'  of  the  pulse  will  diminish  first. 
There  seems  to  be  a  definite  relationship 
between  the  condition  of  the  myocardium 
and  the  appearance  of  a  free  flow. 
(Orvosi  Hetilap,  1909,  Nos.  17-32.) 


DRY  HEAT  IN  GYNECOLOGY. 

Dr.  Gellhorn  says  that  the  employment 
of  hot-air  boxes  or  chambers  is  in- 
valuable in  the  treatment  of  chronic 
exudates,  irrespective  of  their  location  in 
the  parametric  tissues  or  in  the  pelvic 
peritoneum.  The  results  obtained  with 
hot-air  in  this  affection  can  not  be  ap- 
proached by  any  other  method.  The 
prompt  objective  improvement  is  intensi- 
fied by  an  almost  instantaneous  relief 
from  pain.  The  hot-air  therapy  has  also 
been  very  promising  in  the  treatment 
of  certain  menstrual  disorders,  notably 
amenorrhea.  Furthermore,  hot-air  treat- 
ments have  been  found  exceedingly  use- 
ful in  a  number  of  conditions  arising 
after  operations,  such  as  infiltration  of 
the  incision,  post-operative  fistulse,  paral- 
ysis of  the  intestines,  etc.,  with  growing 
experience,  the  sphere  of  usefulness  for 
this  new  mode  of  treatment  is  likely  to 
extend  still  further.  As  its  application 
is  quite  simple,  it  is  equally  suited  to 
hospital  or  private  practice.  (American 
Journal  of  Obstetrics  and  Diseases  of 
Women  and  Children,  July,  1909.) 


GELATIN  IN  THEEAPEUTICS. 
Dr.  0.  Wandel  remarks  that  gelatin 
is  found  useful  in  lung,  stomach,  bowel, 
uterus  and  other  hasmorrhages,  but  it 
is  also  valuable  in  constitutional  affec- 
tions of  the  blood  entailing  a  hosraor- 
rhagic  tendency.  The  technique  at 
Quincke's  clinic  at  Kiel  aims  to  destroy 
angerobic  spores  and  protect  the  gelatin 
from  external  influences.  This  is 
accomplished  by  sterilizing  a  neutralized 


10  per  cent,  solution  of  gelatin  in  an 
Erlenmeyer  jar  with  a  layer  above  the 
fluid  paraffin  to  keep  out  oxygen.  A 
long  glass  tube  reaches  to  the  floor  of 
the  jar,  the  upper  end  capped'  with  a 
rubber  tube  and  stop  cock.  A  larger 
short  tube  in  the  stopper,  filled  with 
cotton,  allows  the  entrance  of  air.  The 
whole  is  sterilized  in  a  linen  bag  in 
steam  for  forty  minutes  at  100  degrees 
C.  (212  degrees  E.)  After  cooling,  it 
is  kept  in  the  incubator  at  37  degrees  C. 
(98.5  degrees  F.),  then  sterilized  again 
for  30  minutes  the  following  day.  The 
gelatin  thus  sterilized  is  poured  into 
vials  containing  50  cubic  centimeters, 
which  are  then  fused.  In  a  niuuber  of 
tests  the  gelatin  was  inoculated  with 
garden  soil  and  tetanus  spores,  but  after 
this  sterilization  inoculation  of  guinea- 
pigs  gave  negative  results.  (Therapie 
der  Gegenwart,  June,  1909.) 


HYPOPHYSIS    EXTRACT    UPON    THE 
BLOOD-VESSELS. 

Dr.  Pal  prepared  an  extract  from  the 
posterior  lobe  of  the  hypophysis,  1  cubic 
centimeter  corresponding  to  0.01  of  the 
dried  substance.  About  two  per  thou- 
sand of  the  efficient  substance  were  con- 
tained in  the  extract.  Intravenous 
injection  was  followed  in  the  first  place 
by  a  brief  transitory  lowering  of  the 
blood-pressure ;  passing  into  a  moderate 
rise  of  pressure.  The  same  phenomenon 
could  be  determined  over  again  by  re- 
peated infections.  The  hypophysis 
extract  furthermore  showed  a  well- 
marked  diuretic  action.  The  examina- 
tion of  excised  arteries  from  beeves,  in 
Einger's  solution  to  which  hypophyseal 
extract  had  been  added,  served  to  show 
that  the  carotid,  mesenteric,  and 
femoral  artery  underwent  shortening 
(as  under  the  addition  of  adrenalin), 
whereas    the    venal     arteries    become 


lODIPIN,  USES  OF. 


POTATO  DIET  IN  OBESITY. 


639 


lengtheued  (opposite  findings  nnder  ad- 
dition of  adrenalin),  at  least  in  the 
periplieral  portion  towards  the  renal 
pelvis.  The  findings  upon  the  cor- 
onary arteries  were  not  entirely  uni- 
form. The  pnpil  of  the  excised  eye  of 
frogs  is  dilated  by  hypophyseal  extract 
as  well  as  by  adrenalin.  (Wiener  Med. 
TTochenschrift.  No.  3,  1909.) 


lODIPIN,  USES  OF. 
Dr.  E.  Lust\Yerk  prefers  the  subcu- 
taneous administration  of  iodipin.  The 
following  cases  were  treated  by  him:  1. 
Gonorrhoeic  sciatica.  The  sciatic  nerve 
was  tender  and  palpable  after  several 
attacks  of  gonorrhoea.  After  five  injec- 
tions, each  of  10  cubic  centimeters  of 
25-per-cent.  iodipin,  there  was  much  im- 
provement. The  patient  was  cured  after 
ten  more  injections.  2.  Syphilitic  optie 
neuritis.  Four  hundred  and  fifty  cubic 
centimeters  of  iodipin,  given  within  three 
months  (15  cubic  centimeters  every  other 
day)  brought  about  a  marked  subjective 
and  objective  improvement,  and  also 
favorably  affected  an  existing  myocardi- 
tis. 3.  Tabes  dorsalis.  The  most  pro- 
nounced symptoms  were  the  lancinating 
pains.  After  25  intramuscular  injec- 
tions of  15  cubic  centimeters  each,  the 
pains,  h}^era3sthesia,  and  ataxia  had  dis- 
appeared, 60  that  the  patient  could  again, 
take  up  his  vocation.  4.  Struma.  Syrup 
of  iron  iodide  and  applications  of  iodine 
were  inetrectual,  but  50  cubic  centimeters 
of  iodipin,  injected  in  5-cubic-centimeter 
doses  every  day,  led  to  complete  disap- 
pearance of  the  tumor.  5.  Acute,  trau- 
matic gonitis,  in  a  patient  sixty  years 
old,  was  cured  by  2  cubic  centimeters 
injected  every  other  day  near  the  knee 
for  20  doses.  6.  Empyema.  The  sup- 
puration could  be  checked  by  evacuatioQ 
of  the  pus,  but  a  cure  was  not  established 
until  several  doses    (15-20  cubic  centi- 


meters) of  25-per-ccnt.  iodipin  had  been 
injected.  7.  Asthma  bronchiale.  The 
usual  mixture  relieved  the  attacks,  but 
iodipin  given  in  tablet  form  seems 
to  have  cured  the  disease.  8.  Arterio- 
sclerosis. All  symptoms  improved  after 
10  cubic  centimeters  of  iodipin  had  been 
injected  every  other  day  for  one  and  one- 
half  months.  9.  Transverse  dorsal  mye- 
litis. 20  cubic  centimeters  of  iodipin, 
injected  daily  for  six  weeks,  and  every 
other  day  for  two  more  weeks,  completely 
cured  the  patient.  (Deutsche,  med.  Zeit., 
1909,  No.  42.) 


POTATO  DIET  IN  OBESITY. 
Dr.  G.  Eosenfeld  states  that  the  main 
features  of  this  treatment  are:  the 
necessary  amounts  of  albumin,  prohibi- 
tion of  fat,  diet  scanty  in  calories,  but 
with  plenty  of  carbohydrates,  especially 
in  the  form  of  potato,  with  large 
amounts  of  cold  water  for  the  beverage, 
rest  in  bed  and  frequent  meals.  The 
food  must  be  such  that  fills  the  stomach 
and  thus  satisfies  the  appetite  with  small 
amounts  of  nourishing  substances.  Pota- 
to, water  and  soups  fulfill  these  require- 
ments and  aid  in  reducing  the  fat. 
Every  quart  of  cold  water  (10  degrees 
C.  or  50  degrees  F.)  ingested  causes  the 
consumption  of  27  calories  to  bring  it 
to  body  temperature — that  is  equivalent 
to  the  consumption  of  3  Gm.  fat.  As 
"filling'^  foods  must  he  selected,  fats 
should  be  avoided.  Small,  frequent 
meals  prevent  the  development  of  a  too 
hearty  appetite,  as  also  repose,  especial- 
ly bed  rest.  The  diet,  therefore,  is, 
for  the  first  moal:  Tea  with  saccharine 
and  30  or  40  Gm.  of  rolls  with  marma- 
lade or  the  like;  the  second  meal  is  10 
Gm.  of  cheese  and  water;  the  third,  100 
Gm.  apple  and  water;  at  noon,  2  glasses 
of  water,  1  or  2  plates  of  soup  with 
potatoes  and  vegetables,  lean  meat  and 


640  BOOK  REVIEWS. 

salad  without  oil.     During    the    after-  thrive  on  this  diet,  and  feel  better   in 

noon,  tea  with  saccharine,  G  prunes  and  every  respect,  as  he  shows  by  a  number 

water;  later  100  Gm.  apple.    For  supper  of  examples.    Caution  is  necessary  with 

2  eggs  and  potato  salad  or  lean  meat  diabetes,  and  the  amount  of  fluids  inges- 

and  vegetables.     The  principal  advan-  ted  had  better  be  kept   below   2    liters 

tage  of  this  diet  is  that  the  patients  do  if  there  is  a   general  dropsy.    It  often 

not  feel  the  restrictions  and  do  not  be-  requires  more  than  six  months  to  bring 

come  irritable  and  nervous.     The  only  the  patient  down  to  his  normal  weight, 

by-effect  noticed  was  occasionally  back-  and  it  is  wise  to  keep  up  this  diet  a 

ache,  which  probably  was    due    to  the  few  days  in  each  week  to  maintain   the 

change  in  the  attitude  of  the  spine  as  benefit.        (Archiv.     fiir     Verdauungs- 

the  abdomen  lost  its  fat.    The  patients  Krankheiten,  June,  1909.) 


8©ol{  ^evv^\Ms 


BuiXETi?f  OF  THE  Lloyd  Librakt  of  Botanv,  Pharmacy  and  Materia  Ttledica.  Cincinnati, 
Ohio:  J.  W.  &  C.  G.  Lloyd.  Reproduction  Series,  No.  7.  Life  and  Medical  Discoveries 
of  Samuel  Tliomson  and  a  History  of  The  Thomsonian  Materia  Medica,  as  sliown  in 
"The  New  (Tiiide  to  Health,"  (1835),  and  the  Literature  of  that  Day,  including  Por- 
traits of  Samuel  Thomson;  Facsimile  of  Thomson's  "Patent"  to  the  Practice  of 
Medicine;  the  Famous  Letters  of  Professor  Benjamin  Waterhouse,  M.D. ;  the  Celebrated 
"Trial  of  Dr.  Frost,"  and  Other  Features  of  a  Remarkable  Epoch  in  the  American  Medical 
History. 

Tliis  bulletin  grveq  the  reader  a  very  ^ood  picture  of  the  knowledee  of  the  practice  of 
medicine  at  the  beginning  of  the  nineteenth  century.  In  it  are  portrjiyed  the  narrative  of 
the  life  and  medical  discoveries  of  Samuel  Thomson,  a  famous  and  successful  physician  at 
that  time.  It  is  well  worth  reading,  as  it  shows  the  passion,  dogmatism,  the  vituperation,  of 
the  period. 

Third  Report  of  the  WET.T.cojrE  Research  Laboratories  at  the  Gordon  Memorial  College 
Khartoum.  Andrew  Balfour,  M.D.,  B.Sc,  F.R.C.P.,  Edin.,  D.P.H.,  €amb.,  Director;' 
Fellow  of  the  Royal  Institute  of  Public  Health,  the  Society  of  Tropical  Medicine  and 
Hygiene,  and  the  Society  for  the  Destruction  of  Vermin;  Member  of  the  Incorporated 
Society  of  Medical  Officers  of  Healtli.  and  the  Association  of  Economic  Biologists; 
Corresponding  Member  of  Soci^^tf-  de  Pathologic  Exotique;  Medical  Officer  of  Health' 
Khartoum,  etc.  Published  for  Department  of  Education,  Sudan  Government.  Khartoum] 
by  Bal]i^re,  Tindall  and  Cox,  8  Henrietta  Street,  Covent  Garden,  London,  1908.  Depot 
for  U.  S.  A.:    Toga  Publishing  Co.,  45  Lafayette  Street,  New  York. 

Tin's  report  is  the  result  of  an  enormous  amount  of  labor  spent  in  resea.rch  work  at  the 
Gordon  Memorial  College.  It  contains  480  pages  of  detailed  records  and  papers  by  Sudan 
officials  on  original  investigations,  and  niaiiy  interesting  experiments,  principallv  connected 
with  tropical  medicine.  The  lines  along  which  this  valuable  research  work  has  been  done  are 
chemical  and  bacteriological. 

An  especial  feature  of  this  volume  is  the  review  of  the  most  important  recent  advances 
and  discoveries  in  tropical  and  veterinary  medicine,  bacteriology  and  hygiene.  Among  the 
contents  worthy  of  mention  are:  — 

"On  Some  Interesting  Reptiles  Collected  by  Dr.  C.  M.  Wenyon  on  the  Upper  Nile;" 
"Turtles,  Lizards,  Chameleons,  Snakes;"  "Animals  Injurious  to  Farm  and  Garden  Crops;'" 
"Animals  Injurious  to  Stored  Goods  and  Timber;"  "New  Mosquitoes  from  Sudan;" 
"Medical  Practice  and  Superstition  Amongst  the  People  of  Kordofan." 

Tliis  report  will  prove  of  the  utmost  benefit  to  those  interested  in  tropical  research. 
The  Tolume  is  profusely  illustrated  and  includes  many  valuable  plates. 


Monthly    CvcLOPiEDiA 

AND 

Medical   Bulletin 


PUBLISHKD   THE   LaST   OF   EaCH    jSIONTH 


Monthly  Cyclopaedia  Section 


Vol.  II.  PHILADELPHIA,  NOVEMBER,  1909.  No.  11. 


Original  Articles 


Department  in  charge  of  J.  MADISON  TAYLOR,  A.M.,  M.D. 


ACHYLIA  GASTRICA. 

By  a.  L.  benedict,  M.D., 

BUFFALO. 

We  think  largely  in  words,  hence  a  word  or  technical  term  is  of  great 
assistance  in  focussing  our  attention  and  crystallizing  our  knowledge.  On  the 
other  hand,  if  our  conception  is  inexact  or  too  arbitrary,  we  shall  be  misled 
not  only  theoretically  but  practically. 

Passing  the  etymology  of  the  term,  achylia,  in  an  uncritical  spirit,  we 
should  remember  that  it,  as  well  as  hypochylia  and  hyperchylia,  is  not 
limited  to  the  stomach,  but  applies  to  all  glands.  Even  more  broadly,  any 
organ  may  functionate  too  much  or  too  little,  or  may  cease  to  act. 

Neither  theoretically  nor  practically,  can  we  draw  a  line  between  hypo- 
chylia and  achylia.  Occasionally  we  find  gastric  contents  which  do  not  give  a 
lilac  band  with  alkaline  copper  solution;  which,  reinforced  with  hydrochloric 
acid  and  incubated,  do  not  appreciably  dissolve  coagulated  albumin;  which  do 
not  coagulate  milk.  I  have  never  found  a  case  which  did  not,  after  filtering 
off  the  albumin  coagulated  by  heat,  give  a  considerable  precipitate  with  phos- 
phomolybdic  or  phosphotungstic  acid  or  other  reagents  for  albumoses  and 
peptones  generally.  Just  how  reliable  these  tests  are,  in  the  sense  of  support- 
ing absolute  statements  as  to  the  presence  or  absence  of  gastric  digestion,  has 
not  been  fully  determined.  Moreover,  the  degree  of  gastric  function  varies 
somewhat  in  the  same  case  at  different  times. 

It  is  generally  stated  that  the  intrinsic  secretor}'  functions  of  the  stomacli 
are  three:  the  formation  of  HCl,  of  pepsin,  and  of  rennin.  But,  apparently, 
the  maltose  formed  by  ptyalin  digestion  in  the  stomach,  is  changed  into  dox- 
3  (641) 


642  ACHYLIA  GASTRICA. 

trose  in  passing  through  the  gastric  wall,  and,  by  the  way,  very  little  of  this 
or  anything  else  is  actually  absorbed  through  the  stomach.  There  has  also, 
rather  recently,  been  demonstrated  a  slight  splitting  of  iats  within  the  stomach 
but  scarcely  enough  to  warrant  the  conception  of  a  definite  gastric  lipase,  for 
such  a  change  might  be  expected  to  occur  to  some  degree  in  any  moist,  warm 
and  not  entirely  sterile  chamber.  It  has  sometimes  seemed  to  me,  even  from 
the  comparatively  superficial  view  of  the  clinician,  that  the  amount  of  sugar 
found  in  chyme  deficient  in  HCl  and  peptic  activity,  might  indicate  something 
more  than  the  negative  fact  that  ptyaiin  digestion  was  not  so  much  interfered 
with  as  normally,  but  an  achylia  in  the  limited  sense  of  failure  of  the  inverting 
ferment  has  not  been  actually  demonstrated  and,  indeed,  to  do  so  would 
require  very  elaborate  qualitative  and  quantitative  chemic  study  of  an  experi- 
mental as  well  as  of  a  clinical  nature. 

Hence  practically  and  probably  intrinsically,  the  problem  of  achylia  may 
be  limited  to  peptic  digestion  of  proteids.  By  common  consent,  the  hydro- 
chloric acid  factor  is  omitted  from  the  definition  though,  so  far  as  I  know, 
any  considerable  secretion  of  HCl,  even  if  no  free  hydrochloric  acid  remains  in 
the  chyme,  is  incompatible  with  the  idea  of  achylia  gastrica.  In  other  words, 
cases  of  achylia  gastrica  are  clinically  a  sub-group  of  cases  of  achlorhydria. 
There  is,  however,  no  a  priori  reason  why  there  should  not  be  a  complete,  or 
practically  complete,  failure  of  the  chief,  peptic  cells  of  the  gastric  tubules, 
while  the  parietal  or  oxyntic  cells  preserve  their  function  of  secreting  HCl. 
So  far  as  I  am  aware,  no  such  case  has  been  recorded  but  there  seems  to  be  no 
theoretic  demonstration  of  its  impossibility. 

An  important  question  in  the  definition  of  achylia  or  hypochylia  is  as  to 
the  identity  or  distinction  of  pepsin  and  rennin.  No  ferment  has  ever  been 
isolated.  It  is  a  priori  strange  if  not  actually  improbable,  that  there  should  be 
a  ferment  for  one  particular  kind  of  food.  If  all  raw,  soluble  proteids  were 
coagulated  by  gastric  juice,  the  individuality  of  rennin  would  stand  out  more 
clearly,  but  this  is  not  the  case.  Or  if  rennin  action  were  conspicuous  in 
infants  and  in  adults  who  continued  the  habit  of  taking  raw  milk  and  were 
lacking,  or  essentially  weak,  in  those  who  had  abstained  from  milk  for  a  long 
time,  its  specific  nature  would  be  more  readily  conceivable.  The  pancreatic 
and  intestinal  juices  also  coagulate  caseinogcn.  Under  normal  conditions,  the 
"factor  of  safety"  would  scarcely  require  this  triple  provision  for  a  sino-le 
constituent  of  a  single  food  stuff  and,  from  rather  rare  and  imperfect  observa- 
tions, 1  am  inclined  to  believe  that  it  fails  in  the  very  cases  in  which  it  is 
needed,  on  accoimt  of  achylia  gastrica. 

I  am  well  aware  of  reports  showing  the  occasional  independent  occurrence 
of  milk  coagulation  and  of  solution  of  albumin,  by  gastric  filtrates.  I  have 
made  such  observations  myself  but,  so  far  as  personal  experience  is  concerned, 
have  become  convinced  of  an  error.  Many  samples  of  milk,  apparently  fresh 
and  declared  not  to  have  been  treated  by  the  milkman,  do  not  coagulate  with 
active  gastric  filtrate  and  various  errors  of  technic  might  occur  in  clinical 
tests  of  solution  of  albumin.  Laboratory  workers,  at  difl'erent  times,  have 
stated  positively  that  pepsin  and  rennin  were  identical  and  that  they  were  dis- 


ACHYLIA  GASTRICA.  643 

tinct.  The  general  principles  of  the  action  of  precipitants  in  general  or  of 
ferments  in  particular,  upon  colloid  solutions,  at  least  do  not  require  the  hypo- 
thesis of  a  separate  milk-curdhng  ferment. 

It  is  possible  that  such  a  ferment,  or  ferments,  may  be  definitely  established 
by  further  research.  However  this  may  be,  in  the  vast  majority  of  cases  the 
peptic  and  the  milk-coagulating  function  rise  and  faU  together  and  are  never 
deficient  to  any  marked  degree  when  there  is  even  a  moderate  secretion  of  HCl. 

Thus,  the  definition  of  achylia  gastrica  hinges  on  the  absence  of  pepsin. 
Furthermore,  if  by  washing  the  stomach  with  HCl  or  by  administering  it 
by  mouth  a  proteolj'tic  gastric  juice  is  obtainable,  we  may  conclude  that  pep- 
sinogen has  been  formed  already  but  lacked  the  developing  action  of  HCl. 
In  other  words,  an  apparently  demonstrated  case  of  achylia  which  yields  readily 
to  acid  treatment  can  not  be  considered  genuine. 

Achylia  gastrica  is  clinically  divisible  into  acute  functional  and  chronic, 
more  or  less  demonstrably,  organic  types,  culminating  in  anadenia  or  atrophy 
of  the  gastric  mucosa,  after  a  prolonged  gastritis.  As  for  most,  if  not  all, 
diseases  the  term  functional  is  purely  a  matter  of  convenience.  Not  even  a 
new  ultra  method  of  histologic  examination  is  necessary  to  demonstrate  an 
organic  lesion.  A  condition  may  also  be  functional,  perhaps  even  in  the  strict 
sense,  so  far  as  the  local  manifestation  is  concerned,  but  ultimately  organic 
as  to  the  nerve  centers,  or  some  organ  through  whose  faulty  action  a  toxsemia 
develops. 

The  division  of  achylias  into  acute  functional  and  chronic  organic  is 
merely  approximately  correct  and  various  subtypes  may  be  made  out. 

Perhaps  the  simplest  type  of  achylia  is  due  to  chilling,  fatigue,  etc.,  and 
is  often  nocturnal.  In  such  cases  as  are  discovered,  gastric  stagnation  usually 
occurs  and  the  stomach  contents  are  furnished  by  spontaneous  vomiting.  As 
they  are  often  quite  acid  through  fermentation,  if  not  examined,  the  diagnosis 
of  hyperchlorhydria  may  be  made.  Indeed,  it  would  appear  that  the  general 
opinion  as  to  the  prevalence  of  hyperchlorhydria  is  due  to  diagnosis  by  guess. 
Such  cases  are  transient,  and  the  treatment  is  palliative  and  prophylactic,  and 
of  the  simplest  nature.  Sometimes  a  hot  brick  in  the  bed  is  all  that  is 
necessary. 

Similar  acute  functional  achylia  may  be  noted  in  asthmatic  crises  and, 
doubtless,  if  it  were  practicable  to  make  the  requisite  examinations  would  be 
found  very  frequently,  perhaps  quite  regularly,  in  mental  and  physical  shock, 
after  anaesthesia,  in  acute  fevers,  etc.  In  urajmia,  acid  auto-intoxication, 
intestinal  putrefaction  with  marked  indicanuria  and  other  more  or  less  exogenic 
toxic  states,  achylia  may  occur.  The  toxic  gastritis  cases,  of  acute  and  sub- 
acute degree  are  pretty  regularly  marked  not  only  by  deficient  HCl  secretion, 
as  stated  in  text-books,  but  by  more  or  less  typic  achylia.  Certain  exogenic 
poisons  cause  lesions  while  others,  as  well  as  endogenic  poisons,  do  not,  at  least 
not  unless  long  continued.  Still,  an  achylia  due  to  a  toxic  condition  of  any 
kind  does  not  exactly  correspond  to  the  conception  of  functional  disturbance. 

A  very  practical  obstacle  to  our  understanding,  or  even  detection,  of  such 
cases  is  the  reluctance  to  pass  the  tube  after  a  test  meal,  in  a  case  of  typhoid. 


644  ACHYLIA  GASTRICA. 

after  an  abdominal  section,  during  a  paroxysm  of  asthma  and  in  the  various 
toxaimias  and  exogenic  poisonings.  Hence  we  must  form  our  ideas  largely 
from  matter  accidentally  furnished  by  vomiting,  in  occasional  instances.  In 
all  such  cases,  the  therapeutic  indications  are  mainly  along  the  lines  of  the 
underlying  affection  and  usually  the  digestive  indication  is  either  to  keep  the 
stomach  empty  or  to  administer  foods  which  will  pass  the  stomach  with  as 
little  trouble  as  possible  and  be  digested  in  the  intestine. 

The  ordinary  type  of  chronic  achylia,  usually  considered  organic,  may  be 
best  discussed  by  an  illustrative  case: — 

A.  F.  D.,  No.  101  of  year  1905-6,  aged  37,  male,  mechanic  at  light  work, 
gave  a  history  of  stomach  trouble  of  6  years'  duration,  somewhat  intennittent 
and  apparently  due  to  nervous  strain.  His  principal  complaint  was  that  the 
food  seemed  to  lie  heavy  in  the  stomach — a  common,  vague  and  not  very 
reliable  symptom.  He  would  belch  gas  and  occasionally  eructate  gastric  con- 
tents, which  were  never  either  sour  or  bitter.  On  physical  examination,  he 
was  found  to  have  a  mitral  regurgitant  murmur,  with  some  cardiac  enlarge- 
ment and  good  compensation.  .(No  history  of  rheumatism  except  slight  pains 
in  knee  nor  other  apparent  cause.)  The  liver  was  small,  the  area  by  ausculta- 
tory percussion  extending  only  from  the  fourth  to  the  eighth  rib,  and  there 
were  the  dendritic  veins  at  the  diaphragmatic  level,  which  the  writer  described 
several  years  ago  as  a  valuable  sign  of  hepatic  sclerosis.  There  was  also  a 
tender,  palpable  appendix.  The  amount  of  chyme  after  the  standard  test 
meal  of  50  grams  of  bread,  5  of  butter  and  250  of  water,  was  110  cubic  centi- 
meters, not  much  more  than  normal.  The  total  acidity  was  9  degrees, 
there  was  no  free  HCl  and  the  alizarin  reaction  was  already  present  without 
neutralization,  indicating  that  the  acidity  was  practically  entirely  due  to 
organic  acids.  There  was  no  starch  nor  erythrodextrin,  but  an  abundance  of 
sugar.  The  peptone  ring  with  alkaline  copper  solution  was  absent.  On  boil- 
ing, there  was  a  trace  of  albumin,  and  on  adding  phosphomolybdic  acid  and 
centrifuging,  a  3  per  cent,  bulk  precipitate.  Normally  or  even  in  simple 
cases  of  hypochlorhydria,  this  last  precipitate  usually  exceeds  20  per  cent. 
Milk  was  not  coagulated.     Albumin  digestion,  after  adding  HCl,  negative. 

This  patient  did  not  have  gastric  stagnation  to  any  appreciable  degree, 
although  tbere  was  some  gastric  mucus.  Treatment  consisted  in  the  attempt 
to  stimulate  and  reinforce  gastric  secretion  by  salty  foods,  ammonium  chloride, 
strychnine  and  HCl.  Locally,  lavage  and  gastric  spraying  with  menthol  in 
purpetrol  (pure  mineral  oil)  were  employed.  Various  detergents  were 
employed  during  lavage,  as  soda,  borax,  liydrogen  peroxid. 

At  the  end  of  two  and  one-half  months,  the  patient  felt  perfectly  well  but 
nothing  had  been  accomplished  toward  relieving  the  achylia.  Occasional 
reports  of  favorable  subjective  condition,  state  of  nutrition,  etc.,  have  been 
received. 

In  some  such  cases,  anaemia  is  found  so  that,  a  few  years  ago,  it  was 
thought  that  in  achylia  we  miglit  have  an  explanation  of  pernicious  anasmia. 
This  patient  manifested  no  true  angemia  though  the  haemoglobin  was  only  80 
per  cent.     However,  the  cells  appeared  normal  and  the  blood  was  not  examined 


ACHYLIA  GASTRICA.  645 

after  the  subjective  improvement  had  become  pronounced,  as  the  patient  wrote 
that  he  was  satisfied  with  results  and  did  not  report  for  further  examination. 
Marked  anaamia  occurs  in  achylic  cases  just  often  enough  to  confuse  us  as  to 
the  mutual  or  common  etiologic  relations. 

In  favorable  cases,  intestinal  digestion  undoubtedly  proceeds  normally, 
and,  indeed,  physiologically,  human  gastric  digestion  docs  not  amount  to  much 
quantitatively.  Other  cases  of  this  type  have  been  discovered  quite  acciden- 
tally in  making  a  routine  gastric  analysis  on  account  of  some  intercurrent 
digestive  disturbance.  The  favorable  course  that  they  take  is  the  chief  reason 
for  our  lack  of  definite  knowledge  concerning  them.  How  long  has  the  achylia 
existed  before  its  discovery?  How  long  does  it  continue  after  its  discovery? 
Is  the  condition  functional,  that  is,  due  to  defective  innervation  or  is  it  due 
to  congenital  failure  of  development  or  to  anadenia,  that  is,  an  obliterating 
chronic  gastritis,  or  to  some  other  lesion?  The  first  question  obviously  cannot 
be  answered  until  a  routine  examination  of  apparently  healthy  persons  is 
made.  Patients  usually  do  not  allow  the  second  question  to  be  answered,  but 
a  few  cases  have  been  observed  sufficiently  long  and  with  a  sufficient  number 
of  examinations  to  render  it  probable  that  the  gastric  condition  is  permanent, 
at  least  in  many  cases.  As  to  the  third  question,  we  might  jump  to  the  con- 
clusion that,  in  the  present  case,  there  was  a  chronic  gastritis  due  to  poi*tal 
stagnation,  but  such  a  conclusion  would  be  fallacious.  In  many  cases, 
there  is  no  evidence  of  chronic  gastritis  and  in  many  others  with  hepatic 
sclerosis  and  gastric  mucus,  there  is  no  achylia.  To  secure  necropsies  under 
proper  conditions,  on  such  cases,  would  require  years  of  waiting  and  a  lucky 
chance.  As  to  microscopic  examination  of  cells  obtained  by  intubation,  it 
seems  to  me  quite  on  a  par  with  diagnosing  skin  lesions  by  getting  exfoliated 
epidermis  from  the  bath  tub.  The  stomach  is  constantly  throwing  off 
epithelium,  which  we  find  in  a  more  or  less  changed  condition.  Indeed,  the 
mechanic  and  thermic  and  chemic  insults  which  a  civilized  ( ?)  diet  inflicts  on 
the  stomach,  render  localized  catarrhal  lesions  quite  the  rule. 

That  there  is  such  a  condition  as  anadenia  cannot  be  questioned,  though 
the  term  is  not  an  ideal  one.  That  it  is  associated  with  more  or  less  absolute 
achylia  cannot  be  denied.  But  that  it  is  typic  of  chronic  achylia  in  spite  of 
which  general  good  health  is  restored,  is  suh  judice. 

Achylia  or,  at  least,  very  marked  hypochylia  is  characteristic  of  advanced 
gastric  cancer  of  almost  any  type,  though  obviously  it  is  not  diagnostic  in  any 
true  sense.  In  this  connection,  the  personal  confession  may  be  made  of  an 
entire  inability  to  locate  the  lesion  according  to  special  failure  of  HCl,  peptic 
power  and  milk  coagulation. 

A  rather  scattering  series  of  examinations  also  shows  that  achylia  may 
occur  in  tuberculosis,  gall-stones,  chronic  nephritis,  myxoedema,  cancer  at  a 
distance  from  the  stomach,  and,  in  short,  in  almost  any  depressing  disease. 
Such  achylias  are  presumably  really  functional,  so  far  as  the  stomach  is  con- 
cerned, and  probably  more  or  less  intermittent. 

In  Addison's  disease,  achylia  gastrica  may  occur  and,  in  spite  of  our 
inability  to  demonstrate  satisfactorily  achylia  pancreatica  and  acliylia  intes- 


646  ACHYLIA  GASTRICA. 

tinalis,  when  we  find  gross  e\'idences  of  intestinal  indigestion  and  the  patient 
emaciates  and  apparently  dies  largely  of  starvation  in  spite  of  abundant  or 
reasonably  full  ingestion  it  is  obvious  that  there  has  been  in  a  practical  sense, 
achylia  digestiva  totalis. 

There  is  a  general  impression  that  gastric  ulcer  depends  upon  and  is 
associated  with  hyperchlorhydria.  Scrutiny  of  the  evidence  shows  that  it  is 
inadequate.  I  have  never  dared  submit  acute  cases  of  ulcer  to  intubation.  In 
chronic  gastric  ulcer,  especially  of  the  angiosclerotic  type,  there  is  usually 
h}'pochlorh5-dria,  sometimes  achlorhydria  and  occasionally  achylia.  On  the 
otlier  hand,  in  a  very  marked  case  of  this  nature  which  terminated  by  rupture 
into  the  peritoneum  the  peritoneal  contents  post-mortem  gave  a  distinct 
lilac  ring  with  alkaline  copper  solution.  Haemorrhagic  gastritis  with  minute 
ulcers,  dependent  on  hepatic  sclerosis,  is  usually  close  to  achlorh5'dria  and  tends 
toward  achyKa. 

In  the  New  Yorh  Medical  Journal  of  August  7,  1909,  I  have  discussed, 
somewhat  at  length,  Knapp's  conception  of  Insufficient] a  Pylori.  While,  from 
the  standpoint  of  physiologic  experimentation.  Cannon  seems  to  have  shown 
that  HCl  is  the  factor  which  causes  the  pylorus  to  relax  and  discharge  the 
chjTne  into  the  duodenum,  from  the  practical  clinical  standpoint,  just  the 
opposite  is  true.  That  is  to  say,  without  any  infallible  rule  obtaining,  an 
excess  of  HCl  is  usually  associated  with  more  or  less  ischochymia,  and  the  cases 
in  which  a  test  meal  slips  through  the  pylorus  rapidly  are  hypochlorhydria. 
Knapp  has  charged  Einhorn  with  erroneously  considering  insufficientia  pylori 
as  achylia  gastrica.  The  two  conceptions  are  clearly  too  different  even  to  be 
contrasted.  Whether  the  slipping  of  unirritating,  nearly  neutral  chyme 
through  the  pylorus  deserves  a  Latin  name  and  to  be  considered  as  a  disease 
or  definite  functional  disturbance,  is  very  doubtful.  In  my  own  experience, 
appointments  for  the  extraction  of  stomach  contents  prove  disappointing  in 
about  one  case  in  five,  although  I  use  a  large  tube  with  a  bulb,  and  prove  the 
stomach  empty  or  practically  so  by  introducing  and  removing  water,  when 
the  contents  are  not  obtainable  after  a  reasonably  patient  effort  to  extract  them. 
In  such  cases,  I  simply  increase  the  bulk  or  nature  of  the  test  meal  and  try 
again.  It  is  only  occasionally  that  such  cases  show  any  consistent  weakness  of 
the  pylorus  or  motor  excitability.  Usually,  the  second  attempt  proves  suc- 
cessful, occasionally  one  must  try  several  times. 

A  very  recent  case  may  be  cited  as  an  example,  the  commonness  of  the 
occurrence  and  my  scepticism  as  to  the  existence  of  any  intrinsic  lesion  or  func- 
tional failure  having  prevented  the  accumulation  of  any  statistics.  Mrs.  J.  D., 
ISTo.  21  of  1909-1910,  yielded  no  ch}Tne  an  hour  after  a  test  meal  of  two  slices  of 
bread  and  butter  and  a  glassful  of  water,  except  that  lavage  showed  a  few 
crumbs  remaining.  Pepeating  the  test  with  four  slices  of  bread  and  butter  and 
a  glassful  of  water,  200  cubic  centimeters  were  obtained.  The  total  acidity 
was  9  degrees.  HCl  was  entirely  lacking,  there  being  not  even  an  orange  tint 
with  dimethylamidoazobonzol.  There  was  only  a  trace  of  lactic  acid.  There 
was  a  faint  lilac  band  with  alkaline  copper  solution,  denoting  peptonized  pro- 
teid,  but  the  precipitate  with  phosphomolybdic  acid  amounted  to  18  per  cent. 


ACHYLIA  GASTRICA.  647 

by  bulk,  indicating  pretty  fair  digestion.  Ho\A'ever,  the  peptic  power  was 
nearly  exhausted  as,  after  adding  HCl  to  make  a  30-dcgree  solution  (i.e.,  30 
per  cent,  of  decinormal)  and  incubating  at  body  temperature  for  9  hours, 
there  was  very  slight  solution  of  coagulated  albumin.  This  case  may  be  con- 
sidered one  of  marked  hypochylia. 

It  should  be  distinctly  understood,  however,  that  cases  of  hypochylia  and 
achylia  do  not  by  any  means  always  show  what  Knapp  terms  iusufficientia 
pylori  nor,  on  the  other  hand,  can  we  safely  prophesy  achylia  from  the  fact 
that  the  stomach  is  empty  an  hour  after  the  test  meal,  though  in  the  latter 
event,  we  shall  usually  find  a  marked  deficiency  of  HCl  and,  in  this  group  of 
hypo-  or  achlorhydric  cases,  we  shall  find  most  of  our  cases  of  marked  hypo- 
chylia or  nearly  absolute  achylia. 

As  to  treatment,  achylia  and  marked  hypochylia  may  be  considered  as 
essentially  identical.  Cases  of  the  acute,  more  or  less  typically  functional, 
type  should  be  fasted  unless  there  is  urgent  need  of  nutrition,  when  the 
endeavor  should  be  made  to  spare  the  stomach  and  rely  on  intestinal  digestion, 
rather  than  immediately  to  restore  the  gastric  function. 

Chronic  cases  like  that  of  A.  F.  D.  should  be  treated,  as  outlined,  with 
the  hope  of  restoring  gastric  function.  If,  after  a  couple  of  months,  this 
shows  no  sign  of  recuperation  but  subjective  improvement  is  marked,  we  should 
comfort  ourselves  with  the  thought  that,  after  all,  the  intestine  is  the  main 
digestive  and  absorptive  organ  and  worry  neither  the  patient  nor  ourselves 
with  the  fear  of  starvation.  Indeed,  in  many  cases,  it  is  not  even  necessary 
to  be  particular  about  the  diet  though  obvious  indiscretions  should  be  dis- 
couraged. 

If,  in  addition  to  the  achylia,  there  is  marked  anaemia,  this  should  be 
treated  to  the  best  of  our  ability,  remembering  that  such  anaemia  is  not  due 
to  lack  of  iron  in  the  food  and,  hence,  that  medicinal  iron  preparations  are 
not  especially  indicated. 

In  Addison's  disease,  m5^xoedema,  chronic  gastric  ulcer  and  all  sorts  of 
conditions  of  general  depression  in  which  the  patient  emaciates  and  is  evidently 
tenfling  toward  starvation  in  spite  of  adequate  ingestion,  the  prognosis  is 
grave.  Dextrose  should  be  given  in  considerable  amounts  unless  there  is 
diabetes.  Sometimes  a  careful  study  will  show  what  kind  of  organic  nutriment 
is  best  digested  and  assimilated.  Pepsin  and  pancreatic  ferments  are  not 
usually  successful,  though  theoretically  indicated.  Vegetable  digcstants  seem 
to  be  more  satisfactory  though  they  do  not  necessarily  fulfill  our  desires. 
Possibly  there  is  a  defect  in  absoqition  or  metabolism  for  which  we  have  no 
known  remedy.  Predigested  foods  are  a  disappointment,  whether  administered 
by  mouth  or  by  the  rectum.  Dextrose  is  predigested  carbohydrate.  Glycerin 
and  soaps  are  predigested  fats  but  are  not  practically  available.  Artificial 
peptones  are  toxic.  Evidently,  we  do  not  understand  thoroughly  the  physiology 
of  digestion,  or  we  interpret  as  "indigestion"  failures  of  absorption  and 
secondary  alterations  of  nutriment. 

It  is  scarcely  necessary  to  say  that  ordinary  hj'gienic  and  general  restora- 
tive measures  should  be  applied  and  that  we  should  treat  underlying  condi- 


648  DEMENTIA  PR^ECOX  CAUSED  BY  DENTAL  IMPACTION. 

tioDS.  Very  frequently,  failure  of  nutrition,  not  always  accompanied  with 
typic  achylia,  is  due  to  thyroid  failure  whose  symptoms  are  not  sufficiently 
marked  to  attract  attention.  With  due  care  to  avoid  increasing  the  thyroid 
secretion  in  a  typic  hyperthyroidism,  it  is  a  good  rule  of  thumb  to  administer 
thyroid  extract  to  any  elderly  person,  especially  a  woman,  who  shows  vague 
signs  of  malnutrition.  Adrenalin  is  usually  without  value  in  Addison's  dis- 
ease, but  it  is  possible  that  the  entire  adrenal  gland  may  prove  useful.  In 
some  cases,  the  Smith  lymph,  which  is  essentially  a  testicular  and  lymphatic 
extract,  gives  good  results.  We  must  be  on  the  lookout  for  indicanuria  and 
all  sorts  of  toxgemias  and,  in  general,  must  try  to  treat,  after  discovering,  an 
underlying  cause  or  contributory  factor. 


DEMENTIA  PRAECOX  CAUSED  BY  DENTAL  IMPACTION. 

By  HENRY   S.   UPSON,  M.D., 

Professor  Neurology  Western  Reserve  University, 

CLEVELAND,    OHIO. 

Among  the  insane  and  other  so-called  degenerates  there  are  often  found 
such  physical  peculiarities  as  irregular  teeth  and  the  high-arched  palate. 
Statistical  study  has  given  much  information  in  regard  to  the  occurrence  of 
these  so-called  stigmata,  none  at  all  of  their  significance.  One  explanation 
of  this  curious  association  seems  to  the  writer  to  be  furnished  by  his  investiga- 
tions of  the  past  two  or  three  years  into  the  role  of  dental  diseases  in  causing 
nervous  and  mental  disorders. 

Of  58  cases  examined  by  skiagi'aph,  in  about  half  impactions  were  found, 
that  is,  teeth  so  angled  against  their  neighbors  as  to  be  possible  irritants. 
This  lesion  has  been  Imown  as  an  occasional  cause  of  intense  pain,  but  has 
never  before  been  studied  clinically  in  its  other  relations. 

The  patients  in  whom  impactions  were  found  suffered  from  a  great  variety 
of  nervous  disorders,  ranging  from  headache,  habit  spasm,  restlessness, 
epilepsy,  through  insomnia  to  melancholia  and  dementia  prascox. 

Dental  treatment  in  these  cases  has  been  carried  out  by  removal  not  only 
of  the  impactions  but  of  all  irritations  of  teeth  and  jaws,  as  the  irritation 
caused  by  impaction  differs  only  in  degree,  not  in  kind,  from  that  of  other 
dental  lesions. 

The  therapeutic  results  have  thus  far  been  encouraging.  They  have  been 
more  decisive,  that  is  more  truly  and  completely  curative,  in  the  severer  mental 
disorders,  and  in  those  cases  in  which  the  more  marked  dental  lesions  have 
been  found.  The  best  results  have  been  attained  in  severe  cases  of  manic- 
depressive  insanity  and  dementia  praecox.  Of  eight  such  cases  seen  in  con- 
sultation, in  whom  thorough  dental  treatment  has  been  carried  out,  including 
the  extraction  of  one  or  more  impacted  teeth,  six  have  recovered  mental  health, 
one  is  convalescent,  and  one  much  improved.  Of  these  patients,  five  were 
cases  of  dementia  praecox,  of  whom  four  have  recovered  and  one  is  convalescent. 


DEMENTIA  PE^ECOX  CAUSED  BY  DENTAL  IMPACTION.  649 

Details  of  these  cases  have  been  published  elsewhere.  ^  It  is  sufficient  to 
say  here  that  such  results,  if  confirmed  by  the  subsequent  work  of  others, 
indicate  the  direct  dependence  of  at  least  a  large  proportion  of  cases  of  manic- 
depressive  insanity  and  dementia  prascox  on  pure  irritation,  often  situated  in 
the  teeth  and  jaws,  and  their  ready  curability  when  dealt  with  early. 

These  mental  cases  diverge  so  widely  from  the  conditions  commonly 
apprehended  as  reflex  nervous  disorders,  that  it  may  be  desirable  briefly  to 
discuss  the  mode  of  reaction  of  the  sensory  system  especially  in  view  of  the  fact 
that  in  none  of  these  cases  has  impaction  caused  local  pain,  and  in  few  of  them 
pain  of  any  kind.  Pain  has  been  absent  also  in  many  cases  due  to  caries  and 
alveolar  abscess.  It  is  fair  to  suppose  that  these  cases  are  not  exceptional, 
but  in  conformity  with  the  usual  action  of  the  sensory  system.  It  should  be 
possible  to  work  out  a  formula  of  sensory  action,  not  only  by  close  study  of 
dental  lesions,  but  by  instances  taken  from  familiar  processes  of  disease  of 
wider  range. 

The  obvious  fact  of  sensory  action  is  that  stimulation  causes  pain  which 
increases  pari  passu  with  the  irritation.  That  there  are  divergences  from  this 
rule  is  seen,  for  instance,  in  malaria  and  typhoid  fever.  The  irritant  poisons 
of  these  diseases  cause  headache  and  backache.  With  the  irritation  at  its 
height  the  pain  ceases,  and  delusions  and  hallucinations  supervene.  That  is, 
reaction  to  these  irritant  toxins  begins  in  pain  and  ends  in  definite  mental 
aberration. 

Certain  special  kinds  of  irritation  of  the  skin  cause  itching  and  tickling. 
Both  of  these  sensations  are  accompanied  by  more  of  emotion  than  of  pain,  and 
finally  a  point  is  reached  near,  if  not  actually  within,  the  confines  of  insanity. 

Hunger  and  thirst  are  sensations  akin  to  pain.  Deprivation  of  either 
food  or  water  causes  sufliering  by  irritation.  Delusions  and  hallucinations 
supervene,  and  the  suffering  is  replaced  by  delirium. 

Gall-stones  probably  cause  as  much  anguish  as  do  any  known  lesions. 
With  increase  of  the  irritation  there  results  a  numbing  of  the  sensation  and 
unconsciousness.  The  very  intensity  of  the  process  finally  withdraws  it  from 
the  field  of  conscious  reaction. 

A  man  is  run  over  by  a  locomotive,  and  both  of  his  legs  mangled  and 
severed.  With  nerves  and  nerve-ends  without  number  crushed  and  lacerated, 
he  often  lies  free  from  pain,  either  in  delirium  or  melancholy,  or  with  an 
exaltation  bordering  on  mania;  peripheral  irritation  has  overwhelmed  the 
mind. 

Chronic  processes  of  disease  give  a  wider  range  of  nervous  reaction,  often, 
like  some  of  the  acute  processes,  painless  from  the  beginning.  The  sufferer 
from  consumption  or  from  organic  heart-disease  becomes  depressed,  or,  in  some 
cases,  excited  and  maniacal,  delusions  are  developed,  and  the  closing  scene  is 
saddened  by  violent  insanity. 

The  emotional  and  mental  results  of  digestive  disturbances  are  usually 
more  trivial,  but  at  times  serious  and  threatening.     Uterine  and  ovarian  disease 


1  Cleveland  Medical  Journal,  Aug.,  1009. 


650  DEMENTIA  PR.'ECOX  CAUSED  BY  DENTAL  IMPACTION. 

and  sagging  kidneys  send  to  the  asylums  many  victims  in  whom  the  total  lack 
of  pain  or  other  localizing  symptom  makes  the  causative  lesion  obscure,  or  in 
whom  such  symptoms  are  slight  and  therefore  neglected. 

These  few  examples  have  been  purposely  selected  so  as  to  include  a  wide 
range  of  lesion,  both  in  location  and  in  kind.  It  should  be  possible,  by 
eliminating  features  not  common  to  all  of  them,  to  arrive  at  the  determining 
factor  in  the  causation  of  mental  disturbances  alike  in  the  sane  and  the  insane. 
This  common  factor,  whether  the  irritant  is  mechanical  or  chemical  and 
whether  active  in  the  skin  or  in  the  viscera  or  other  deep  tissues,  is  peripheral 
irritation.  Experiment  shows  that  nerve-cells  cannot  be  stimulated  centrally 
by  any  toxic  or  other  irritants  whatever,  which  leads  inevitably  to  the  same 
conclusion. 

After  even  so  brief  a  review  as  this,  of  painless  and  painful  reactions,  it 
is  unnecessary  to  accoimt  further  for  the  fact  that  the  lesions  underlying 
the  severer  psychoses  are  usually  painless.  Nowhere  in  the  body  can  painless 
sensory  imtation  be  studied  to  so  good  advantage  as  in  the  teeth  and  jaws. 
In  the  teeth,  in  spite  of  their  rich  nerve  supply,  pain  is  comparatively  rare, 
although  caries  and  other  diseases  are  so  common  as  to  be  almost  universal. 
Another  fact  contributes  to  the  greater  potency  of  dental  irritation,  the  fact 
that  pressure  on  sensory  nerve  structures  is  at  its  maximum  in  these  rigid, 
highly  innervated  tissues.  Stimulation  by  pressure  is  especially  productive  of 
emotional  and  mental  phenomena,  and  impaction,  exostosis  and  alveolar 
abscess  develop  the  possibilities  of  emotional  reaction  to  a  high  degree. 

The  causative  relationship  between  lesion  and  resultant  sj'mptoms  has 
been  made  especially  clear  by  the  fact  that,  in  the  majority  of  these  cases, 
improvement,  until  then  conspicuously  absent,  has  begun  within  a  week  or  two 
after  the  operation.  Such  a  sequence  is  peculiarly  convincing,  and  it  is  made 
more  rather  than  less  so  by  the  fact  that  in  several  instances  sharp  relapse 
has  followed  renewal  of  irritation  by  accident  or  dental  interference.  In 
several  cases  I  have  watched  the  development  of  an  alveolar  abscess  and  the 
simultaneous  evolution  of  an  acute  psychosis,  which  was  finally  relieved  by 
the  extraction  of  the  offending  tooth. 

Taken  together  these  experiments  constitute  a  mass  of  evidence  compar- 
able with  that  furnished  by  inoculation  experiments  in  tuberculosis  and  tetanus. 

Dementia  pra.>cox,  then,  is  a  product  of  purely  peripheral  irritation.  As 
dental  irritation  is  common  at  all  ages,  there  must  occur  consequent  mental 
disorders  in  the  young  and  the  very  old,  varying  from  the  dementia  prascox 
type  as  the  reaction-mode  varies  with  age.  The  predominating  type  of  lesion 
also  is  determined  by  the  age  of  the  patient. 

The  psychoses  of  senility,  when  dental  in  origin,  are  usually  caused  by 
caries,  abscess  and  exostosis.  In  children,  on  the  other  hand,  recent  experi- 
ment has  convinced  me  that  imbecility,  whose  S3anptoms  run  so  close  a  parallel 
with  dementia  precox  that  a  few  cases  of  acute  onset  have  lately  been  de- 
scribed as  demeniia  prcecocissima,  has  as  its  underlying  lesion,  in  many 
instances,  im.pactions,  usually  multiple,  and  capable  of  causing  the  terrible 
mental  ravaires  found  in  this  condition. 


CATARACT.  651 

The  prognosis  in  dementia  prrecox  has  been  sufficiently  indicated  above. 
In  patients  seen  early,  in  whom  existing  irritations  are  thoroughly  removed, 
the  outlook  is  good,  without  regard  to  the  family  history,  and  even  in  tlie 
presence  of  severe  symptoms.  In  the  psychoses  of  the  aged  and  the  dementia 
of  imbecility  in  childliood  the  problem  is  still  to  be  worked  out  by  early  and 
careful  removal  of  the  lesions  already  showTi  to  be  the  noxious  agents  in  the 
psychoses  of  adolescence. 


CATARACT. 
(Two  DemoDsiration  Lectures.)* 

By  CHAELES  A.  OLIVER,  A.M.,  M.D., 
PHILADELPHIA,    PA. 


(first  lecture.) 

This  afternoon  we  shall  consider  the  important  subject  of  cataract. 

The  term,  wliich  signifies  either  a  partial  or  a  complete  opacification  of 
the  crystalline  lens,  is  derived  from  a  Greek  word  "to  fall  down." 

Practically,  there  are  two  varieties  of  the  disease:  that  which  is  second- 
ary to  other  ocular  disturbances;  and  that  which  is  S}Tnptomatic  of  general 
disorder. 

The  objective  signs  and  symptoms  vary  in  accordance  with  the  variety  of 
the  disturbance,  being  mainly  dependent  upon  the  character,  the  density,  and 
the  extent  of  the  lenticular  opacity. 

In  the  immature  forms,  the  anterior  chamber  becomes  shallower  than 
normal,  this  being  due  to  a  forward  protrusion  of  the  iris,  produced  by  a  swell- 
ing of  the  lens.  In  hypermature  cataract,  the  anterior  chamber  may  become 
deep.     In  mature  cataract,  the  chamber  is  practically  of  normal  size. 

In  fairly-advanced  cases,  the  pupillary  area  generally  assumes  a  dull  gray 
tint  or  a  glistening  white  appearance,  in  accordance  with  the  age  and  the 
character  of  the  opaqueness  of  the  lens  material;  a  condition,  however,  which 
needs  careful  clinical  confirmation  before  any  certainty  as  to  diagnosis  can  be 
vouchsafed.  At  times,  the  pupil  may  appear  almost  black  or  brown  in  tint. 
In  some  indeterminate  cases  of  this  type,  the  catoptric  test  is  of  value.  Very 
rarely,  glistening  polychromous,  crystalline  masses  may  stud  the  pupillary  area. 

Study  of  the  eyeground  in  the  incipient  stages  of  the  disease  will  fre- 
quently, especially  in  comparatively  young  and  ametropic  subjects,  reveal 
coarse  local  changes  connected  with  the  uveal  tract.  In  all  cases,  except  when 
contraindicated,  and  in  all  stages,  mydriatics  should  be  resorted  to,  in  order  to 
make  as  thorough  a  study  of  the  intraocular  conditions  as  possible.  Vision  is 
always  disturbed  to  a  greater  or  a  less  degree,  according  to  the  extent,  tlie 
nature,  and  the  situation,  of  the  opacity. 


•Delivered  before  the  Junior  and   Senior  Classes  in  the  Woman's  Mcdicul  College 
of  Pennsylvania. 


652  CATARACT. 

The  subjective  signs  are  fairly  constant  in  ail  forms  of  cataract.  Large, 
circumscribed,  peripherally-seated  opacities  are  much  less  disturbing  to  sight 
than  small  ones,  or  even  faint  nuclear  hazes,  situated  opposite  the  pupillary 
area.  Nearly  always,  during  the  formative  period,  "cobwebs,"  "motes,"  and 
"veils"  are  spoken  of,  while  at  times,  distorted  and  multiple  vision  are  the 
chief  complaints.  As  the  lens  becomes  more  opaque,  however,  the  sight 
becomes  more  greatly  reduced,  until,  eventually,  large  objects  can  be  no  longer 
discerned;  although  if  the  condition  is  uncomplicated,  distinction  between 
light  and  darkness  remains. 

During  the  incipient  stages  of  cataract,  it  frequently  happens  that  pres- 
byopic subjects  are  able  to  dispense  with  the  lenses  that  they  have  ordinarily 
employed  for  near-work,  and  at  times,  they  may  desire  concave  ones  for  use 
during  distant  vision.  This,  which  is  due  to  an  increase  in  the  refractive 
poAver  of  the  eye,  consequent  in  part  upon  swelling  of  the  lens,  before  any  coarse 
opacity  makes  its  appearance,  is  known  as  "second  sight."  Pain  and  photo- 
phobia, which  are  best  relieved  by  smoked  glasses,  are  rather  infrequent  symp- 
toms in  the  early  stages  of  the  condition,  and  are  referable  to  the  pressure  of 
the  swollen  lens  upon  the  ciliary  body  and  the  iris. 

A  cataract  may  remain  limited  to  some  particular  portion  of  the  lens,  or 
it  may  gradually  involve  the  entire  lens-substance,  and  lead  to  practically  com- 
plete opacification.  The  former  variety,  which  is  divided  into  several  types, 
dependent  upon  the  locality  of  the  lens  which  is  involved,  may  be  either  con- 
genital or  acquired. 

When  the  opacity  is  situated  in  the  anterior  pole  of  the  lens,  the  condi- 
tion is  known  as  "anterior  polar  cataract"  or,  by  some,  as  "anterior  pyramidal 
cataract."  The  cause  of  the  congenital  form  is  supposed  to  be  due  to  some  foetal 
disturbance  operating  during  the  development  of  the  lens  structure.  In  the 
polar  variety,  which  is  one  of  the  true  cataractous  forms,  the  opacity  assumes 
the  figure  of  a  star  or  rosette  with  its  radii  extending  toward  the  periphery  or 
equator  of  the  lens.  It  has  been  seen  to  follow  contusions  of  the  globe;  to 
appear  as  a  part  of  so-called  pigmentary  retinitis;  and  to  exhibit  itself  as  a 
consequence  of  uveitis.  The  post-natal  form,  as  a  rule,  is  the  permanent 
result  of  rupture  of  a  deep  corneal  ulcer,  by  which  the  anterior  capsule  of  the 
lens  is  brought  into  contact  with  the  inflamed  cornea,  leading  to  proliferation 
of  the  endothelial  cells  of  the  lens  occupying  the  position  of  the  pupillary  area, 
with  the  formation  of  a  subcapsular  opacity  after  the  re-formation  of  the 
anterior  chamber;  this  being  in  addition  to  a  nebule,  which,  as  a  rule,  marks 
the  site  of  the  previous  corneal  ulceration. 

When  there  is  a  deposition  upon  the  anterior  face  of  the  capsule  which  in 
itself  is  irregular,  opaque,  and  thickened,  the  condition  is  known  as  "anterior 
pyramidal  cataract" ;  in  reality,  it  is  situated  in  both  the  lens  and  the  anterior 
capsule.  The  disturbance  in  vision  depends  upon  the  density,  the  extent,  and 
the  position  of  the  opacity.  Treatment,  as  a  rule,  is  unavailing,  except  the 
possibility  of  the  performance  of  an  optical  iridectomy,  should  the  opaque 
area  be  large  and  the  pupil  be  small. 

When  the  opacity  is  situated  at  the  opposite  pole  of  the  lens,  the  condition 


CATARACT.  653 

is  designated  as  ^'posterior  polar  cataract/'  or  "posterior  p3'ramidal  cataract/' 
In  most  instances,  the  posterior  form  is  congenital  in  character,  and  is  due  to 
some  interference  with  the  disappearance  of  the  hyaloid  artery.  It  is  recog- 
nized as  a  minute  dot  or  a  small  area  on  the  posterior  capsule  at  the  posterior 
pole  of  the  lens,  projecting  backwards  into  the  vitreous  humor.  True  posterior 
polar  cataract  is,  at  times,  found  as  the  initial  point  of  election  of  the  senile 
form,  and  is  not  infrequently  seen  associated  with  uveal  disorder  associated 
with  hanph-stream  disturbance  and  improperly  called  liquefaction  of  the  vit- 
reous humor.  Generally  it  appears  in  the  stellar  form.  In  this  variety,  inter- 
ference with  vision  depends  not  only  upon  the  size  of  the  opacit}^  but  also  upon 
concomitant  and  relevant  changes.  Treatment,  to  be  of  any  avail,  must  be 
directed,  if  possible,  towards  any  existing  cause. 

A  third  form,  although  separated  into  quite  a  series  of  groupings,  consists 
of  localized  opacities  in  various  parts  of  the  lens.  Opaque  stripes  extending 
from  pole  to  pole,  and  often  combined  with  the  central  and  the  zonular  forms, 
are  known  under  the  name  of  "spindle-shaped"  or  "fusiform"  cataract. 
Minute  dots,  usually  mostly  situated  in  the  central  portion  of  the  lens,  and 
frequently  grouped  in  the  anterior  cortex,  are  known  as  "punctate  cataract." 
Small  spheroidal  opacities  in  the  nucleus,  of  congenital  type,  have,  by  some, 
been  described  as  "central  cataract."  As  a  rule,  they  are  all  mere  concomitants 
of  gross  intraocular  pathological  change. 

Zonular  opacities  situated  between  the  nucleus  and  the  cortex  of  the  lens, 
both  of  these  portions  being  transparent,  are  most  uncommon.  At  times,  they 
may  progress  as  a  series  of  minute  opaque  processes,  or  "riders,"  as  they  are 
termed,  rendering  the  lens  quite  opaque.  This  variety  of  cataract,  also  known 
as  "perinuclear"  or  "lamellar,"  is  either  congenital  or  appears  during  infancy  in 
rachitic  subjects  or  in  those  who  have  been  affected  with  convulsions.  Usually, 
it  is  binocular,  and  almost  without  exception,  it  is  but  slowly  progressive, 
though  cases  in  which  it  has  become  total,  have  been  reported.  Upon  account 
of  the  situation  of  the  main  opacity  or  opacities,  vision  is  generally  markedly 
disturbed,  necessitating  either  artificial  mydriasis,  iridectomy,  or  lensrremoval. 

If  the  appearance  of  the  lens  shows  that  the  opacity  is  probably  stationary, 
and  if  the  opaque  zone  be  not  so  broad  that,  after  the  pupil  has  been  dilated 
with  a  mydriatic,  vision  is  bettered,  it  is  advisable  to  expose  a  portion  of  the 
transparent  periphery  of  the  lens  by  an  iridectomy,  thus  obtaining  an  eccentric 
pupil  through  which  the  subject  can  look.  If,  on  the  other  hand,  the  periph- 
eral zone  of  the  transparent  lens-matter  be  narrow,  and  if  there  be  evidences  of 
increase  in  the  cataract,  it  is  preferable  to  remove  the  lens,  either  by  extraction, 
when  the  nucleus  seems  well  hardened,  or  by  discission,  when  the  lens-matter 
appears  soft. 

Traumv\tic  Cataract.  As  a  rule,  this  form  of  lenticular  opacity  is  the 
result  of  a  rupture  or  a  disturbance  of  the  capsule  of  the  lens  from  an  injury 
which  permits  the  aqueous  humor  or  the  lymph  in  the  vitreous  humor  channels 
to  come  into  contact  with  the  lens-fibers.  The  laceration  in  the  capsule  may 
be  the  result  of  either  direct  injury  from  penetration  of  a  foreign  body  or 
indirect  disturbance  by  contusion. 


654  CATAHACT. 

Shortly  after  the  capsular  laceration,  the  lens-fibers  near  the  rent  begin 
to  swell  and  to  cloud.  Later,  if  it  be  the  anterior  capsule  which  is  injured, 
they  exude  into  the  posterior  and  anterior  chamber,  appearing  as  gray,  fluffy- 
like  masses.  The  aqueous  humor,  however,  soon  dissolves  the  lens-material 
which  has  gotten  into  the  two  chambers,  and  thus  gaining  freer  access  to  the 
interior  of  the  lens  by  the  removal  of  the  primary  plugs  of  lens-matter,  causes 
more  or  less  of  the  lens-substance  to  become  swollen,  opaque  and  absorbed.  In 
this  way,  after  the  lapse  of  some  time,  the  major  portion  of  the  lens-material 
may  be  dissolved  and  the  pupil  again  become  almost  l)lack.  In  most  cases, 
however,  the  capsular  wound  cicatrizes  and  becomes  closed,  stopping  the  process 
of  absorption  by  the  liquefying  method  before  the  removal  of  all  of  the  lens- 
matter  has  been  fully  accomplished. 

Many  cases  of  traumatic  cataract  pursue  their  courses  with  but  few  signs 
of  inflammation;  but  a  successful  termination  is  often  prevented  by  the 
development  of  an  iritis,  caused  either  by  direct  injury  or  by  the  pressure  of 
loose  or  swollen  lens-matter.  Septic  matter  may  be  also  introduced  into  the 
eye  either  at  the  time  of  the  traumatism  or  later,  giving  rise  to  an  iridocyclitis, 
or  a  panophthalmitis,  which,  if  left  alone,  may,  in  some  instances,  produce  an 
orbital  inflammation.  If  not  prevented,  it  not  infrequently  happens  that  sec- 
ondary glaucoma  supervenes.  This  condition  is  generally  due  either  to  a 
blocking  of  the  angle  of  the  anterior  chamber  by  pressure  or  to  the  presence  of 
a  mass  of  lens-matter  obstructing  the  passage  of  the  anterior  lymph  streams 
through  the  circumlental  space,  the  pupillary  area,  or  the  spaces  of  Fontana. 
The  increasing  forms  of  cataract  are  roughly  divided  into  four  stages.  As 
a  rule,  the  changes  begin  in  isolated  areas,  but  increase  and  multiply  until 
practically  all  of  the  lens-substance  is  afl'ected.  One  of  the  most  frequent 
varieties  is  that  known  as  'senile  cataract.' 

In  the  first,  or  incipient  stage,  the  opacities  usually  appear  in  the  periph- 
ery of  the  lens.  They  are  foimd  either  in  tlie  form  of  spots  or  of  stria  which 
radiate  from  the  lenticular  equator  toward  the  center  of  the  lens.  This  con- 
dition is  generally  known  as  "cortical  cataract."  In  other  cases,  the  nucleus  of 
the  lens  becomes  quite  hazy  and  opaque,  while  the  periphery  may  i-omnin  com- 
paratively clear.  This  variety  is  ordinarily  designated  as  "nuclear  cataract." 
In  most  instances,  however,  the  two  forms,  in  which  both  the  cortical  and 
the  nuclear  portions  of  the  lens  are  effected,  arc  associated. 

Clinically,  in  the  stage  of  development  of  the  cataract,  the  anterior  cham- 
ber will  be  found  to  be  but  slightly  shallowed  or  of  normal  depth,  and  the 
opacities  will,  by  oblique  ilhmiination,  appear  as  whitish  or  grayish  streaks  and 
sectors  with  dots. 

In  the  second  stage,  or  that  of  the  ripening,  the  leus  is  swollen,  this  being 
due  to  the  fact  that  it  contains  an  increased  quantity  of  fluid.  The  opacities 
are  more  pronounced,  while  numerous  clear  spaces  are  scattered  throughout 
the  lens-substance.  As  a  rule,  the  anterior  surface  of  the  lens  has  an  irides- 
cent, bluish-white  appearance.  The  anterior  chamber  is  shallow.  Clear  spaces 
situated  in  the  leus  between  the  iris  and  the  opaque  portions  of  the  lens-sub- 
stance, can  be  recognized  by  oblique  illumination,  allowing  a  shadow  of  the 
iri'^  to  be  cast  upon  the  lens  nt  the  side  from  which  tlip  b>l,t  ]^  thrown. 


CATARACT.  655 

In  the  third,  or  mature  stage,  the  lens  has  returned  to  its  ordinary  size, 
this,  in  great  measure,  being  due  to  the  loss  of  the  lenticular  fluids  by  resorp- 
tion. The  clear  spaces  in  the  lens-substance  are  replaced  by  opacities,  and  the 
anterior  chamber  regains  its  normal  depth.  The  iris  fails  to  cast  a  shadow. 
The  lens  presents  a  dull-gray  or  waxy  appearance,  and  its  anterior  face  is  seen 
to  be  situated  on  a  level  with  the  pupillary  margin  of  the  iris.  Should  the 
pupil  be  artificially  dilated,  it  will  be  found  that  the  red  reflex  from  the  fundus, 
which  can  be  dimly  obtained  while  the  cataract  is  in  its  immature  stage, 
is  lost. 

In  the  fourth,  or  hypermature  stage,  as  a  rule,  one  of  two  changes  occur: 
either  the  cortical  substance  disintegrates  and  becomes  fluid,  while  the  nucleus 
remains  hard,  so-called  "Morgagnian  cataract,"  or  the  broken-down  cortical 
substance  becomes  more  greatly  inspissated  and  dries  into  a  hard  and  some- 
what flattened  mass. 

In  hypermature  cataract,  the  anterior  chamber  is  of  normal  or  of  increased 
depth,  the  iris  generally  fails  to  cast  any  shadow,  and  the  surface  of  the  lens 
appears  either  homogenous  or  it  exliibits  irregular  dots  in  the  situation  of  the 
ordinary  physiologic  sectors.  If  the  overripening  process  be  more  advanced, 
fatty  and  calcareous  degenerations  in  the  lens  and  its  capsule  occur,  the 
anterior  chamber  becomes  deeper  than  normal,  and  tremulousness  of  the  iris 
can  he  recognized. 

In  j\Iorgagnian  cataract,  the  nucleus  may  sink  to  the  bottom  of  the  liquid 
contents  contained  within  the  lens-capsule,  the  walls  of  the  capsule  will  come 
in  contact  with  one  another,  and  the  volume  of  the  lens-mass  may  become 
increasingly  smaller,  until  nothing  but  a  thin,  transparent  membrane  remains: 
the  improperly  termed  "membranous  cataract." 

Practically,  according  as  the  dimensions  of  the  nucleus  of  the  lens  vary, 
a  cataract  is  spoken  of  as  "hard"  or  as  "soft."  When  there  is  no  grossly  hard 
nucleus,  the  cataract  is  said  to  be  soft;  so  that,  as  a  rule,  all  cataracts  occur- 
ring in  persons  under  thirtj'-five  years  of  age  fall  under  this  category.  In 
older  subjects,  however,  the  lenticular  nucleus  is  larger  and  it  is  more  or  less 
sclerosed;  so  that  opacities  occurring  in  such  persons  are  designated  as  hard 
cataracts,  although  the  cortices  of  such  lenses  may  be  quite  soft. 

In  some  senile  cataracts  the  general  sclerosis  becomes  so  pronounced  that 
practically  the  entire  lens  is  involved  in  it.  In  such  a  condition,  the  cataract, 
as  a  rule,  appears  of  a  dense  reddish  brown  tint,  and  is  markedly  translucent. 
This  variety,  when  complicated  with  the  remains  of  old  htcmorrhagic  extrava- 
sations, is  usually  known  as  "black  cataract." 

Secondahy  Cataract. — This  improperly  termed  condition  refers  to  the 
changes  that  are,  at  times,  observed  in  the  capsule  of  the  lens,  following,  for 
example,  extraction  of  the  lens.  It  it  frequently  seen  after  the  attempted 
removal  of  an  immature  cataract  in  which  a  portion  of  the  lens-substance 
remains.  This  occurs  when  the  capsular  membranes  become  agglutinated 
and  the  escape  of  any  remaining  lens-material  is  prevented.  In  many  instances 
it  happens  that  the  entire  pupillary  area  is  not  covered  by  the  opacity,  and 
fairly  satisfactory  vision  may  be  obtained. 


656  CATAKACT. 

When  the  condition  does  not  develop  until  some  months  after  tlie  primary 
operation  for  extraction,  it  is  generally  dependent  upon  a  fresh  proliferation 
of  the  so-called  epithelial  layer,  with  reduplication  of  the  capsular  remains. 

Etiology. — Congenital  conditions  operating  upon  the  causation  of  cata- 
ract, which,  at  times,  based  upon  well-founded  clinical  observation,  have  been 
determined  to  be  hereditary  in  type,  practically  resolve  themselves  either  into 
developm.ental  disturbances  in  the  eye  or  into  antenatal  inflammatory  reaction 
of  the  organ. 

General  disease,  independent  of  senility,  particularly  if  of  vascular  or 
lymphatic  type,  becomes,  at  times,  a  causative  factor.  In  these  cases  there  is 
an  imperfect  abstraction  of  autotoxic  substances :  (The  fact  that  subjects  with 
increased  blood-pressure  are  more  prone  to  cataract  than  those  with  normal 
vascular  tension,  illustrates  this  very  well).  Diabetes  mellitus  is  responsible 
for  about  one  per  cent,  of  cases,  this  variety  being  bilateral  and  developing 
rapidly.  Eachitis,  nephritis,  diabetes  (vascular  and  lymph  disturbances),  and 
some  affections  of  the  skin,  are  accredited  with  the  production  of  the  condition. 

Certain  drugs,  such  as  ergot  and  napthalin  introduced  into  the  system, 
are  eminently  causal  in  character. 

Local  diseases  and  traumatism  frequently  produce  all  forms  and  varieties, 
especially  in  subjects  in  whom  there  are  changes  affecting  the  l3Tnph-stream 
formation  and  circulation,  and  where  the  solvent  powers  of  the  l3Tnpb-fluids 
can  be  made  to  exert  their  influences  directly  upon  the  unprotected  and  the 
exposed  fibers  themselves.  Constant  direct  exposure  of  the  eye  to  high  degrees 
of  heat,  such  as  is  found  among  glass-blowers  and  puddlers  or  among  those 
who  are  subjected  to  continued  undue  action  of  x-rays,  ultraviolet  or  chemic 
rays,  etc.,  will  not  infrequently  give  rise  to  the  condition.  (In  this  condition, 
it  is  interesting  to  note  that  the  eye  situated  the  nearer  to  the  heat,  etc.,  is  the 
one  which  becomes  the  cataractous.) 

Pathology. — By  some  recent  authorities,  cataract  is  said  to  be  ordinarily 
caused  by  a  too-rapid  sclerosis  and  shrinkage  of  the  nucleus.  As  one  of  the 
results,  a  cessation  in  the  growth  of  the  surrounding  lens-fibers  takes  place. 
These  separate  from  one  another  at  certain  places,  especially  in  the  area  be- 
tween the  nucleus  and  the  cortex,  and  particularly  in  the  equatorial  region 
of  the  former,  producing  fissures  or  cavities  that  gradually  become  filled  with 
an  albuminous  liq-uid  which  coagulates  and  produces  spheroidal  bodies  known 
as  the  spheres  of  Morgagni.  Later,  the  lens-fibers  which  constitute  the  walls 
of  the  fissures,  become  translucent  and  unequally  swollen,  giving  rise  to  large 
and  mostly  nucleated  vesicles  of  varying  shapes  and  sizes.  After  disinte^Ta- 
tion  of  these  fibers  and  cells,  with  their  remains,  has  fairly  well  taken  place, 
the  so-termed  epithelium  of  the  lens  becomes  abnormally  thickened,  the  most 
peripheral  lens-fibers  become  vacuolated,  and  the  capsule  of  the  organ  becomes 
abnormally  separated  by  the  pathologic  processes  at  work.  In  contrast  to  this 
breaking-down  of  the  cortex,  the  shrunken  and  hardened  nucleus,  as  a  rule, 
remains  practically  unchanged. 

Prognosis. — The   diagnosis   of   cataract   being   once   established,   it   fre- 
quently becomes  necessary  to  be  able  to  decide  how  long  it  will  take  for  the 


CATARACT.  657 

cataract  to  become  mature,  or  what  is  known  as  -'ripe."  This  is  difficult,  as 
the  rate  of  progress  is  variable.  Senile  cataract  may  require  years  to  become 
sufficiently  opaque  and  hardened  for  operative  interference,  while  in  a  few 
rare  instances,  they  have  ripened  over  night.  It  is  generally  wise,  therefore, 
if  the  incipient  signs  of  cataract  be  discovered  in  elderly  persons,  not  to  alarm 
them  by  telling  them  of  their  existence,  as  vision  may  not  be  seriously  dis- 
turbed for  long  periods  of  time.  Particularly  is  this  so  in  nervous  females 
in  frail  health.  Under  all  circumstances,  however,  it  is  better  that  the 
diagnosis  be  communicated  to  some  responsible  friend  or  relative  of  the  patient. 
At  times,  among  men,  especially  with  those  who  are  harassing  themselves 
with  monetary  and  business  affairs,  it  is  best  to  acquaint  them  with  the  nature 
of  the  disturbance  in  order  that  better  hygienic  living  may  be  obtained,  and 
proper  arrangements  of  business  affairs  may  be  consummated. 

As  a  general  rule,  cataracts  in  the  young,  those  due  to  general  dyscrasia, 
and  the  secondary  forms,  all  develop  rapidly.  On  the  contrary'-,  all  forms  of 
opacity  which  commence  in  the  periphery  as  narrow  radii,  are  slower  in  exten- 
sion than  those  in  which  there  are  broad  and  dot-like  opacities. 

In  reference  to  the  prognosis  of  the  result  of  operative  interference  for 
the  removal  of  cataract,  numerous  factors  must  be  taken  into  consideration. 
In  many  cases  it  is  essential  to  determine  the  probable  condition  of  the  interior 
of  the  eye  by  means  of  the  so-called  candle-test.  No  matter  how  dense  a  catar- 
act may  be,  a  patient  with  a  healthy  fundus  should  be  able  to  determine  the 
exact  position  of  a  localized  glare  of  a  candle-light  placed  in  all  parts  of  the 
visual  field  while  the  organ  is  constantly  directed  towards  a  second  candle 
flame  situated  at  a  central  fixation-point.  If  the  image  of  the  moving  lio-ht 
be  lost  at  any  point  in  the  field,  a  disturbance  of  one  or  more  of  the  ocular 
tunics,  or  of  some  sentient  area  of  the  visual  apparatus  may  be  diagnosed  with 
almost  certain  precision,  and  the  prognosis  for  operation  rendered  relatively 
unfavorable.  If  all  light-perception  be  gone,  operative  procedure  is  useless. 
The  condition  of  the  appendages  and  adnexa  of  the  eye  must  be  noted,  and 
any  disturbance  of  them  must  be  carefully  treated  and  removed  as  much  as 
possible;   particularly  is  this  so  with  lacrymal  disease. 

The  state  of  health  of  the  patient  should  be  good  as  can  be.  General 
dyscrasiffi,  such  as  diabetes,  rheumatism  and  syphilis,  do  not  contraindicate 
operative  interference,  although  their  active  expressions  should  be  removed 
in  order  to  render  the  chances  of  a  successful  termination  more  certain. 
Healthy  old  age  is  no  contraindication. 

Profound  anaemias,  abnormal  mental  conditions,  and  pulmonary  compli- 
cations, are  all  apt  to  militate  against  operative  success,  which  should  not  be 
considered  as  such  until  at  least  six  months  after  the  actual  procedure. 

The  surroundings  of  the  patient,  the  character  of  the  place  of  operation, 
the  time  of  the  year,  and  the  hour  of  the  day,  must  all  be  taken  into  considera- 
tion. The  more  aseptic  the  conditions  under  which  the  operation  is  to  be 
performed,  the  gxcater  will  be  the  chances  for  a  successful  termination;  in 
fact,  this  is  the  greatest  of  all  the  prognostic  factors.  Operations  performed 
4 


658  THE  PROBLEM  OF  EFFICIENT  NURSING. 

in  hospitals  are  much  more  certain  to  have  a  good  outcome  than  those  that 
are  performed  in  private  houses. 

lu  regard  to  the  efforts  of  the  character  and  the  condition  of  the  cataract 
itself  upon  the  prognosis,  the  general  rule  is  that  the  more  nearly  mature  the 
cataract  is,  the  more  certain  are  the  chances  of  resultant  good  vision.  For 
many  reasons,  operations  upon  even  uncomplicated  immature  cataracts  are 
not  advisable.  The  procedure,  particularly  in  the  hands  of  the  inexperienced, 
is  apt  to  be  associated  with  some  disastrous  complication,  which  in  spite  of 
prompt  healing,  will  give  rise  to  later  loss  of  functioning  value.  This,  in 
spite  of  the  keen  rivalry  for  operative  procedure,  should  be  remembered  and 
considered,  whenever  possible,  in  order  to  give  the  patient  the  best  possible 
chances  for  a  permanent  successful  result.  In  some  very  old  subjects,  where 
the  nucleus  of  the  lens  is  large  and  well  sclerosed,  extraction  may  be  made 
with  every  chance  of  eventual  excellent  result.  Operations  upon  overripe 
cataracts  are  not  apt  to  be  very  successful.  The  frequency  of  "fluid  vitreous," 
the  degenerate  condition  of  the  zonule,  and  the  density  of  the  capsule,  are  all, 
with  the  possibility  of  the  production  of  secondary  glaucoma,  serious  compli- 
cating conditions. 

At  our  next  lecture  we  will  take  up  the  question  of  Treatment. 

(To  he  concluded  in  the  December  issue.) 


THH  PROBLEM  OF  EFFICIENT  NURSING  FOR  PERSONS  OF 
MODERATE  MEANS.* 

Bt  WlUAAli  0.  STILLMAN,  M.D., 

ALBANY,   N.   T. 

While  poverty  is  not  a  crime,  some  of  its  punishments  are  more  severe 
than  those  frequently  meted  out  to  criminals.  One  of  the  greatest  misfor- 
tunes which  falls  to  the  lot  of  persons  of  small  or  limited  means,  is  the 
entirely  inadequate  provisions  which  are  usually  within  their  reach  in  order 
to  secure  scientific  or  even  intelligent  nursing  care  in  case  of  sickness. 

Among  the  propositions  advanced  for  relieving  this  condition  have  been, 
first,  an  attempt  to  increase  the  general  knowledge  of  physiology  and  hygiene 
by  having  it  more  thoroughly  taught  in  the  public  schools.  This  certainly 
does  not  meet  the  essential  needs  of  the  case  which  are  largely  special  and 
technical.  A  second  proposition  is  that  there  shall  be  increased  hospital 
facilities  and  community  hospitals  established  for  rural  districts.  This  propo- 
sition seems  also  wholly  to  fail  to  meet  the  requirements  of  the  great  masses 
of  people  of  small  income,  both  in  city  and  country,  for  home  care.  A  third 
proposition  which  has  been  advanced,  is  that  the  visiting  nurse  should  solve 
the  problem.    While  the  visiting  nurse  is  a  most  excellent  idea,  in  cases  of 


*  Author's  abstract  of  paper  read  before  tbo  Medical  Society  of  the  State  of  New 
York,  .TannRjf,  1909. 


l-HE  PROBLEM  OF  EFFICIENT  NURSING.  659 

severe  sickness  close  and  constant  skilled  attention  is  imperatively  needed. 
A  fourth  plan  is  that  an  endowment  should  be  created  to  assist  patients  in 
paying  a  trained  nurse.  This  method  has  had  some  respectable  sponsors. 
Aside  from  the  fact  that  this  plan  is  financially  unattainable,  other  great 
difficulties  are  that  the  majority  of  people  of  small  means  do  not  care  to  be 
pauperized  by  any  such  method,  and,  furthermore,  that  the  supply  of  hos- 
pital trained  nurses  is  entirely  inadequate  to  meet  the  necessities  of  the  case 
for  our  vast  population,  and  is  likely  to  remain  so.  The  iifth  plan  is  that 
of  the  less  highly  trained,  lower-priced  nurses  and  attendants.  My  o^mi  experi- 
ence is  along  the  line  of  this  proposition.  Dr.  James  Tyson,  of  Philadelphia, 
is  quoted  as  saj'ing,  in  regard  to  poor  patients,  "Either  the  trained  nurse 
must  be  willing,  as  physicians  are,  to  take  such  cases  at  less  than  their  usual 
fee,  or  they  must  consent  that  there  shall  be  a  class  of  nurses  not  so  well 
trained  as  their  more  favored  sisters,  who  are  willing  for  this  reason  to  work 
for  smaller  compensation.'^  As  we  all  know,  the  resource  in  case  of  sick- 
ness for  most  families  of  small  income,  has  been  to  employ  what  is  com- 
monly known  as  "the  domestic  nurse,"  She  has  usually  been  without 
training,  oftentimes,  in  the  past,  superannuated  or  physically  partially  inca- 
pacitated, and  unable  to  earn  her  living  in  any  other  way.  In  all  probability 
the  great  mass  of  the  people  will  continue  to  employ  domestic  nurses,  and 
it  seems  to  me  that  the  most  reasonable  plan  which  presents  itself  is  to  give 
these  domestic  nurses  a  moderate  amount  of  scientific  and  technical  training 
so  as  to  fit  them  for  more  intelligent  and  efficient  service,  gradually,  in  the 
course  of  time,  increasing  the  standard  of  efficiency.  The  effect  of  any  sys- 
tematic attempts  to  giving  such  an  education  at  a  reasonable  price,  is  to 
attract  to  this  service  young  and  capable  women  who  will  rapidly  displace  the 
incompetent  persons  who  have  so  largely  monopolized  domestic  nursing. 

Nearly  four  years  ago  I  undertook,  in  connection  with  some  eighteen,  or 
more,  other  physicians,  aided  by  the  skilled  assistance  of  a  registered  nurse 
and  other  trained  help,  to  solve  this  problem  of  efficient  nursing  for  people 
of  moderate  means,  by  establisliing  a  regular  school  for  didactic  and  prac- 
tical instruction  for  domestic  nurses.  This  work  was  located  in  the  city  of 
Albany,  N.  Y.  It  is  unnecessary  to  go  through  the  details  of  the  development 
of  the  idea,  I  think  that  it  will  be  sufficient  to  give  the  results  as  they  now 
stand. 

We  have  undertaken  to  fit  women,  over  twenty-one  years  of  age,  who 
can  come  up  to  the  not  very  exacting  educational  and  physical  standard  for 
admission  to  our  school,  for  intelligent  domestic  service  by  a  six  months' 
course  of  insti-uction.  I  will  say  right  here  that  it  requires  a  good  student 
to  learn  the  lessons  taught  and  to  master  the  course  of  instruction  given. 
Those  persons  who  are  long  since  past  the  age  when  school  lessons  can  be 
easily  acquired,  find  it  very  difficult  to  take  the  course  and  are  discouraged 
by  U3  from  beginning  it. 

The  text-books  employed  are  those  usually  adopted  in  training  schools 
for  nurses.  The  course  of  lectures  continues  for  four  or  five  days  each  week 
for  Bixteen  weeks,  or  practically  four  months,  and  includes  instruction  in 


660  THE  PROBLEM  OF  EFFICIENT  NUESING. 

the  elements  of  nursing  by  the  head  nurses.  This  comprises  taking  tem- 
perature, pulse  and  respiration;  the  keeping  of  charts  and  records,  the  giving 
of  technical  lessons  in  sponging  and  baths  of  all  kinds,  in  bed-making,  and 
in  giving  packs  and  enemata;  the  care  of  instruments  and  materials,  the 
preparation  of  dressings  and  the  patient  for  minor  home  surgery;  the  use 
of  the  syringe  and  the  catheter,  the  preparation  of  antiseptics  and  also  of 
nutrient  enemata.  Our  registered  nurse  was  given  a  course  of  instruction 
in  dietetics  in  the  school  for  domestic  science  at  Columbia  University,  and 
we  have  a  diet  kitchen,  with  a  number  of  tables  and  gas  stoves,  so  that  a 
considerable  class  can  be  trained  at  one  time  to  prepare  food  for  the  sick 
according  to  the  latest  scientific  rules. 

The  physicians  undertake  to  give  instruction  in  anatomy  by  lectures  and 
demonstrations  on  the  skeleton  and  manikin.  They  also  teach  the  elemen- 
tary principles  of  physiolog}'  and  bacteriology,  and  demonstrate  the  sub- 
jects by  means  of  charts  and  the  microscope.  Materia  medica  is  taught,  and 
the  pupils  are  required  to  learn  the  dosage  and  administration  of  drugs, 
together  with  the  weighing  and  measuring  of  the  same,  and  the  physical 
properties  of  the  more  important  medicines.  Attention  is  given  to  poisons 
and  their  antidotes.  Special  emphasis  is  laid  on  the  study  of  hygiene  and 
sanitation,  including  the  usual  problems  relating  to  air  and  water,  the  dis- 
posal of  waste,  disinfection,  ventilation,  personal  hygiene,  etc.  Lectures  are 
also  given  by  physicians  on  accidents  and  emergencies,  including  instruction 
as  to  what  the  nurse  may  do  before  the  physician  arrives  in  cases  of  haemor- 
rhage, fracture,  drowning,  poisoning,  etc.  Lectures  are  given  on  obstetrics 
and  gynascology,  the  proper  care  of  the  child  and  the  mother,  and  on  the 
indications  for  the  surgical  relief  of  female  complaints.  Diseases  of  children 
and  the  care  of  infants  receive  special  attention,  and  contagious  and  infec- 
tious diseases  are  handled  from  the  standpoint  of  public  protection,  as  well 
as  the  protection  of  the  nurse  herself.  Special  attention  is  given  to  tuber- 
culosis; also  to  venereal  diseases,  typhoid  and  other  fevers,  small-pox,  etc. 
Lectures  are  given  on  general  nursing  in  medical  cases,  and  on  the  relation 
of  the  nurse  toward  the  patient  and  physician.  The  pupils  are  also  taught 
to  have  an  intelligent  idea  of  the  interpretation  of  symptoms,  and  what  they 
may  mean.  'For  instance,  they  are  taught  concerning  sputaim  and  its  preserva- 
tion for  examination,  the  significance  of  excessive  perspiration,  chills  and 
their  immediate  treatment,  the  urine  and  the  interpretation  of  its  ordinary 
clinical  appearances.  They  are  taught  concerning  the  significance  of  severe 
pain,  disturbances  of  nutrition,  also  of  the  excretions  and  digestive  apparatus. 
Finally,  a  very  moderate  knowledge  of  the  principles  involved  in  surgical 
nursing  is  given,  lest  a  nurse  be  called  upon  to  assist  in  emergencies  in  the 
country  or  when  hospital  trained  nurses  are  not  within  reach  in  the  home. 
This  instruction  includes  the  knowledge  of  sterilization  and  disinfection, 
the  care  of  instruments  and  surgical  supplies,  the  preparation  of  bandages, 
ligatures  and  gauze,  rubber  gloves,  as  well  as  what  to  do  in  the  case  of 
wounds,  fractures  and  the  care  of  the  patient  before  and  after  operations. 
The  methods  of  using  anaesthetics  are  also  explained.    Specialists  give  instrue- 


THE  PROBLEM  OF  EFFICIENT  NURSING.  6G1 

tion  concerning  the  rudimentary  principles  of  treating  diseases  of  the  eye, 
especially  ophthalmia,  and  the  knowledge  that  every  nurse  ought  to  have 
concerning  skin  diseases  and  maladies  of  the  ear,  nose  and  throat.  Elec- 
tricity and  electro-therapy  are  also  briefly  touched  upon. 

After  four  months  of  oral  instruction  and  class  work,  in  which  the  head 
nurses  give  as  many  lectures  as  do  the  physicians  (something  over  one  hun- 
dred in  all)  and  conduct  quizzes  on  aU  lectures  given,  the  pupils  are  required 
to  perform  two  months  of  actual  bedside  work  on  cases  to  which  they  have 
been  assigned,  subject  to  supervision  by  the  head  nurses.  They  are  care- 
fully instructed  in  regard  to  keeping  records  and  temperature  charts,  and 
are  also  expected  to  wear  a  nurse's  cap  and  distinctive  nurse's  dress.  Every- 
thing is  done  to  encourage  esprit  du  corps  and  respect  for  their  calling,  and 
they  are  encouraged  to  take  magazines  especially  published  for  nurses  and 
to  continue  their  studies  after  graduation.  A  few  ultimately  become  regis- 
tered nurses.  A  few  drop  out.  Many  remain  nurses.  The  fee  for  this 
course  of  instruction  is  the  nominal  one  of  twenty-five  dollars  in  full. 

Now  as  regards  the  results  obtained,  I  believe  them  to  be  very  much 
what  they  are  in  any  school.  Some  of  the  pupils  are  proficient  and  very 
satisfactory,  and  some  are  backward.  At  the  close  of  the  lecture  course, 
written  examinations  are  very  carefully  conducted,  and  I  am  sure  that  an 
inspection  of  the  examination  papers  would  surprise  physicians  generally 
because  of  the  indications  that  a  really  large  amount  of  detailed  and  tech- 
nical knowledge  has  been  absorbed.  Answers  to  questions  are  marked  on 
a  percentage  basis.  Previous  class  standing  is  considered.  Pupils  who  can- 
not come  up  to  the  required  standard  of  marks  are  refused  graduation.  Seven 
classes,  the  last  containing  thirty  pupils,  have  been  graduated  by  the  school, 
and  the  experiment  has  proved,  on  the  whole,  a  very  satisfactory  one  to  those 
conducting  it.  The  weak  point  is  the  short  practical  training.  It  will, 
undoubtedly,  in  time  be  extended,  and  probably  even  now  ia  proportionately 
as  long  as  that  received  by  the  average  medical  student  before  graduation. 

Our  nurses  usually  readily  find  employment,  and  the  demand,  as  a  rule, 
is  in  excess  of  the  supply.  Many  excellent  nurses  are  produced.  I  commend 
this  experiment  to  the  careful  consideration  of  the  profession  at  large  as  a 
practical  attempt  to  solve  the  problem  of  efficient  nursing  for  persons  of 
moderate  means.  It  is  not  felt  that  these  nurses  infringe  on  the  legitimate 
field  of  work  of  the  registered  nurse.  We  endeavor  to  have  the  prices  charged 
vary  from  eight  and  ten  dollars  a  week  for  undergraduates,  to  not  more  than 
twelve  to  fifteen  dollars  a  week  for  graduates.  Occasionally  our  plans  in  this 
respect  are  spoiled  by  persons  ofl^ering  eighteen  dollars  a  week  in  order  to 
secure  the  services  of  some  favorite  nurse.  After  all,  the  great  law  of  supply 
and  demand  must  be  the  final  arbiter  in  this  question  of  nurses  for  people 
of  moderate  means,  and  in  determining  what  compensation  shall  be  paid. 
In  most  families  the  question  is  now  between  a  moderate-priced  nurse  or 
none  at  all. 


6G2  THE  ADRENALS  IN  SUDDEN  DEATH. 


THE  ADRENALS  IN  SUDDEN  DEATH. 

By  GHAELES  E.  de  M.  SAJOUS,  M.D.,  LL.D., 

PHILADELPHIA. 

(Concluded  from,  the  October  numher). 

The  diagnosis  of  this  condition  is  rendered  difficult  by  the  fact  that  its 
sj'mi^toms  are  merged  with  those  of  the  causative  toxajmia.  We  may  conclude, 
however,  that  whenever  purpura  occurs  in  an  infant  or  young  child,  especially 
in  the  course  of  an  infectious  disease,  or  of  any  septic  condition,  after  a  burn, 
etc.,  the  vascular  tension  is  sufficiently  high  at  least  to  expose  the  adrenals  to 
haemorrhage,  and  the  child  to  more  or  less  sudden  death.  In  some  cases,  a 
sudden  onset  of  vomiting,  abdominal  pain,  convulsions  and  a  rise  of  temperature 
— without  purpura — precede  the  terminal  phenomena. 

The  treatment  of  threatening  adrenal  lisemorrhage  receives  no  attention 
in  the  literature  of  the  subject,  so  obscure  is  its  pathogenesis.  Interpreted 
from  my  \dowpoint,  however,  the  indications  are  clear:  the  excessive  vascular 
tension  must  he  reduced  to  relieve  the  adrenals  of  the  intense  congestion  which 
disrupt  their  tissues.  The  experience  of  J.  C.  Wilson  with  chloral  hydrate  in 
scarlatina  indicates  clearly  that  this  agent  is  well  borne  even  in  the  exanthemata. 
As  this  drug  promptly  reduces  the  vascular  tension  it  may  be  used  advan- 
tageously to  reduce  the  adrenal  engorgement.  Other  vasomotor  depressants, 
the  bromides,  preferably  the  sodium  salt,  or  veratrum  viride,  may  be  employed 
instead  if  preferred.  Simultaneously  enteroclysis  or  hj^Dodermoclysis  should 
be  used  to  enhance  the  osmotic  properties  of  the  blood  and  increase  its  fluidit}^, 
besides  promoting  diuresis  and  the  elimination  of  the  pathogenic  substances  to 
which  the  excessive  vascular  tension  is  due.  The  slow  enteroclysis  used  by  sur- 
geons, the  patient  being  in  the  Fowler  position,  is  valuable  in  this  connection. 

When  sudden  collapse,  lividity,  and  hypothermia  follow  the  phenomena 
described,  hannorrhage  into  the  adrenals  sufficient  to  inhibit  their  functions  has 
occurred.  Our  hopes  then  should  be  based  upon  the  possibility  that  one  of  the 
organs  may  be  able  to  resume  its  functions.  As  one-twentieth  of  both  adrenals 
suffices  to  sustain  life,  the  prolongation  of  the  vital  process  by  artificial  means 
is  tiien  indicated.  The  sloiv  injection  into  the  veius,  as  in  the  treatment  of 
shock,  of  adrenalin,  largely  diluted  in  saline  solution,  at  105°  F.,  is  the  best 
means  available.  The  fact  that  Crile*  kept  a  decapitated  dog  alive  over  ten 
hours  by  means  of  a  1  to  50,000  or  100,000  solution  of  this  kind,  emphasizes  the 
value  of  the  procedure. 

Type  2.  Toxwmia  in  the  Newborn. — An  infant  within  a  few  hours  or 
days  after  birth,  often  after  a  difficult  labor,  becomes  jaundiced  and  weak,  and 
has,  perhaps,  diarrhoea.  Collapse  comes  on  rapidly  and  the  child  dies.  At  the 
autopsy  the  only  lesion  found  is  located  in  the  adrenals,  which  are  enlarged, 
exceeding  in  size  in  some  cases,  the  underlying  kidneys.     They  are  brown,  bluish 

4  Boston  Med.  and  Sur,^.  Jour.,  Mar.  5,  1903. 


THE  ADRENALS  IN  SUDDEN  DEATH.  663 

or  slate-colored  and  their  parenchyma  is  converted,  in  the  most  marked  cases, 
into  a  pulpy  mass,  or  may  have  ruptured,  flooding  the  peritoneal  cavity  with 
blood.  In  most  instances,  however,  there  is  intense  hyperemia,  with  here  and 
there  an  hgemorrhagic  area. 

Judging  from  post-mortem  evidence  in  the  newborn,  adrenal  haemorrhage — 
macroscopic  and  microscopic — is  very  common.  Mattei-^  found  it  seventy-five 
times  in  ninety  autopsies  in  infants,  particularly  the  newborn.  Hamill*^  also 
judging  from  numerous  autopsies,  urges  that  "haemorrhage  into  the  suprarcnals 
is  very  common"  in  the  newborn. 

To  explain  the  predilection  of  infants  to  this  morbid  process  many  causes 
have  been  suggested:  the  pneumococcus  (Hamill  and  Dudgeon),  the  staphy- 
lococcus albus  and  aureus  (Eiesmann),  weakness  of  the  intra-adrenal  vessels, 
either  congenital  or  due  to  general  disorders  such  as  syphilis,  infantile  scorbutus, 
lesions  of  the  vascular  walls  of  a  degenerative  type,  miliary  aneurisms,  lack  of 
firmness  of  the  medullary  portion  of  the  organ,  compression  of  the  uterus 
during  labor,  compression  of  the  inferior  cava  of  the  infant,  thus  offering 
resistance  to  the  blood-streams  from  the  adrenals  which  flow  into  this  great 
channel,  ligation  or  prolapsus  of  the  funis  and  other  mechanical  factors  capable 
of  causing  passive  congestion  of  all  organs,  including  the  adrenals.  It  is  prob- 
able, however,  that  these  agencies  are  but  occasional  causes,  that  in  another 
small  proportion  of  cases  we  are  dealing  with  the  results  of  an  infection  such 
as  that  described  when  reviewing  the  first  type,  but  that  in  the  majority,  the 
pathogenic  factor  is  a  toxaemia  of  a  kind  which  so  far,  has  been  overlooked, 
and  due  to  toxic  products  of  metaholism. 

Abelous  and  Langlois,  in  1891,  pointed  out  that  one  of  the  functions  of 
the  adrenals  was  to  destroy  certain  waste  products.  My  own  labors'''  have  not 
only  sustained  this  view,  but  they  have  shown  that  the  adrenal  secretion  played 
an  important  part  (as  amboceptor)  in  all  immunizing  processes  in  conjunction 
with  thyroiodase  (opsonin)  and  trypsin  (complement),  including  the  conversion 
of  products  of  metabolism  into  eliminable  end-products.  When,  at  birth,  the 
infant  ceases  to  receive  maternal  blood  through  the  placenta,  it  has  to  depend 
upon  its  own  resources  for  this  important  function.  If,  for  any  reason,  this 
protective  role  is  imperfectly  carried  out,  intermediate,  and  therefore  toxic, 
wastes  are  allowed  to  accumulate  in  the  blood,  and  the  identical  process  described 
under  the  preceding  heading  prevails,  toxic  wastes  being  the  source  of  tlidi 
excessive  vascular  tension  instead  of  bacterial  toxins. 

The  pathology  of  this  type  is,  therefore,  in  its  general  lines  similar  to  that 
of  the  former.  It  differs  from  it,  however,  in  that  purpura  is  often  replaced 
by  a  cholangitis,  the  underlying  cause  of  the  icterus. 

The  treatment  recommended  for  the  first  type  is  also  indicated  here.  In 
bottle-fed  infants,  however,  the  essential  feature,  if  a  successful  issue  is  at  all 


5Lo  Sperimentale,  p.  386,  1883. 

6  Journal  Anieiicau   Medical   Association,   Dec.   5,   190S. 

7  "Internal  Secretions  and  the  Principles  of  Medicine,"  Volumes  I  and  II;    and  New 
York  Medical  Journal,  Feb.  20  and  27,  190!). 


664  THE  ADRENALS  IN  SUDDEN  DEATH. 

to  be  obtained,  is  their  immediate  transfer  to  the  breast  of  a  wet  nurse.  As 
Welch,  of  Johns  Hopkins,  stated  some  years  ago  in  his  Harvey  Lecture :  "The 
infant  comes  into  the  world  with  protective  antibodies  in  the  blood  smaller  in 
amount  and  less  energetic  than  those  possessed  by  the  healthy  adult.  It  is  an 
important  function  of  the  mother  to  transfer  to  the  suckling  through  her  milk 
immunizing  bodies,  and  the  infant's  stomach  has  the  capacity  which  is  after- 
ward lost,  of  absorbing  these  substances  in  an  active  state."  In  the  class  of 
cases  in  point,  the  milk  of  the  mother  or  of  the  wet  nurse  is  therefore  a  most 
potent  remedy  since  it  antagonizes  directly  the  toxemia.  In  a  case  of  my  own, 
practical  resuscitation  was  thus  obtained,  the  infant  being  out  of  danger  in 
twenty-four  hours. 

Type  3.  Adrenal  Apoplexy  in  the  Adult. — In  the  course  (1)  of  Addison's 
disease,  adrenal  cancer,  tuberculosis  of  any  organ  but  involving  the  adrenals, 
Bright's  disease,  obstructive  renal  or  cardiac  disorders,  pulmonary  congestions 
(especially  bronchitis  and  pneumonia),  extensive  burns;  or  (2)  of  an 
apparently  insignificant,  though  stubborn,  attack  of  lumbago,  accompanied 
perhaps  by  some  bulging  in  the  abdomen  or  immediately  below  the  floating 
ribs  on  one  side  or  the  other, — though  in  most  cases  the  well-defined  signs  of 
hemorrhagic  pseudo-cyst  of  the  adrenals  have  preceded  the  attack — there  occur 
sudden  and  severe  abdominal  pain  with  tympany  and  vomiting,  soon  followed 
by  collapse,  hypothermia,  rapid  and  weak  pulse,  coma  and  death  in  a  few 
hours,  or  within  very  few  days. 

The  cause  of  this  acute  lethal  process,  in  the  light  of  the  data  submitted 
in  the  foregoing  pages,  is  quite  plain :  the  functions  of  the  adrenals  had  ceased, 
and  the  phenomena  were  identically  the  same  irrespective  of  the  cause  of  the 
functional  arrest.  The  enumeration  of  these  causes  from  the  standpoint  of 
pathology  illustrates  the  multiplicity  of  the  disorders  in  which  the  prognosis 
is  materially  influenced  by  the  adrenals.  In  Addison's  disease,  tuberculosis, 
and  cancer,  of  the  adrenals,  death  occurs  when  the  last  vestige  (one-twentieth 
of  both  organs)  has  itself  yielded  to  the  local  destructive  process.  In  bron- 
chitis, pneumonia,  and  burns  it  results  as  in  the  infantile  type,  from  general 
toxaemia  which  in  turn  causes  ha^morrhagic  destruction  of  the  adrenals.  Eenal 
and  cardiac  obstructive  lesions,  by  increasing  the  vascular  tension,  also  submit 
the  adrenals  to  undue  stress  and,  therefore,  to  hsemorrhage.  The  second  order 
refers  to  a  condition  which  ultimately  ends  in  rupture,  a  gradually  developed 
ha^morrhagic  cyst  of  the  adrenal  per  se  which  may  attain  the  size  of  a  child's 
head  before  rupturing  and  pouring  its  contents  into  the  peritoneal  cavity. 

The  treatment  should,  of  course,  be  addressed  to  the  causative  disorder 
in  each  instance,  and  is  therefore  prophylactic.  Important  in  all  the  disorders 
enumerated  however,  is  the  reduction  of  excessive  vascular  tension  which,  by 
subjecting  the  adrenals  to  undue  stress,  exposes  them  to  hemorrhagic  destruc- 
tion, and  the  patient  to  sudden  death. 


ALBUMINURIA. 


BRONCHIAL  ASTHMA,  TREATMENT  OF. 


666 


Cyclopaedia  of  Current  Igitcraturc 


ALBUMINURIA. 

A  large  amoimt  of  albumin,  without 
blood  or  pus,  may  generally  be  taken  to 
indicate  chronic  tubal  nephritis,  and  this 
can  be  confirmed  by  a  high  specific  grav- 
ity, by  microscopic  examination,  and  by 
the  appearance  of  the  patient.  A  very 
small  trace  in  an  elderly  or  middle-aged 
man  will  probably  indicate  chronic  inter- 
stitial nephritis;  confirmatory  evidence 
can  be  found  in  the  aspect,  the  history, 
the  pulse  tension  and  tracing,  the  out- 
ward displacement  of  the  cardiac  impulse, 
the  accentuation  of  the  systolic  apical 
sound,  and  the  accentuation  and  redupli- 
cation of  the  second  sound  at  the  base  of 
the  heart.  These  indications  may  be 
further  supported  in  some  cases  by  the 
pale  color  and  low  specific  gravity  of  the 
urine;  less  frequently  information  may 
be  gathered  from  the  presence  of  casts 
and  from  their  predominant  characteris- 
tics. The  absence  of  casts  is  not,  how- 
ever, to  be  regarded  as  an  indication  that 
the  case  is  not  one  of  chronic  interstitial 
nephritis.  In  a  young  man  a  mere  trace 
of  albumin  may  be  the  only  evidence  of 
a  functional  albuminuria,  and  the  diag- 
nosis must  then  rest  upon  negative  e\a- 
dence  to  a  large  extent,  one  of  the  most 
important  factors  being  the  relatively 
high  specific  gravity,  unless  this  has  been 
influenced  by  nervousness  or  by  the  recent 
consumption  of  a  large  quantity  of  liquid. 
With  the  same  limitations  the  deep  color 
of  the  urine  will  lend  confirmatory 
evidence. 

There  are  so  many  causes  for  great 
variations  in  the  condition  of  the  urine 
that  stress  cannot  be  laid  upon  the 
amount  of  albumin  without  paying  due 
regard  to  most  of  the  changes  which  have 


been  touched  upon  by  the  writer.  After 
all,  albimiin  is  merely  an  indication  of  an 
abnormal  condition,  it  is  not  a  disease. 
Therefore,  as  with  every  other  s3Tnptom, 
by  itself,  it  affords  no  reasonable  ground 
for  a  diagnosis.  Numerous  other  signs 
and  sjTnptoms  must  be  carefully  weighed, 
perhaps  at  short  intervals,  before  it  is 
justifiable  to  express  more  than  a  pro- 
visional diagnosis.  Nestor  Tirard  (Lan- 
cet, October  9,  1909). 

ASTHMA,  CALOMEL  IN. 

The  writer  prescribes  a  powder  of  calo- 
mel, from  one-half  to  two  grains,  accord- 
ing to  the  habit  of  the  patient,  accom- 
panied, of  course,  by  some  of  the  usual 
antispasmodic  remedies,  and  his  experi- 
ence is  that  relief  is  rapidly  obtained, 
even  before  purgation  takes  place.  Other 
cathartic  drugs  do  not  seem  to  have  the 
same  effect  or  certainly  not  so  rapidly, 
and  the  ease  with  which  all  the  powder  or 
tablet  is  taken  is  an  important  factor. 
C.  B.  P.  Tivy  (British  Medical  Journal, 
September  25,  1909). 

BRONCHIAL  ASTHMA,  TREATMENT  OF. 

Bronchial  asthma  is  a  disease  caused 
by  irritation  of  the  hyperassthetic  nervous 
system  of  respiration.  Its  cause  is  to  be 
sought  not  in,  but  outside  of  the  lungs. 
The  mucous  membrane  of  the  nose  la  the 
portion  of  the  respiratory  tract  most  ex- 
posed to  injuries  from  without,  and 
anomalies  of  the  mucous  membrane  and 
of  development  are  caused  which  produce 
points  of  pressure  that  often  excite  bron- 
cliial  asthma  in  persons  of  nervous  dis- 
position, and  in  such  cases  operative 
treatment  of  such  points  of  pressure  are 
indicated.     In  every  asthmatic  the  ap- 


666 


DIABETES,  TREATMENT  OF. 


plication  of  the  high  frequency  inter- 
rupted current  to  the  vagus,  accessorius, 
phrenic,  and  sympathetic  nerves  produce 
an  anesthetic  effect,  relieve  the  breathing 
after  a  few  minutes,  and  after  several 
sittings  often  permanently  terminate  the 
asthma.  The  positive  electrode  should 
be  placed  on  the  lateral  triangle  of  the 
neck  or  in  the  nose.  The  writer  also 
finds  the  use  of  electricity  in  this  manner 
useful  in  other  pains  or  diseases  of  the 
nerves,  such  as  migraine,  intercostal  neu- 
ralgia, angina  pectoris,  lumbago,  sciatica, 
and  pain  in  the  lar3^ix.  Otto  Ganzel 
(Medizinische  klinik,  August  8,  1909; 
New  York  Medical  Journal,  October  9, 
1909). 

DIABETES,  TREATMENT  OF. 

All  authorities  recommend  the  admin- 
istration of  large  quantities  of  fat  on 
account  of  its  high  caloric  value  and 
easy  assimilation.  In  all  his  patients, 
who  have  taken  only  a  small  quantity  of 
fat,  the  writer  has  observed  nothing  but 
good  effects,  but  the  large  quantity  often 
given  caused  severe  digestive  disorders 
in  children,  which  class  of  patients  are 
especially  the  subjects  of  this  study.  In 
some  cases  vegetable  fats  can  be  sub- 
stituted for  animal  fats  with  great  ad- 
vantage. Olive  oil  is  the  best  form  and 
is  especially  well  borne  by  young  sub- 
jects. It  should  be  given  in  gradually 
increasing  doses,  from  one  teaspoonful  to 
three  tablespoonfuls  and  more  after  each 
meal. 

What  to  do  when  acetone  and  diacctic 
acid  appear  is  a  problem  to  be  met  by  the 
practitioner  and  these  usually  are  met 
with  when  a  person  is  suddenly  deprived 
of  all  carbohydrates.  The  text-books 
usually  advise  a  return  to  carbohydrates 
in  care  these  substances  appear  in  large 
quantities,  but  the  writer  thinks  this  dic- 
tum   must    not    be    applied    indiscrimi- 


nately. In  the  majority  of  cases,  espe- 
cially those  of  a  milder  type,  the  acetone 
will  usually  disappear  in  a  few  days  even 
though  the  carbohydrates  be  still  with- 
held. He  has  never  seen  a  single  case 
in  which  coma  followed  a  strict  protein 
and  fat  diet,  with  the  exclusion  of  all 
carbohydrates.  Those  cases  which  have 
been  long  under  ol)servation  and  have 
been  kept  on  a  strict  carbohydrate-free 
diet  for  some  time  are  somewhat  differ- 
ent. If  they  develop  acetone  bodies  it  is 
necessary  to  give  them  some  carbohy- 
drates with  corresponding  diminution  of 
the  proteid,  till  the  diacetic  acid  dimin- 
ishes or  disappears.  The  writer  does  not 
find  it  necessary  to  allow  a  ratio  of  thirty- 
five  to  forty  calories  per  Idlo,  at  least  for 
patients  who  are  mostly  at  rest  in  bed. 
He  gives  examples  of  the  diets  used,  in 
two  of  his  cases  reported  averaging  below 
twenty-five  calories  per  kilo.  In  the 
other  case  a  much  larger  amount  was 
given  at  first,  it  being  a  case  of  some 
duration,  but  was  afterwards  reduced  to 
about  thirty  calories  per  kilo. 

There  is  hardly  a  drug  that  has  not 
been  used  in  the  treatment  of  diabetes 
but  there  are  three  drugs  to  which 
he  specially  calls  attention.  These  are 
sodium  bicarbonate,  opium  and  atropin. 
The  use  of  sodium  bicarbonate  is  usually 
limited  to  the  treatment  of  acidosis  but 
the  author  thinks  that  given  with  a  car- 
bohydrate-free diet  and  in  sufficiently 
large  doses — thirty  to  forty  grains  a  day 
— it  has  a  distinctly  inhibitory  action 
on  the  excretion  of  sugar.  This  state- 
ment has  also  been  made  by  Eeale. 
Opium  and  its  alkaloids  is  specially  valu- 
able where  the  neurotic  element  is  pres- 
ent. The  objection  to  their  use  is  the 
danger  of  causing  habits  and  sometimes 
the  uncertainty  of  their  action.  It  has 
been  the  writer's  good  fortune  to  discover 
that  atropin  has  a  greater  effect  on  the 


EXOPHTHALMOS  IN  CHRONIC  NEPHRITIS. 


FLATULENCY. 


667 


excretion  of  sugar  than  any  of  the  drugs 
that  have  been  tried.  It  has  the  advan- 
tage of  being  well  borne  in  large  doses 
if  given  cautiously  and  in  gradually  in- 
creasing amounts.  It  causes  the  disap- 
pearance of  glycosuria  more  quickly  than 
withdrawing  the  carbohydrates,  and, 
when  these  have  been  cautiously  in- 
creased, it  is  often  possible  to  suppress 
any  glycosuria  that  may  come  on  with 
atropin  alone,  without  any  change  of 
diet.  •  The  sulphate  was  the  salt  gen- 
erally used,  but  the  methyl-bromide  has 
some  advantages  in  being  less  toxic. 
With  the  sulphate  the  initial  dose  with 
adults  was  one-fiftieth  of  a  grain  t.i.d. 
gradually  increased  sometimes  to  one- 
twentieth,  t.i.d.  These  large  doses  were 
"seldom  required.  In  children  it  is  ad- 
visable to  begin  with  one-two  hundred 
and  fiftieth  or  less.  If  toxic  effects  are 
observed,  increasing  the  dose  should  be 
stopped  or  the  drug  stopped  entirely.  J. 
Eudisch  (Jour.  American  Medical  Asso- 
ciation, October  23,  1909). 

EXOPHTHALMOS  AND  OTHER  EYE  SIGNS 
IN  CHRONIC  NEPHRITIS. 
Attention  is  directed  by  the  writers  to 
the  frequent  occurrence  of  exophthalmos 
in  chronic  nephritis  and  the  view  is  ad- 
vanced that  the  exophthalmos  of  chronic 
nephritis  is  very  analogous  to  that  of  ex- 
ophthalmic goiter,  being  but  one  of  a 
number  of  evidences  of  a  chronic  systemic 
intoxication.  They  do  not  think  that  ex- 
ophthalmos is  due  to  chronic  hyperten- 
sion, but  are  of  the  opinion  that  the  arte- 
rial hypertension  and  the  eye  signs  are 
but  evidences  of  poisoning  by  perhaps 
separate  toxins.  It  is  well  known  tbat 
uraemia  may  develop  in  a  patient  whose 
blood-pressure  is  not  increased,  and  it 
seems  very  probal)le  that  in  chronic  renal 
insufficiency  several  toxins  are  present  in 
the  blood  manifesting  themselves  in  vari- 


ous ways.  Among  the  total  admissions 
of  thirty-three  cases  of  chronic  nephritis 
during  the  first  four  months  of  1909  at 
Johns  Hopkins  University  sixteen  (48.4 
per  cent.)  showed  exophthalmos.  The 
exophthalmos  varied  greatly  in  degree,  as 
did  the  gravity  of  the  nephritic  process  in 
the  various  individuals;  those  cases  jDre- 
senting  evidences  of  serious  intoxication 
(suburjemic  or  uraemic  symptoms)  most 
frequently  showed  exophthalmos  and  one 
or  more  of  the  allied  ocular  signs — 
anisocoria,  von  Graefe's,  Moebius's,  or 
Stellwag's  sign.  Exophthalmos  has  been 
an  obvious  sign  in  all  of  the  patients  with 
chronic  nephritis  who  have  died  in  the 
Johns  Hopkins  Hospital  since  January 
1,  1909,  seven  in  number.  The  authors 
also  observed  that  the  patients  with 
chronic  nephritis  showing  albuminuric 
retinitis  during  this  period  showed  in- 
variably exophthalmos,  with  one  or  more 
of  the  other  ocular  signs.  They  empha- 
size that  exophthalmos  is  but  one  of 
several  ocular  signs  which  are  frequently 
present  in  chronic  nephritis.  Llewellys 
F.  Barker  and  Frederick  M.  Hanes 
(American  Journal  Medical  Sciences, 
October,  1909). 

FLATULENCY. 

Besides  dietetic  measures  and  exercise, 
the  author  ascribes  great  importance  to 
massage  of  the  abdomen  in  treatment  of 
habitual  flatulence — energetic  massage 
with  rather  long  sittings — attributing 
the  benefit  to  the  stimulation  of  the 
venous  circulation.  Purgatives  should 
be  used  only  in  emergencies.  Charcoal 
and  ethereal  oils  sometimes  benefit,  al- 
though this  is  not  the  rule.  With  a  ten- 
dency to  flatulence  there  are  generally 
signs  of  interference  with  the  abdominal 
circulation,  some  enlargement  of  tlie  liver 
or  signs  of  beginning  arteriosclerosis, 
which  explains  the  benefit  from  massage 


668 


OBESITY. 


QUINSY,  IxiEATMENT  OF. 


of  the  abdomen.  Cardiovascular  alfec- 
tions  also  induce  a  tendency  to  flatuluuce 
from  this  same  cause.  It  is  also  lial)le 
to  occur  with  cirrhosis  of  the  liver  before 
the  stage  of  ascites  is  reached.  A  seden- 
tary occupation  and  lack  of  exercise  are 
important  factors  in  inducing  sluggisli- 
ness  in  the  abdominal  venous  circulation 
with  its  consequent  defective  absorption 
of  gases  and  resulting  flatulency.  The 
cardiovascular  system  should  be  carefully 
examined  as  the  first  step  in  treatment 
or  the  measures  advised  for  the  flat- 
ulency are  liable  to  overstrain  a  weak- 
ened heart.  E.  Schwarz  (Medizinische 
Klinik,  September  5,  1909). 

OBESITY. 

In  the  most  common  forms,  obesity  is 
due  either  to  over-feeding  or  lack  of 
exercise,  frequently  these  two  factors  are 
combined.  It  is  easy  to  understand  why 
excessive  corpulence  follows  these  two 
factors.  It  is  much  more  difficult  to  ex- 
plain those  cases  in  which  although  the 
proper  amount  of  food  is  taken  and  suffi- 
cient exercise  is  indulged  in,  obesity 
develops.  This  has  been  termed  consti- 
tutional obesity.  After  discussions  which 
have  been  prolonged  for  years  and  after 
careful  investigations,  the  conclusion  has 
now  been  arrived  at  that  in  such  cases 
tlie  oxidation  powef  of  the  organism  has 
become  weakened.  This  is  a  factor  which 
bears  a  direct  relationship  with  the  thy- 
roid gland.  Temporary  changes  in  that 
gland  raise  or  depress  the  power  of 
oxidation.  The  various  forms  of  con- 
stitutional obesity  may  be  classified  as 
follows:  (a)  primary  thyreogenic  obes- 
ity, dependent  on  actual  changes  in  the 
thyroid  such  as  atrophy,  degeneration, 
fimctional  weakness,  and  so  on;  (b) 
secondary  thyreogenic  obesit}^  that  is  to 
say,  functional  anomalies  of  the  tliyroid 
on  the  action  of  other  organs,  such  as  the 


jjancreas,  hypophysis  cerebri,  suprarenals, 
thymus,  pineal  gland,  and  perhaps  other 
organs  also,  so-called  chemical  correla- 
tions by  means  of  internal  secretions. 
These  questions  have  not  only  a  theo- 
retical interest,  but  possess  important 
bearings  on  therapeutics,  as  anomalies  of 
metabolism  loiown  under  the  term  of 
obesity  can  only  be  treated  rightly,  when 
in  any  given  instance,  the  origin  of  these 
anomalies  has  been  correctedly  recog- 
nized. Carl  von  Noorden  (Jour.  Ameri- 
can Medical  Association,  Oct.,  9,  1909). 

GUINSY,  TREATMENT  OF. 

The  frequency  of  suppurative  amyg- 
dalitis in  every  day  practice  causes  it  to 
be  a  disease  whose  management  is  a  mat- 
ter of  no  small  importance.  Attempts  to 
check  its  progress  are  usually  futile, 
unless  resorted  to  very  early  in  the  course 
of  the  attack.  Such  abortive  measures 
consist  in  the  administration  of  guai- 
acum,  salicylates,  etc.,  the  use  of  throat 
paints,  a  brisk  purge,  and  the  external 
application  of  cold  compresses.  With 
regard  to  internal  remedies  a  combina- 
tion of  aspiron  and  salol,  five  grains  of 
each  every  two  hours,  is  most  useful. 
Cold  compresses  in  the  early  stages  are 
of  more  value  and  give  greater  relief  than 
poulticing.  Surgical  measures  hold  a 
high  place  in  the  treatment  of  quinsy, 
and  the  importance  of  early  incision  can 
scarcely  be  too  strongly  advocated,  the 
mucous  membrane  being  alone  incised, 
and  the  operation  completed  by  the  use 
of  Lister's  sinus  forceps.  Occasionally 
the  supratonsillar  incision  must  be  car- 
ried through  the  anterior  pillar  in  order 
to  secure  free  drainage.  Tlie  question  of 
tracheotomy  seldom  arises,  though  oedema 
glottidis  has  been  reported  by  Mygind, 
of  Copenhagen,  and  others.  In  most 
cases  the  oedema  of  the  uvula  and 
epiglottis  rapidly  subsides  as  soon  as  the 


TETANUS,  TREATMENT  OF. 


URIC  ACID,  TREATMENT  OF. 


669 


supratonsillar  swelling  has  been  opened. 

Inhalation  of  steam  from  a  bronchitis 
kettle  often  affords  the  patient  great 
relief.  Compound  tincture  of  benzoin 
ma}^  with  advantage,  be  added  to  the 
water.  The  use  of  creosote  is  less  bene- 
ficial, as  it  causes  a  drjTiess  in  the  throat, 
which  counteracts  the  otherwise  soothing 
influence  of  the  steam.  Spraying  the 
throat  with  hydrogen  peroxide  (10  vols.) 
is  a  valuable  remedy,  especially  if  there 
is  much  foetor  or  co-existent  follicular 
tonsillitis.  Considerable  benefit  is  often 
derived  from  the  sucking  of  small  pieces 
of  ice  at  frequent  intervals.  In  virtue 
of  its  anaesthetic  effect  it  renders  swallow- 
ing much  less  painful,  and  has,  in  addi- 
tion, a  direct  influence  upon  the  inflam- 
matory process. 

Constitutional  treatment  should  never 
be  forgotten.  The  debilitating  effect  of 
an  attack  of  quinsy  is  well  known,  and 
in  many  cases  stimulation  is  called  for. 
Strychnine  may  be  administered  hypo- 
dermically,  and  small  doses  of  brandy  if 
the  patient  is  able  to  swallow.  A  mix- 
ture containing  strychnine  and  iron  is  of 
considerable  value  as  soon  as  the  acute 
stage  has  passed.  Nourishing  fluid  diet, 
such  as  eggs,  milk,  jellies,  and  clear 
soups,  should  be  given  throughout,  and 
increased  as  the  appetite  returns.  Serum 
treatment  must  be  resorted  to  in  those 
dangerous  cases  of  quinsy  which  tend  to 
assume  a  septicaemic  aspect.  D.  J. 
Guthrie  (Glasgow  Medical  Journal,  Sep- 
tember, 1909). 

TETANUS,  TREATMENT  OF. 

Prophylactic  injections  of  antitetanic 
serum  in  cases  of  suspicious  wounds  are 
unquestionably  of  great  value  in  pre- 
venting the  development  of  tetanus. 
After  the  onset  of  the  disease,  the  local 
treatment  of  the  wound,  aside  from  the 
usual  antiseptic   measures,    should    in- 


clude the  use  of  balsam  of  Peru,  a  rem- 
edy which  has  been  shown  to  possess 
some  antagonistic  action  on  the  tetanus 
toxin.  None  of  the  many  special  meth- 
ods of  injcctiug  the  antitoxin  has  prov- 
en of  value,  and  some  of  them  are  too 
dangerous  for  general  use.  Subcutan- 
eous injections  of  serum  in  massive  doses 
will  yield  equally  good,  if  not  better, 
results.  Spinal  injections  of  magnesium 
sulphate  solution,  by  eliminating  the 
spasms,  will  tide  many  a  patient  on  to 
recovery,  who  would  die  under  any  form 
of  serum  treatment  alone.  This  form 
of  treatment  is  destined  to  lower  the 
death  rate  from  tetanus  more  appre- 
ciably than  anything  which  has  been  ad- 
vanced heretofore,  including  the  discov- 
ery of  the  speciflc  serum.  Great  care 
should  be  exercised  in  arriving  at  the 
dosage.  William  Hessert  (Surgen^, 
Gynecology  and  Obstetrics,  August, 
1909). 

XTRIC  ACID,   TREATMENT   OF, 

All  the  uric  acid  solvents,  so  much 
vaunted,  appear  to  be  equally  useless  for 
that  special  purpose;  but  the  writer  be- 
lieves that  salines  have  their  value,  if 
given  with  discrimination,  for  facilita- 
ting the  excreting  power  of  the  several 
abdominal  glands.  And  in  thi=;  way 
water  is  probably  one  of  the  best  reme- 
dies, but  even  drinking  water,  if  exces- 
sive, is  not  to  be  indulged  in  with  im- 
punity. In  the  author's  opinion,  the  late 
Sir  William  Eoberts's  simple  prescrip- 
tion of  half  a  drachm  of  potassium  bi- 
carbonate in  a  tumbler  of  water  at  bed- 
time, to  stem  the  nightly  acid  tide,  is, 
on  the  whole,  one  of  the  most  useful 
recommendations,  apart  from  tonics, 
cures  at  watering  places,  and  change  of 
scene  and  air.  J.  F.  Goodhart  (Prac- 
titioner, July,  1909). 


670 


WHOOPING  COUGH,  QUININ  IN. 


BOOK  REVIEWS. 


WHOOPIHG  COUGH,  QTJINIK  IN. 

The  writer  has  been  giving  quinin  in 
an  epidemic  of  whooping  cough,  and 
states  that  the  disease  seemed  to  be 
aborted  in  every  case  in  which  qiiinin 
was  given  in  large  doses  systematically 
for  several  days  in  succession  and  the 
drug  retained.  The  pertussis  was  of  an 
unusually  serious  type,  both  on  account 
of  its  intensity,  the  number  of  compli- 
cations observed  and  of  adults  affected. 
His  experience  suggests  an  actual  causal 
efficiency  of  the  drug.  The  author  has 
always  found  exceptional  tolerance  for 
quinin  in  children,  no  appreciable  dis- 
turbances having  been  noted  in  a  num- 
ber of  children  in  an  endemic  focus  of 
malaria  who  took  by  mistake,  for  mal- 


aria, 6  and  7  Gm.  of  quinin  bisulphate. 
For  pertussis  he  did  not  hesitate  to  in- 
ject in  the  course  of  a  day  0.5  Gm.  of 
acid  quinin  hydroclilorid  for  infants 
and  1  Gm.  for  children  up  to  the  age  of 
5.  On  cessation  of  the  tendency  to 
vomit  he  gives  the  drug  by  the  mouth 
and  keeps  it  up  for  eight  or  ten  days,  by 
v/hich  time  the  disease  has  usually  com- 
pletely subsided. 

The  vvriter  relates  a  number  of  in- 
stances to  show  the  prompt  relief  from 
the  quinin.  One  patient  had  pertussis 
during  confinement,  but  all  s3'mptoms 
vanished  the  sixth  day  under  1.5  Gm.  of 
the  quinin  daily.  F.  Andalo  (Poli- 
elinico,  July  4,  1909;  Journal  American 
Medical  Association,  August  21,  1909). 


ANNOUNCEMENT. 


Present  Status  of  Obstetrical  Teaching:  in  Europe  and  America. 

The  President  of  the  American  Gynecological  Society  has  appointed  a  committee  to 
report  at  the  next  annual  meeting  in  Washington,  on  the  "Present  Status  of  Obstetrical 
Teaching  in  Europe  and  America,"  and  to  recommend  improvements  in  the  scope  and 
character  of  the  teaching  of  obstetrics  in  America. 

The  committee  consists  of  the  professors  of  obstetrics  in  Columbia  University,  Univer- 
sity of  Pennsylvania,  Harvard,  Jefferson  Medical  College,  Johns  Hopkins  University,  Cornell 
University,  and"  the  University  of  Chicago. 

Communications  from  anyone  interested  in  the  subject  will  be  gladly  received  by  the 
cliairman  of  the  committee.  Dr.  B.  C.  Hirst,  1821  Spruce  Street,  Philadelphia,  Pa. 


5ool<  H^ views 


An  Experimental  Study  of  Sleep.  (From  the  Physiological  Laboratory  of  the  Harvard 
Medical  School,  and  from  Sidis'  Laboratory.)  By  Boris  Sidis,  11. A.,  Ph.D.,  M.D., 
Author  of  "Psychopathological  Researches  in  Mental  Dissociation."  Boston:  Richard 
G.  Badger.     The  Gorham  Press,  1909. 

Dr.  Sidis,  who  has  contributed  so  largely  to  our  knowledge  of  practical  psychology, 
especially  in  the  direction  of  elucidation  of  morbid  phenomena,  lias  collected  his  studies  on 
sleep,  and  developed  them  into  an  exceedingly  interesting  monograph.  This  will  be  found 
useful  by  the  practicing  physician,  as  it  is  not  over-technical,  notwithstanding  the  thorough- 
ness of  tlie  cxpcriinejital  data.  In  this  monograph,  Dr.  Sidis  calls  attention  to  an  impor- 
tant point,  wliich  he  sets  forth,  namely,  that  the  hypnoidal  state  hns  notliing  in  common  with 
the  hypnotic  state,  since  tlie  term  suggests  that  the  state  is  some  modification  of  liypnosis. 
The  hypnoidal  state  is  simply  a  normal  primitive  sleep-state,  as  his  experiments  clearly 
demonstrate. 

"Regarded,  then,  from  various  standpoints,  sleep  is  a  rise  of  moments-thresholds  under 
conditions    of    monotony    and    limitation    of    voluntary    movements.      In    this    respect    sleep 


BOOK  REVIEWS.  671 

strongly  contrasts  -with  hypnosis.  In  hypnosis  the  individual  is  specially  accessible  to  any 
kind  of  suggestions  coming  from  the  external  world,  the  psyclio-niotor  reactions  are  greatly 
lightened,  and  the  released  by  the  suggestion  or  external  stimulus  with  great  facility,  far 
greater  than  in  the  waking  slate.  This  great  facility  is  often  expressed  by  the  statement 
that  in  hypnosis  the  inhibitions  are  removed.  What  specially  characterizes  ht/pnosis  is  the 
fact  of  a  fall  of  thresholds  present  in  individuals,  with  a  predisposition  to  states  of  dis- 
sociation; in  sleep,  on  the  contrary,  we  have  found  from  our  study,  the  general  character- 
istic  rise   is   the   rise   of  psycho-motor   thresholds." — J.   M.   T. 

Nebvous  and  Mental  Diseases.  By  Archibald  Church,  M.D..  Professor  of  Nervous  and 
Mental  Diseases  and  Medical  .Turispriidenee  in  Northwestern  University  iMedical  School, 
Chicago;  and  Frederick  Peterson,  ]\I.D.,  Professor  of  Psychiatry,  Columbia  University. 
Sixth  Edition,  Revised  and  Enlarged.  Octavo  Volume  of  944  Pages,  with  .341  Illustra- 
tions. Philadelphia  and  London:  W.  B.  Saunders  Company,  1908.  Cloth,  $5.00,  net; 
Half-Morocco,  $6.50,  net. 

This,  the  sixth  edition  of  Church  and  Peterson's  excellent  work,  presents  considerable 
evidence  of  its  right  to  being  regarded  as  a  new  edition.  Besides  many  insertions  in  the 
general  text,  it  contains  a  new  chapter  on  "Psychasthenia,"  to  establish  clearly  its  dif- 
ferentiation from  neurasthenia.  The  chapter  relating  to  subjects  which  bring  in  the  Rolandic 
area  has  been  remodeled,  and  new  diagrams  have  been  added.  The  section  on  "Mental 
Diseases"  has  been  carefully  revised  and  a  new  article  on  "Psychotherapy"  added.  On  the 
whole,  the  work,  thus  carefully  brought  up  to  date,  is  an  excellent  one,  and  fully  deserves 
the  great  popularity  it  has  earned  among  general  practitioners,  for  whom  it  was  mainly 
written. 

On  Infantixissi  frosi  Chronic  Intestinal  Infection  Characterized  by  the  Overgrowth 
and  Persistence  of  Flora  of  the  Nursling  Period.  A  Study  of  the  Clinical  Cour.se, 
Bacteriology,  Chemistry  and  Therapeutics  of  Arrested  Development  in  Infancy.  By  C.  A. 
Herter,  M.j).,  Professor  of  Pharmacology  and  Therapeutics,  Columbia  University.  New 
York;     The  Macmillan  Company,  1908.  "  Cloth,  90  Cents,  net. 

In  this  monograph,  Herter  studies  five  eases  of  intestinal  infantilism  which  he  regards 
as  typical,  and  five  additional  of  shorter  duration,  and  subacute  course,  which  he  is  dis- 
posed to  attribute  to  intestinal  infection.  He  concludes  among  other  features  that  intestinal 
infantilism  may  be  due  to  a  chronic  infection  and  persistence  of  bacterial  flora  belonging 
to  the  nursling  period;  that  the  chief  manifestations  of  this  condition  are  arrested  in  the 
development  of  the  body,  with  fair  development  of  the  brain  and  good  mental  powers;  that 
the  dominant  bacteria  are  a  Gram-positive  organism  he  designates  as  B.  bifidus  and  B. 
infantilis,  and  a  coccal  type;  that  the  prominent  urinary  expressions  of  this  state  are  the 
presence  of  putrefactive  products,  especially  indican  and  phenol  compounds;  that  the 
intestinal  products  include  mainly  neutral  fat,  fatty  acids,  and  soaps  in  marked  excess, 
indicating  important  fat  absorption;  that  rational  interference  in  cases  of  chronic  intestinal 
infantilism  offers  hope  of  the  re-establishment  of  the  processes  of  growth.  Dr.  Herter's 
book  represents  a  valuable  addition  to  our  knowledge. 

Obthopedic  StTBGERY  FOR  PRACTITIONERS.  By  Henry  Ling  Taylor,  M.D.,  Professor  of  Ortho- 
pedic Surgery,  New  York  Post-Graduate  Medical  School,  Etc.,  Assisted  by  Charles 
Ogilvy,  M.D.,  and  Fred  H.  Albee.  New  York  and  London:  D.  Appleton  and  Com- 
pany,' 1909. 

Dr.  H.  Ling  Taylor  is  so  well  known  as  an  authority  in  orthopedics,  that  his  systematic 
book  will  receive  a  warm  welcome.  His  father,  C.  Fayette  Taylor,  to  whom  he  dedicates  his 
book,  was  his  earliest  and  constant  teacher.  Dr.  Taylor  gives  credit  for  assistance  to 
various  colleagues,  Drs.  Gibney,  Townsend,  and  Whitman.  It  is  impossible  in  the  space 
at  our  disposal  to  do  more  than  allude  to  the  fact  that  the  book  thoroughly  covers  the 
practical  experience  of  a  master  in  this  special  line  of  surgery;  that  it  is  well  written,  clear, 
systematic,  and  admirably,  though  not  excessively,  illustrated. — J.  M.  T. 

Experimental  Reseabciies  on  Specific  Therapeutics.  By  Prof.  Paul  Elirlich,  ]\1.D.,  D.Sc, 
Oxon.  Director  of  the  Krmigliches  Institut  fiir  Expcrimentclle  Therapie,  Frankfort. 
New  York:     Paul  B.  Hoeber,  1909. 

Those  who  are  prone  to  judge  the  actual  value  of  a  book  by  the  name  of  its  author, 
rather  than  by  its  merits,  will  doubtless  sp;'ak  glowingly  of  this  little  book.  In  truth,  it 
will  serve  to  add  confusion  to  the  subj'^ct  treated,  rather  tlian  to  elufidate  it.  Ehrlich  has 
never  established  on  a  firm  basis  his  side-chain  theory,  insofar  as  Hie  side-cliain  feature  itself 
is  concerned;  the  views  set  forth  in  the  present  vohime,  being  based  on  this  theory,  they 
lack  a  solid  foundation.     In   the  first  lecture,   he  reviews   his   "haptine"   theory — haptines 


672  BOOK  REVIEWS. 

being  substances  Avhich  connect  pathogenic  bacteria  or  their  toxins  with  the  cell  products 
that  destroy  them,  while  insuring  the  union  of  opsonins  and  bacteriotropins  in  the  process 
of  phagocytosis.  In  the  second  lecture,  he  tries  to  explain  by  another  theoretic  process 
he  terras  "atrepsy,"  the  inability  of  certain  cells  or  organisms  to  grow  in  certain  animals, 
by  assuming  that  the  specific  cellular  receptors  had  previously  atrophied.  In  the  third 
chapter,  on  "Chemo-therapeutic  Studies  on  Trypanosomes,"  the  author  extols  polypharmacy 
on  the  justified  plea  that  several  remedies  may  conciirrently  destroy  a  pathogenic  organism 
while  similar  results  could  only  be  obtained  by  using  large  and  perhaps  toxic  doses  of  a 
single  remedy. 

The  PsyciioLOGY  of  Dementia  Pr.^^cox.  By  Dr.  C.  G.  Jung,  Private  Decent  in  Psychiatry, 
University  of  Zurich.  Authorized  Translation,  with  an  Introduction  by  Frederick 
Peterson,  M.D.,  and  A.  A.  Brill,  Ph.B.,  M.D.  ^;ew  York:  The  Journal  of  Nervous 
and  Mental  Disease  Publishing  Company,  1909. 

The  work  before  us  is  a  trifle  too  technical  to  recommend  for  general  reading,  and  the 
subject  is  as  yet  too  unclear  from  a  clinical  standpoint.  None  the  less,  so  carefully  does 
Dr.  Jung  approach  and  analyze  this,  as  well  as  other  subjects,  that  much  is  presented  which 
makes  fascinating  reading.  Fortunately  clinicians  are  becoming  increasingly  interested  in 
psychic  problems,  and  as  they  do  this,  many  obscurities  will  become  clear. — J.  M.  T. 

The  Every-day  Diseases  of  Children  and  Their  Rational  Treatment.  By  George  H. 
Candler,  M.  D.     Chicago:     The  Clinic  Publishing  Co.,  1907. 

This  small  work  of  386  pages  is  interesting  in  many  particulars.  It  is  not  intended 
for  the  pediatrist,  but  for  the  general  practitioner,  who,  as  the  author  says,  is  brought 
into  contact  with  children  and  their  disorders  "more  than  all  pediatrists  put  together." 
Nor  does  he  believe  in  therapeutic  nihilists;  in  fact,  he  asserts  that  "the  changes — normal 
and  pathological — which  take  place  in  the  human  body  are  fairly  constant,  and  that  the 
right  remedy  for  the  conditions  present  (usually  given  in  small  repeated  doses  to  effect) 
must  produce  definite  results."  With  practically  all  of  us — the  exception  being  the  nihilist, 
of  course — the  author  asserts  that  "the  main  thing  is  to  recognize  the  pathological  con- 
dition present,  and  select  the  proper  remedy,"  and  he  proceeds  to  tell  his  readers  how  to  do 
this.  Each  disease  is  briefly  described,  and  followed  by  a  great  number  of  practical  hints  which 
must  have  proven  of  value  in  the  hands  of  the  author,  if  we  judge  from  the  emphatic  way 
in  which  each  remedy  or  remedial  measure  is  recommended.  As  the  alkaloidal  method  is 
endorsed,  many  uniisual  agents  are  mentioned,  a  feature  which  cannot  but  prove  attractive 
to  the  broad-minded  practitioner. 

Expansion  of  Races.  By  Charles  Edward  Woodruff,  A.M.,  M.D.,  Member  of  the  American 
Association  for  the  Advancement  of  Science,  Etc.,  Etc.;  Author  of  "Effects  of  Tropical 
Light  on  \^niite  Men,"  Etc.     New  York:     Rebman  Company,   1909. 

Major  Woodruff  has  already  earned  the  position  of  authority  on  many  important 
subjects.  In  the  book  before  us,  he  has  presented  the  fruition  of  a  life-long  series  of 
studies  and  experiences.  In  his  preface,  he  says:  "This  work  is  an  anthropological  study 
of  one  of  the  reasons  for  migration,  war,  famine,  and  pestilence,  and  why  mankind, 
in  obedience  to  natural  law,  is  unconsciously  organizing  to  prevent  these  disasters,  and  to 
make  it  possible  for  every  babe  to  reach  old  age — excepting  those  meeting  unavoidable 
fatal  accidents,   and   even   these  become   aA'oidable  as  knowledge   increases." 

Again,  he  takes  up  tlie  reason  for  the  increase,  spread,  and  organization  of  popu- 
lations, together  with  the  checks  to  overpopulation.  The  book  applies  to  man  the  natural 
laws  which  are  known  to  govern  the  spread  of  all  other  species  of  plant  or  animal.  It 
then  explains  the  relationships  of  higher  and  lower  races  of  man,  and  shows  why  we  expanded 
across  the  Atlantic  to  America  in  the  sixteenth  and  seventeenth  centuries,  and  thence 
across  the  Pacific,  and  why  tlie  higher  races  must  always  control  the  tropics,  though  ac- 
climatization and  colonization  are  not  possible. 

Tlie  author  describes  the  facts  and  the  laws  governing  them.  He  offers  no  Utopian 
plan  for  curing  nature,  but  shows  that  we  are  governed  by  natural  law  to  an  extent 
which  few  or  none  have  heretofore  realized.  His  chapter  on  the  "Diminishing  Birth-Rate" 
will  help  many  who  are  interested  in  eugenics.  There  is  much  that  is  not  only  thoughtful 
and  accurately  scientific,  but  eminently  practical  in  the  work,  notably  in  the  chapter  on 
"Unnatural  Democracy  in  America,"  and  the  "Evolution  of  Democracies."  In  short,  it  is 
an  important  contribution  to  the  science  of  medicine,  made  by  a  man  of  adequate  scien- 
tific equipment,  and  a  most  unusually  large  and  varied  experience.  It  cannot  fail  to 
enlighten  many  subjects  by  giving  them  breadth  and  side-illumination  which  they  rnust 
otherwise  lack.  The  style  throughout  is  vigorous,  clear,  and  engaging,  and  a  sufficient 
index  completes  the  work. — J.  M.  T. 


ONTHLY     CYCLOPiEDIA 

AND 

EDicAL   Bulletin 


PtJBLISHED  THE  LaST  OF  EACH   MONTE 


Medical  Bulletin  Section 


Vol.  II.  PHILADELPHIA,  NOVEMBER,  1909.  No.  11. 


Clinical  Lectures 


INFLUENZA. 


By  JOHN  V.  SHOEMAKER,  M.D.,  LL.D,, 

Professor  of  Materia  Medica,  Therapeutics,  Clinical  Medicine,  and  Diseases  of  the  Skin, 
in  the  Medico-Chirurgical  College  and  Hospital  of  Philadelphia. 

Pnii:.ADELPHIA. 

Gentlemen  : — The  patient  before  you  this  morning  is  suiiering  from  an 
acute  contagious  disease,  which  is  caused  by  a  specific  bacillus  and  occurs  in 
wide-spread  epidemics.  She  is  28  years  of  age;  nativity,  U.  S.  A.;  occupation, 
domestic  servant. 

Family  History. — We  will  not  go  into  her  family  history  since  it  is  nega- 
tive as  regards  the  cause  and  heredity  of  this  disease. 

Personal  Uislory. — She  had  the  ordinary  diseases  of  childhood :  whooping- 
cough,  measles  and  diphtheria;  typhoid  fever  at  the  age  of  twenty,  and  a  year 
ago  she  suffered  from  muscular  rheumatism.  She  is  married  and  is  the  mother 
of  five  healthy  children. 

Habits. — Her  habits  are  good  except  that  she  drinks  coffee  excessively. 

Present  Ulness. — She  was  in  good  health  until  two  days  ago,  when  the 
attack  was  ushered  in  with  a  chill.  She  had  coryza  and  was  constantly  sneezing 
and  her  eyes  were  watery.  She  coughs  and  expectorates  copiously.  Her 
temperature  rose  to  102°  F;  her  pulse  112,  and  is  small  and  weak.  She  is 
prostrated  and  feels  a  distressing  pain  over  the  stomach.  She  is  nervous, 
irritable  and  unable  to  sleep  at  night.  She  complains  of  muscular  pains  over 
her  entire  body,  but  especially  in  the  lumbar  region. 

Urinalysis. — Color,  dark  amber;  S])eoific  gravit}^  1028;  reaction,  acid; 
albumin,  a  trace;   glucose,  negative;   indican,  marked  reaction. 

5  (67S ! 


674  INFLUENZA. 

Diagnosis. — The  dingnosis  of  this  disease  in  thxis  patient  is  eas3\  The 
diagnostic  features  are  the  abrupt  onset,  profound  prostration,  fever  of  short 
duration  and  the  muscular  pains  in  addition  to  the  catarrhal  symptoms.  To 
confirm  the  diagnosis  in  doubtful  cases  a  bacteriologic  examination  of  the 
sputum  should  be  made. 

Differcnlial  Diagnosis. — Sometimes  this  disease  may  be  confounded  with 
simple  broncliitis,  nasal  catarrh  and  other  climatic  catarrhal  affections. 
Influenza  may  be  differentiated  from  these  by  the  predominance  of  tlie  nervous 
symptoms  and  debility  over  the  catarrhal  manifestations. 

Influenza.  Z'  Typhoid  Fever. 

1.  Onset  sudden.  1.  Onset  not  sudden. 

2.  Absence  of  a  typical  temperature  curve.  2.  Temperature  curve  is  typical. 

3.  Absence  of  diarrhoea.  3.  l^iarrhoea  present. 

4.  Ko    cliaraeteristic    eruption    present.  4.  Characteristic  eruptioji  present. 

5.  Absence  of  Widal  reaction.  5.  Presence  of  Widal  reaction. 

Influenza.  Pneumonia. 

1.  Lung  involvement  is  usually'  bilateral.  1.  Lung  involvement  is  luiilateral. 

2.  Physical  signs  of  congestion  and  oedema.  2.  Physical  signs  of  consolidation. 

3.  Nervous  symptoms  and  debility  marked.  3.  Not  so  marked. 

Pathology. — There  are  no  specific  lesions  which  characterize  this  disease 
and  the  anatomical  changes  are  those  of  the  complications.  Intense  catarrhal 
processes  are  provoked  by  this  bacillus.  However,  when  death  occurs  as  a  direct 
result  of  the  disease,  all  the  alterations  in  the  tissues  disappear. 

This  disease  is  subject  to  complications  and  the  most  serious  of  these  is 
pneumonia  and  is  often  brought  about  by  exposure.  Its  symptoms  are  modified 
thus  making  the  diagnosis  difficult.  A  common  and  very  serious  complication 
is  a  severe  bronchitis  particularly  affecting  the  capillary  tubes  and  leading  to 
broncho-pneumonia.  Other  pulmonary  complications  are  pulmonary  cedema, 
congestion  associated  with  oedema,  pleurisy  and  sometimes  abscess  and  gangrene 
of  the  lungs. 

The  cardiac  complications  are  purulent  pericarditis,  endocarditis,  attacks 
of  angina  and  "heart  failure." 

Of  the  nervous  lesions  we  have  perineuritis,  cerebrospinal  meningitis,  and 
delirium.  These  complications  are  not  common  occurrences.  Encephalitis, 
abscess  of  the  brain,  have  also  been  noted.  Other  complications  may  be  severe: 
gastro-enteritis  with  frequent  vomiting  and  purging  and  intense  abdominal 
pains,  and  more  rarely  haemorrhage  from  the  stomach  and  bowels,  renal  conges- 
tion and  acute  nephritis. 

Etiology. — The  cause  of  influenza  is  attributed  to  the  bacillus  influenzae, 
which  was  discovered  by  Pfeifer  in  1892.  The  bacilli  are  from  0.8  to  1  micron 
in  length  and  0.1  to  0.2  microns  broad.  They  occur  singly  though  they  are 
occasionally  united  by  the  ends,  forming  chains.  When  stained  with  Ziehl's 
carbol-fuchsin  it  may  be  observed  as  a  small  dumb-bell,  having  knobbed  ends 
connected  by  a  rod-like  shaft.     These  bacilli  are  numerous  in  the  nasal  and 


INFLUENZA.  675 

bronchial  mucus  whence  they  are  conveyed  to  others,  constituting  a  true 
contagium. 

The  bacilli  have  also  been  found  in  the  blood.  They  occur  abundantly  in 
the  sputum  of  the  diseased,  decreasing  in  quantity  as  the  case  advances.  The 
bacillus  is  not  motile.  Inoculated  into  rabbits  and  monkeys  this  organism  has 
proven  pathogenic  and  has  produced  sjanptoms  resembling  those  of  human 
influenza.     The  bacillus  can  be  cultivated  in  agar  and  other  culture  media. 

The  period  of  greatest  susceptibility  is  from  twenty  to  thirty  years  and  is 
more  common  in  those  individuals  whose  vitality  is  lowered. 

The  disease  is  contagious  and  can  travel  very  fast.  Its  course  may  be 
opposite  to  that  of  the  prevailing  winds.  Its  mode  of  invasion  is  believed  by 
some  authorities  to  be  through  the  alimentary  canal  with  the  inspired  air 
through  the  respiratory  tract,  and  other  authorities  still  believe  that  infection 
may  take  place  through  the  conjunctivas. 

The  immunity  from  this  disease  is  exceedingly  short  as  relapses  may  be 
frequent  and  succeed  each  other  frequently. 

Treatment. — Calomel,  in  my  opinion,  is  the  very  best  drug  in  the  begin- 
ning treatment  of  influenza.  In  nearly  all  of  these  cases,  as  in  this  patient,  the 
tongue  is  heavily  coated ;  the  bowels  are  constipated,  and  the  skin  feels  hot  and 
dry.  These  symptoms  are  indicative  of  inactivity  of  the  glands  throughout 
the  entire  body.  Calomel  combined  with  sodium  bicarbonate  will  stimulate 
the  glands  in  the  mucus  membrane  lining  the  alimentary  canal  and  act  as  a 
cholagogue  assisting  the  body  in  casting  off  retained  waste-products  and  estab- 
lishing free  portal  circulation.  Three  grains  of  calomel  combined  with  half  a 
dram  of  sodium  bicarbonate  divided  into  twelve  powders  and  one  powder  given 
every  half  hour,  dry,  on  the  tongue  is  a  sufficiently  large  dose  for  any  patient. 

The  drug  indicated  to  stimulate  the  sudoriferous  glands  and  relax  the 
skin  is  pulvis  ipecacuanhas  et  opii  which  will  also  act  as  a  sedative  to  the  bron- 
chial mucus  membrane  as  well  as  an  antipyretic.  Quinin  bisulphate  and 
phenylis  salicylatis  may  be  combined  with  the  pulvis  ipecacuanhas  et  opii  because 
of  their  antipyretic  and  analgesic  value. 

We  have  prescribed  for  her  as  follows :  Ten  grains  of  pulvis  ipecacuanha} 
et  opii  to  be  given  after  the  calomel  had  been  taken  and  the  bowels  had  been 
freely  evacuated.     Also  a  capsule  containing: 

IJ   Strychninac  sulphutis    gr.  Voo 

QuiiiiiiiC  bisulpliati3   gr.  iss. 

Phenylis  salicylatis gr.  v. 

One  such  capsule  to  be  given  every  two  hours. 

This  treatment  will  soon  relieve  the  patient  of  her  s3Tnptoms  and  in  the 
course  of  four  or  five  clays  will  be  entirely  well.    . 

Tlie  employment  of  any  of  the  coal-tar  products  is  not  at  all  necessary  in 
the  treatment  of  influenza.  They  are  dangerous  which  is  comparativelv  greater 
than  their  value. 


676  INFANTILE  GONOERHCEAL  VULVG- VAGINITIS. 


INFANTILE  GONORRHOEAL  VULVO-VAGINITIS.   APHTHOUS  STOMATITIS. 

By  WM.  C.  HOLLOPETER,  M.A.,  M.D. 
Professor    of    Diseases    of    Children    in    tlie    Medico-Cliirurgical   College  and   Hospital 

of  Philadelphia. 

GONORRHCEAL   YULVO-VAGINITIS   ASSOCIATED   AVITH    CYSTITIS.* 

GENTLEiiEN : — The  case  for  consideration  is  a  female  white  child,  age  live 
months  suffering  from  acute  indigestion  with  gonorrhoeal  vulvo-vaginitis  and 
cystitis. 

Family  History. — Father  alive  and  well.  Mother  now  in  Philadelphia 
Hospital  with  tuberculosis.  This  is  the  second  child ;  the  first  is  two  and  one- 
half  years  old  and  quite  healthy. 

Previous  Personal  History. — The  patient  was  breast-fed  up  to  three  weeks 
ago,  and  had  always  seemed  healthy  until  that  time.  When  the  mother  was 
taken  to  the  Philadelphia  Hospital,  it  became  necessary  to  wean  the  child,  so 
the  relative  to  whose  care  it  was  consigned  carelessly  fed  it  on  whole  milk, 
improperly  administered,  sometimes  boiled,  or  again  milk  and  water. 

Physical  Signs. — The  child's  face  is  flushed,  as  you  notice,  in  sections, 
and  it  perspires  considerably  about  the  face  and  neck.  It  coughs  now  and  again, 
hard  and  dry,  and  the  buttocks  are  excoriated.  The  hands  and  feet  are 
shrivelled,  and  there  is  a  rash  on  the  skin.  The  skin  is  dark  and  looks  like 
parchment. 

Present  Hlness. — Started  just  one  week  ago.  The  diapers  were  very  foetid, 
stools  copious  and  of  white  cheese-like  masses,  intermingled  with  lumps  of 
green.  The  child  defecated  three  times  a  day,  some  days  more  frequently, 
and  had  trouble  and  pain  in  expelling  the  faces.  A  thick  yellow  pus  was  also 
observed  discharging  from  the  urethra  and  vagina.  It  has  now  been  in  the  hos- 
pital three  days.  On  the  first  day  it  had  one  bowel  movement;  on  the  second, 
six;  on  the  third,  two.  It  has  vomited  at  least  once  or  twice  daily,  cries  on 
every  urination,  and  sleeps  most  of  the  time  with  its  eyes  partly  open,  moaning 
and  moving  its  arms  and  legs.  It  also  cries  violently  on  each  bowel  movement, 
and  the  rectum  protrudes.  The  temperature  varies  from  98.4  to  99.2,  pulse 
122-130,  respiration  24-30.  It  does  not  care  for  the  bottle  and  will  not  take 
more  than  one  and  one-half  ounces  at  each  feeding. 

Urinary  Analysis. — ^The  urine  is  milky,  and  the  microscopic  examination 
shows  it  to  be  laden  with  urates  and  phosphates.  The  bacteriological  report  of 
the  discharge  points  strongly  to  gonorrhoea. 

Diagnosis. — A.cute  indigestion,  acute  food  poisoning,  gonorrhoeal  vulvo- 
vaginitis and  cystitis. 

Etiology. — The  slightest  abrasion  of  the  skin  will  allow  the  entrance  of 
the  gonococcus.     Cases  are  on  record  in  which  a  healthy  person  was  infected 


*  From   a    clinic   held    in    the    amphitheatre   of   the    Mcdico-Chirurgical    Hospital, 
AviW  6.  1909. 


APHTHOUS  STOMATITIS.  677 

by  taking  a  bath  in  the  same  tub  in  which  a  person  affected  with  gonorrhoea 
had  bathed  the  day  before.  Gonorrhoeal  vulvo-vaginitis  is  frequently  met  with 
in  practice,  and  it  occurs  generally  among  the  poorer  classes  where  families  are 
compelled  to  crowd  and  where  conditions  are  unsanitaiy.  Most  frequently  the 
infection  is  transmitted  from  the  parents  to  the  child  by  sleeping  in  an  infected 
bed.  The  gonococcus  most  probably  is  transmitted  in  this  case  by  careless 
handling  of  the  child  with  unwashed  hands. 

Treatment. — Withdraw  the  milk.  Eegulate  the  diet  by  substituting  barley 
and  plain  water,  albimiin  water  or  meat  juice.  Alternate  these  until  the  tract 
is  free.  If  the  mucous  membrane  is  very  sore,  give  gum  water.  The  excoriated 
buttocks  is  due  to  improper  feeding  or  bad  assimilation.  Use  two  per  cent, 
ichthyol  in  water  for  it,  and  remove  the  cause.  Stools  that  are  green  with 
limipy,  cheesy  masses  are  nearly  always  associated  with  stomatitis.  Observe  a 
careful  toilet  of  the  mouth.  Give  calomel  and  wash  out  the  bowels.  We 
must  prevent  cystic  irritation,  as  it  is  a  difficult  thing  to  deal  with.  Give 
urotropin,  grains  two,  four  times  a  day  for  five  days,  and  then  liquor  potassi 
citratis  dram  one-half,  t.  i.  d.     This  will  sterilize  the  bladder. 

Treat  the  vaginitis  by  cleanliness  and  irrigation.  A  pad  should  thoroughly 
cover  the  vulva  and  be  saturated  with  a  weak  solution  of  bichloride.  Should  the 
child  show  any  tendency  to  scratch  the  parts,  the  hands  must  be  guarded  so  that 
the  infection  cannot  be  carried  from  the  genitals  to  the  eyes.  Irrigate  the 
vagina  with  1-8000  K  mn  O4  once  daily.  Increase  to  1-4000.  Follow  this  with 
argj'rol,  ten  per  cent.,  or  protargol,  or  Ag  N  O3,  2  per  cent.,  twice  a  day. 

For  food,  when  the  child's  alimentary  tract  is  in  better  condition,  give:  — 

IJ  Skim  milk   5^'>:iv.  Fat,  6  per  cent. 

Sugar  of  milk,  Proteid,    1.8    per    cent. 

Lime  water,  of  each oij.  Carbohydrates,  3.1  per  ceut. 

Water,   (boiled)    3x1  v. 

Mipce.     Sig. :     5vj  every  three  hoiirs  from  6  a.m.  to  12  p.m. 

Prognosis. — Usually  good,  though  it  must  always  be  borne  in  mind  that  if 
these  cases  are  neglected,  serious  results  will  inevitably  follow.  The  danger  of 
transmitting  gonorrhoeal  infection  by  the  hands  from  the  genitals  to  the  eyes 
must  always  be  borne  in  mind,  and  infection  may  spread  from  the  urethra  into 
the  bladder,  and  from  the  bladder  into  the  ureters  and  so  infect  the  kidneys. 

Aphthous   Stomatitis.* 

The  next  case  is  that  of  a  white  male  child,  five  months  old,  suffering  from 
aphthous  stomatitis. 

Family  History. — Father  and  mother  well.  This  is  the  first  and  only 
child. 

Present  Illness. — It  has  been  ailing  for  four  months.  During  first  three 
months,  it  was  breast-fed,  since  then  has  used  the  bottle.  After  each  feeding 
it  vomited,  and  the  stools  were  green  and  foul  smelling.     It  had  constant  pain. 


•  From    a   clinic   held    in    the    amphitheatre   of    the   Medico-Chinirgical    ITospitfll, 
September  29,  1908. 


678  MEDICO-LEGAL. 

as  was  evidenced  by  the  drawing-up  of  its  legs  and  clenching  of  its  hands,  also  by 
the  painful  expression  of  its  face.  The  temperature  was  subnormal.  Its 
weight,  which  should  be  twelve  pounds,  is  only  eight. 

Physical  Signs. — The  child  is  pale  and  wasted,  with  cold  hands  and  feet. 
Its  tongue  is  coated,  and  small  elevated  lesions  are  present  on  the  mucous  mem- 
brane of  the  mouth,  pearly  in  appearance  and  very  sensitive. 

Diagnosis. — Aphthous  stomatitis,  due  to  careless  and  imsystematic  feeding. 

Treatment. — As  the  child  cannot  retain  anything  on  its  stomach,  we  will 
feed  it  on: — 

I^  Barley    water     fl'iss. 

Milk    flsiss. 

Sig.:     Every  two  hours. 

Owing  to  the  poor  state  of  the  child's  digestion,  we  must  feed  it  as  we 
would  a  child  of  two  months.  Colonic  irrigation  will  be  necessary,  and  we 
will  also  give  an  oily  inunction  daily.  Aphthous  stomatitis  often  poisons  the 
entire  alimentary  tract,  and  for  this  we  will  prescribe  the  following: — 

1}   Potassii     chlorate     3j. 

Acidi    bydrochlorici     fl3.j. 

Glyc'crini    fl.^ss. 

Aqua   nienth.   pip q.   s.  ad.   flSiij. 

Misce.     Sig.:     Every  four  hours  fl3j. 

and  apply  as  a  mouth  wash  after  each  feeding.  Keep  hot  water  bottles  to  the 
feet,  and  thus  prevent  a  further  fall  of  temperature.  Plenty  of  sunsliine  and 
fresh  air  are  very  essential,  and  aseptic  details  must  be  rigidly  enforced  in 
dealing  with  the  nursing  bottles  and  nipples. 


Original  Articles 


MEDICO-LEGAL. 

By  E.  S.  McKEE,  M.D., 

CINCI?fNATI. 

A  Decision  on  Cut  Eate  Drugs. 

A  DECISION  of  interest  was  handed  down  by  Judge  IlofCheimer  in  the 
Superior  Court  at  Cincinnati,  October  3d.  The  suit  was  against  Eaphael 
^Miller,  druggist,  by  W.  D.  Freeman.  Freeman  manufactures  perfumes  and 
face  powder.  He  sued  Miller  for  breach  of  contract  in  agreeing  to  sell  no 
goods  to  retailers  who  would  not  agree  not  to  sell  it  for  less  than  25  cents  a 
box.  He  stated  that  the  fonuulas  were  secret  and  that  in  addition  to  manu- 
facturing, he  operated  a  retail  store,  the  trade  of  which  was  injured  by  the 
powder  being  sold  at  cut  rates.  He  alleged  that  ]\Iiller  sold  the  powder  to 
Cora  Dow  and  other  pharmacists  who  placed  it  on  sale  at  cut  prices  and  spoke 


MEDICO-LEGAL.  679 

derogatorily  of  it,  claiming  that  it  contained  flake  white  wliich  was  injurious  to 
the  skin.  He  sued  for  $21,000.  Judge  Ilofl'heimer  followed  the  decision  of 
Federal  Judge  Lurton  at  Cincinnati  (153  Fed.  24)  in  the  suit  of  John  D. 
Park  and  Sons,  vs.  Hartman  in  which  the  Court  said:  '"We  are  not  dealing 
here  with  contracts  which  relate  to  the  secret  formula  itself,  but  with  con- 
tracts which  relate  to  and  affect  only  the  tralFic  in  the  manufactured  product 
of  the  secret  formula."  The  law  applicable  to  patented  or  copyrighted  articles 
is  not  equally  applicable  in  guarding  restraint  to  trade.  The  judge  held  that 
Freeman  in  manufacturing  this  article  and  attempting  to  control  sales  and 
sub-sales  is  in  exactly  the  same  position  as  any  other  individual  who  under- 
takes to  make  contracts  to  restrain  trade  barring  the  exception  of  trade  secrets. 
Like  any  other  merchant  or  manufacturer,  he  is  subject  to  the  rules  of  the 
common  law  against  the  restraint  of  trade  and  the  statutory  enactment  against 
monopolies.  The  Court  held  that  the  contract  sued  upon  was  illegal  and  con- 
trary to  public  policy  and  the  law  of  the  land,  therefore,  cannot  be  enforced. 
Freeman  admitted  a  limited  attempt  to  restrain  trade  but  claimed  that  it  was 
justifiable  to  protect  his  retail  trade.  Judge  Hoffheimer  held  that  what  he 
held  for  would  be  a  complete  and  entire  control  and  general  restraint  of  trade. 
Frank  II.  Freerichs,  attorney  for  the  druggists'  association  and  an  ex- 
druggist  filed  the  suit. 

Medico-LecxAl  Matters  in  Canada. 

Dr.  R.  J.  Blanchard,  of  Winnipeg,  president  of  the  Canadian  Medical 
Association,  at  its  recent  meeting  at  Winnipeg,  in  his  presidential  address, 
took  up  some  matters  of  medico-legal  interest.  There  are  6,000  doctors  in 
Canada,  and  this  is  the  only  interprovincial  organization.  There  was  a  neces- 
sity for  closer  organization  to  broaden  their  efficiency,  and  by  an  interchange 
of  ideas  and  centralization  of  effort,  to  develop  all  lines  of  investigation.  It 
was  the  duty  of  every  member  to  defend  the  association  against  the  inroads 
of  quackery,  and  the  association  should  have  the  power  to  discipline  the 
members  more  severely  than  is  possible  under  the  existing  circumstances. 
The  matter  of  expert  testimony  in  the  law  courts  has  come  to  such  a  pass 
that  it  has  become  a  subject  for  ridicule,  and  the  testimony  has  been  found 
very  unreliable.  He  found  it  difficult  to  understand  why  the  provincial  bar- 
riers should  not  be  removed  and  the  whole  medical  profession  of  Canada 
placed  upon  one  single  standard.  Federal  authorities  he  thought  much 
better  suited  to  handle  a  subject  of  such  magnitude.  The  laxity  of  provincial 
and  municipal  authorities  in  taking  steps  for  the  prevention  of  the  spread 
of  disease  was  almost  criminal  in  some  respects.  Proper  precautionary 
measures  are  of  inestimnhle  value,  and  those  in  authority  should  not  be 
derelict  in  this.  Everything  possible  should  be  done  to  raise  the  standard  of 
medicine.  Not  so  much  by  extending  the  time  of  study  and  making  it  more 
expensive,  but  rath.er  by  making  the  examinations  more  difficult,  and  weeding 
out  the  undcsirnble,  and  also  giving  better  facilities  for  study.  The  handling 
of  insane  patients  was  like  a  page  from  the  dark  ages,  and  needed  improve- 
ment.    Eeciprocal  registration   of  medical   men,   since   confederation   of   the 


680  MEDICO-LEGAL. 

Canadian  provinces,  has  been  much  desired.  Dominion  registration  has  been 
considered,  but  that  can  not  be  accomplished  without  changing  the  British 
North  American  Act.  There  is  no  such  thing  as  a  Canadian  physician,  in 
the  broad  sense  of  tlie  term.  The  provinces  are  as  wide  apart  as  if  they  flew  a 
different  flag.  The  name  Canadian  Medical  Association  is  itself  a  misnomer. 
The  organization  of  a  Dominion  l^Iedical  Council  was  proposed,  which  should 
issue  a  license  to  practice  which  should  be  so  high  in  its  requirements  as  to 
be  acceptable  to  any  province.  This  is  the  idea  which  is  to  be  brought  before 
Parliament.  The  four  western  provinces  have  practically  agreed  on  reci- 
procity among  themselves.  The  province  of  Quebec  seems  to  be  the  stumbling- 
block  to  reciprocity,  as  it  is  the  only  one  which  allovrs  the  professors  teaching 
the  students  to  serve  on  the  provincial  board  examining  these  same  students. 
The  conditions  are  strikingly  similar  to  those  in  the  United  States. 

How  TO  Suppress  Quacks  and  Quackery. 

We  need  a  department  of  public  health  in  the  President's  Cabinet  to 
suppress  quacks  in  and  out  of  the  profession,  says  Dr.  Otto  Juettner,  in  the 
Medical  Summary.  *'I  believe  in  the  highest  standard  of  medical  education. 
Physicians  should  have  the  right  to  practice  anywhere  within  the  confines  of 
our  country,  but  there  should  be  a  Federal  law  to  control  and  protect  them," 
says  the  doctor.  This  is  all  very  nice  and  proper,  but  it  is  against  the  Con- 
stitution of  the  United  States,  and  it  has  been  found  a  diDBcult  thing  to  go 
contrary  to  this  document.  The  Constitution  puts  matters  of  education  com- 
pletely in  the  hands  of  the  different  States,  and  I  suppose  our  fathers  were 
wise  in  this.  This  whole  thing  has  been  threshed  over  and  over.  It  can  only 
come  down  to  two  questions.  A  change  in  the  Constitution  or  reciprocity. 
One  seems  about  as  difficult  of  accomplishment  as  the  other.  Further,  in  the 
doctor's  most  interesting  article,  he  says:  "The  proper  way  to  fight  charla- 
tans who  usurp  practice  is  by  means  of  greater  knowledge,  better  work  and 
results.  Our  patients  care  naught  for  diplomas,  licenses,  membership  in 
societies,  or  what  not.  They  want  results.  If  we  cannot  produce  results, 
patients  will  go  where  tliey  think  they  can  get  them.  Physicians  should 
not  bewail  the  ascendency  of  the  faker,  hnt  remove  their  own  shortcomings, 
which  make  it  possible  for  the  faker  to  succeed.  The  latter  would  not  usurp 
our  work  if  we  were  as  competent  as  the  times  demand.  Study  psychotherapy, 
and  disarm  Christian  Science  and  Emanuelism.  Familiarize  yourself  with 
personal  Iwgiene,  dietetics,  massage,  hydrotherapy,  etc.,  and  the  'naturopath' 
will  no  longer  compete  with  you.  Don't  bewail  the  things  thot  are,  and  wish 
for  the  things  that  might  be,  but  study  and  hustle!  The  world  is  too  busy 
to  listen  to  fault-finders,  or  to  people  who  are  thirty  years  behind  the  times." 

Syphilis^  Segregation  and  the  "Shrieking  Sisterhood." 

Professor  Fournier,  on  hearing  of  the  repeal  of  the  Contagious  Disease 
Acts  by  the  English  Parliament,  remarked,  "Prostitution,  and  with  it  syphilis, 
regained  its  liberty  throughout  the  British  Empire."  The  repeal  of  this  Act 
was   accomplished   by   the   efforts   of   a   society  of   fanatics   known   as   "the 


LIGHT  ENERGY  IN  THE  TREATMENT  OF  DISEASE.  681 

Shrieking  Sisterhood."  This  organization  used  their  pernicious  influence  to 
hoodwink  an  ignorant  and  credulous  public,  under  the  cloak  of  religion  and 
morality.  During  a  recent  visit  to  Winnipeg,  to  attend  the  Canadian  Medical 
Association  and  the  British  Association  for  the  Advancement  of  Science,  1 
was  made  aware  of  the  fact  that  there  were  many  sporting  women  in  Winnipeg 
by  a  religious  body,  also  in  session  there  at  that  time.  This  religious 
body  was  shrieking  itself  hoarse  about  segregation  in  Winnipeg.  It  seems 
that  not  long  since,  the  Winnipeg  authorities  gathered  up  their  whores  and 
set  them  down  in  a  back  street,  beliind  the  railroad,  and  quite  at  one  side, 
which  street  bears  the  name  of  Eachel.  Here  they  are  confined,  and  if  the 
young  man  wants  them,  or  the  old  man,  either,  he  must  go  after  them.  They 
do  not  flaunt  their  trade  where  they  will,  and  are  not  allowed  to  solicit  young 
men,  or  to  entice  young  women  by  their  fine  clothes  and  false  smiles.  They 
are  under  carefiil  police  surveillance.  The  diseased  are  removed  to  the  hos- 
pital and  kept  there  till  well.  Winnipeg  is  a  bright,  happy,  prosperous  city. 
Her  streets  are  clean,  and  her  population  is  morally  so,  at  least,  it  so  appears. 
Syphilis,  I  am  told,  is  decreasing  already,  just  as  it  did  in  Cincinnati,  when 
the  demi-monde  were  under  inspection  by  the  police  and  physicians,  and  it 
increased  again  alarmingly  when  this  supervision  was  discontinued  in  Cincinnati, 
Alcohol,  tuberculosis,  and  syphilis,  the  three  great  plagues  of  modern  society. 
The  greatest  of  these  is  syphilis;  the  least,  alcohol.  The  Church  expends  its 
greatest  force  against  the  least  of  these,  while  the  greatest  is  tabooed  entirely, 
or  encouraged  by  their  fight  against  its  regulation  by  law,  claiming  with 
wondrous  want  of  wisdom  that  it  ought  not  to  be  recognized  at  all,  and  that 
it  but  affords  security  for  debauchery.  Were  it  but  the  sinner  who  suffered 
it  were  but  little  compared  with  the  suffering  of  the  innocent  of  his  own 
household.  Police  surveillance  of  the  army  and  navy  has  reduced  syphilis 
in  those  quarters  one-half.  Of  course,  it  is  Utopian  to  expect  to  dispel 
syphilis  altogether,  but  to  reduce  it  fifty  per  cent. — is  that  not  a  great  deal? 
That  nation  which  first  successfully  deals  with  the  problems  of  the  suppres- 
sion of  syphilis  is  the  one  which  will  survive  in  the  struggle  for  existence. 
Woe  unto  those  peoples  who  do  not  soon  bestir  themselves  on  this  momentous 
question ! 

UGHT  ENERGY  IN  THE  TREATMENT  OF  DISEASE,* 
By  J.  FRANK  WALLIS,  M.D., 

Consulting  Dermatologist  in  the  State  Hospital  for  the  Insane,  Norriato^vn;  Consulting 

Dermatologist  to  the  Southern  Dispensary;   Rudiotherapeutist  and  Consulting 

Dermatologist    to    the   Kensington    Hospital    for    the    Treatment    of 

Tuberculosis,  riiiladelphia. 

NOBRISTGWN,   PEXXA. 

Kabolla  declared  that  light  is  the  primordial  essence  of  the  Universe. 
Ancient  and  modern  research  teach  us  that  lisrht  is  life  and  how  can  we  believe 


•Read   before   the    North    Branch   of    the    Philadflphin    County    Medical    Society, 
December  15,  1908. 


682  LIGHT  ENERGY  IX  THE  TREATMENT  OF  DISEASE. 

otherwise,  when  we  consider  that  both  animal  and  vegetable  life  are  dependent 
upon  it,  Liglit  maintains  and  supports  our  existence,  our  life  and  health  are 
sustained  b\-  the  rays  of  the  sun,  our  food  matures  under  its  influence,  the  cloth- 
ing and  material  for  our  homes  are  due  to  its  reaction,  and  drugs  and  alkaloids 
are  products  of  the  sun's  chemical  rays.  The  experiments  of  General  Pleasanton 
proved  without  doubt  the  maturing  influence  of  blue  light  upon  animal  and 
vegetable  life,  i'ruit  became  ol  abnornuil  size  and  of  unusual  flavor,  and  swine 
became  prodigious  under  filtered  blue  light.  The  experiments  were  followed 
by  Deherain  in  T' ranee,  Siemens  in  England  and  Cornell  University  in  this 
country.  Tlierefore,  if  normal  conditions  were  improved  we  can  readily  see  the 
value  of  light  in  disease.  On  vegetable-  life  v:e  have  all  seen  the  baneful 
influence  of  light  starvation.  Potatoes  will  sprout  in  darkness  with  abundance 
of  succulent  tissue,  but  with  the  absence  of  the  familiar  green  color  of  chlorophyl 
always  present  when  grown  in  the  sun.  When  a  plank  is  permitted  to  remain 
upon  the  lawn  for  a  short  time  the  grass  beneath  it  will  become  white  and  die. 
\\'e  are  also  familiar  with  the  colorless  grain  that  has  been  permitted  to  take 
root  under -a  granery.  House  plants  th^It  have  sufficient  heat  and  moisture  fail 
to  flourish,  but  when  they  are  placed  at  the  window  they  will  immediately 
recover,  and  every  leaf  will  worship  the  sun.  Forest  trees  frequently  have  more 
abundant  foliage  and  wood  on  the  side  facing  the  light.  Studying  these 
familiar  lessons  in  nature,  can  we  doubt  that  light  is  life?  Disease  and  death 
would  result,  if  this  factor  was  absent  for  a  short  time.  It  is  necessary  for 
hygiene  and  sanitation,  and  according  to  the  studies  of  Prausnitz,  Moment, 
Buchner  and  Procaccini,  many  millions  of  germs  are  destroA'ed  daily  by  the 
purifying  action  of  the  rays  of  the  sun.  Germs  will  not  flourish  in  dwellings 
and  factories  that  are  flooded  with  sunlight  and  air,  hence  the  folly  of  closed 
and  darkened  dwellings.  Prausnitz  has  given  abundant  evidence  of  the  dis- 
infecting power  of  the  sun  upon  rivers  and  streams,  and  Wittlin's  experiments 
prove  the  destruction  of  germs  in  the  dust  of  the  streets  by  sunlight. 

Dieudonne  found  that  peroxide  of  hydrogen  was  formed  when  water  was 
exposed  to  the  action  of  the  arc  lamp  or  sunlight.  Bactericidal  property  of  light 
is  only  possible  when  in  the  presence  of  oxygen,  this  has  been  proved  by  the 
experiments  of  Tizzoni  and  Gattani.  They  found  that  the  long  continued 
action  of  sun  light  upon  the  tetanus  bacillus  in  the  presence  of  oxygen  destroyed 
the  bacillus,  also  rendering  inert  its  toxines.  These  experiments  were  confirmed 
by  Cellis  and  Fermis.  Finsen  and  Dreyer  have  shown  that  vaccines  are 
destroyed  by  ultra-violet  light.  This  destructive  power  has  been  proved  by 
Finsen  and  others,  to  be  due  to  the  chemical  action  of  the  actinic  rays.  To  this 
property  we  owe  the  oxidizing  process  upon  silver  salts  in  photography.  Finsen 
in  his  experiments  proved  that  sun  burn  was  due  to  this  influence.  He  painted 
a  black  circle  around  his  ami  and  after  three  hours'  exposure  to  the  rays  of  the 
sun  an  intense  erythema  developed  leaving  the  part  protected  by  the  ring 
unaffected.  When  the  erythema  had  subsided  he  removed  the  paint,  and  again 
exposed  the  arm  to  the  light.  After  the  same  length  of  time,  the  area  occupied 
by  the  ring  became  intensely  inflamed,  but  the  surface  previously  acted  upon  by 
the  sun  was  unaffected,  having  been  protected  by  the  coat  of  tan  or  pigment. 


LIGHT  ENERGY  IN  THE  TREATMENT  OF  DISEASE.  683 

Finsen  having  found  these  actinic  rays  capable  of  inflammatory  reaction,  con- 
ceived the  idea  of  filtering  these  frequencies  by  the  means  of  red  glass  screens  in 
the  treatment  of  small-pox.  The  red  light  treatment  in  small-pox  was  practiced 
centuries  ago  in  England,  also  in  China  and  Japan.  Finsen  did  not  consider 
that  the  red  rays  influenced  the  disease,  other  than  occluding  the  chemical 
frequencies.  Eed  light  has  not  only  been  successlul  in  preventing  suppuration 
and  scarring  in  small-pox,  but  has  had  favorable  results  in  the  treatment  of 
erysipelas,  scarlet  fever  and  measles.  That  all  the  frequencies  of  the  spectrum 
are  of  special  value  therapeutically  does  not  admit  of  question,  but  in  the  writer's 
experience  the  combined  rays  from  the  arc  lamp,  or  high  power  incandescent 
light,  are  much  more  satisfactory  in  treating  functional  or  pathological  con- 
ditions than  the  use  of  filtered  light.  In  her  work  entitled  Light  Energy,  Dr. 
Margaret  Cleaves  states:  "In  the  absence  of  the  energy  of  light  as  a  whole, 
bodily  deformities,  intellectual  deterioration,  crime  and  disease  are  found 
manifested  in  a  higher  state  than  in  its  presence.  When  the  vital  stimulus  of 
light  is  withdrawn,  a  material  as  well  as  moral  and  mental  etiolation  occurs." 

So  true  is  this  statement  made  by  this  brilliant  advocate  of  light  energy, 
that  I  do  not  hesitate  to  aifirm  that  many  of  our  criminals,  physical  deformities, 
degenerates  and  the  insane,  are  or  have  at  some  time  in  their  life  been  victims 
of  light  starvation.  There  is  no  greater  proof  in  this  assertion,  than  the  clinical 
reports  embodied  in  this  paper.  I  have  seen  the  vicious  child  at  the  age  of  three 
years  or  older  become  in  the  course  of  a  few  weeks  a  normal  child  under  the 
physiological  influence  of  light.  Also  the  mentally  abnormal  child  assume  the 
faculties  of  a  healthy  mind.  Most  of  these  children  show  this  abnormal  con- 
dition shortly  after  birth,  and  if  allowed  to  continue  to  remain  unchecked,  will 
fill  the  criminal  list  before  they  have  reached  adult  age.  Many  a  child  who  is 
physically  and  mentally  ill  has  been  cruelly  punished,  or  treated  with  indulgence 
when  it  needed  a  sun  bath.  The  rachitic  boy  or  girl  is  fed  on  medicine  instead 
of  plenty  of  sun  light,  fresh  air  and  nutritious  food.  I  have  treated  children 
suffering  with  rheumatism  associated  with  enlarged  tonsils.  These  children  are 
angemic,  generally  poorly  nourished,  irritable,  and  mentally  dull.  If  given 
daily  sun  baths,  kept  most  of  the  day  in  the  open  air,  an  appropriate  diet  with 
plenty  of  milk,  they  will  soon  get  well  without  medicine,  liebellious  skin 
lesions  associated  with  faulty  metabolism  will  disappear  under  the  same  treat- 
ment with  no  special  selection  of  a  local  remedy. 

I  have  seen  a  case  of  refractory  psoriasis  that  has  resisted  the  usual 
remedies  acquire  a  permanent  cure  after  spending  two  months  in  the  sun  wear- 
ing only  swimming  trunks.  Tuberculosis  reacts  excellently  under  daily  treat- 
ment of  electric  light  baths.  The  disease  is  assailed  through  the  action  of  the 
light  upon  the  life  of  the  bacillus  and  its  stimulation  of  leukocytosis.  It  also 
improves  the  cheniistry  of  the  blood  stream  inci-easing  the  ha-moglobulin  and 
thereby  aiding  cell  nutrition.  It  is  claimed  that  light  has  a  destructive  power 
on  the  bacilli  in  the  tissues,  but  from  the  experiments  of  Bernard  aiid  Morgan, 
bacteria  have  not  been  destroyed  by  light  when  passed  through  organic  tissue, 
yet  short  exposures  have  destroyed  the  cultures. 

The  conclusion  deduced  from  their  experiments,  were  that  tlie  bactericidal 


684  Llt^HT  ENERGY  IN  THE  TREATMENT  OF  DISEASE. 

rajs  were  not  penetrative  in  living  structures,  but  the  therapeutic  eifects  of 
light  are  due  to  the  unfavorable  media  produced  by  its  action,  and  increasing 
phagocytosis.  Nevertheless  the  experiments  of  Nagelschmidt  in  Lesser's  Clinic, 
gives  undoubted  proof  of  the  destructive  action  of  light  on  the  bacilli  in  the  skin 
of  the  guinea-pig.  He  ru);>bed  into  the  shaved  backs  of  the  animals,  living 
cultures  of  tubercle  bacilli  in  two  places  located  sjTnmetrically.  After  the 
inoculated  areas  had  healed,  local  changes  appeared  in  the  skin,  portions  of 
both  sides  were  excised,  after  one  side  had  been  previously  exposed  to  the  action 
of  light  for  one  hour.  These  excised  portions  were  inoculated  into  two  series 
of  guinea-pigs.  Eight  of  the  nine  of  the  series  treated  with  light  remained 
free  while  the  other  nine  were  all  affected  with  tuberculosis. 

There  are  few  diseases  or  pathological  conditions  in  which  light  energy 
does  not  have  a  beneficial  reaction.  Certain  skin  affections  that  have  resisted 
the  usual  treatment  have  been  cured  by  light.  Forms  of  acne  that  are  so 
refractory  to  treatment  have  responded  to  the  arc  lamp.  The  affections  that 
have  received  the  happiest  results  are:  Acne,  acne  rosacea,  eczema,  psoriasis, 
alopecia,  lichen  planus  and  all  pustular  conditions  including  abscesses,  car- 
buncles, boils  and  leg  ulcers,  even  lupus  and  epithelioma  have  responded  to  the 
light.  Widner,  of  Vienna,  reports  the  disappearance  of  an  epitbelioma  by 
exposures  of  several  hours  a  day  to  the  direct  rays  of  the  sun.  Dr.  Hirshberg, 
in  1905,  reported  the  cure  of  an  epithelioina  on  his  ear  by  exposing  it  to  the 
direct  rays  of  the  sun.  He  maintains  that  the  treatment  must  be  carried  out 
in  the  high  altitudes  of  the  mountains  and  in  the  winter  sun,  as  the  ultra- 
violet raj's  are  absorbed  by  the  dust-laden  atmosphere  of  the  lowlands,  and  in 
summer  there  is  always  the  risk  of  erythema  solare  if  there  is  prolonged 
exposure  to  the  sun. 

In  aufemia,  light  is  nature's  remedy.  The  atoms  of  oxygen  combine  with 
the  iron  when  the  patient  is  exposed  to  the  ultra-violet  frequencies.  Winternitz 
has  demonstrated  that  there  is  an  increased  percentage  of  htemoglobin  after 
each  bath.  In  diabetes,  Strebel  has  reported  success  in  a  series  of  cases.  Both 
the  arc  and  the  incandescent  light  have  acted  favorably  in  this  affection.  In 
nervous  diseases  excellent  results  have  been  reported  by  Colombo,  Strebel,  Freund 
and  Kellogg.  I  have  found  the  physiological  action  of  light  of  the  utmost 
importance  in  treating  the  various  disorders  of  the  nervous  system.  In 
neuralgia  I  have  obtained  excellent  results,  relieving  pain  in  ten  minutes  at 
the  ffrst  treatment.  Eosenberg  reports  twenty  cases  successfully  treated  with 
the  arc  lamp.  In  forms  of  neurasthenia,  especially  associated  with  malnutrition 
I  have  found  it  of  great  value.  In  locomotor  ataxia  it  also  does  well,  and 
favorable  results  have  been  reported  by  conservative  men.  Dr.  Albert  Stern 
claims  that  the  chemical  frequencies  of  light  have  been  more  satisfactory  in 
this  disease  than  any  other  method.  Cleaves  has  had  brilliant  results  in  the 
treatment  of  a  physician  suffering  from  this  affection.  In  rheumatism  it  is 
the  remedy  par  excellence.  This  is  one  of  the  diseases  in  which  remedies  so 
often  fail.  In  my  experience  I  find  very  few  cases  that  do  not  respond  to  the 
action  of  light.  If  the  infection  is  through  the  tonsils  I  always  apply  the 
light  to  the  angles  of  the  jaws  as  well  as  to  the  seat  of  the  pain,  also  is  this 


LIGHT  ENERGY  IN  THE  TREATMENT  OF  DISEASE.  685 

adhered  to  if  the  poison  is  possibly  formed  in  the  intestinal  tract.  Both  the 
arc  and  the  incandescent  lamp  do  well  in  rheumatism.  The  electric  light 
cabinets  are  better  adapted  for  treating  this  disease.  Friedlander  found  that 
these  cabinets  give  superior  results  than  the  Turkish  or  Eussian  baths.  Crothcrs 
reported  great  benefit  in  a  thousand  cases  of  toxic  neurosis  treated  with  electric 
baths,  he  claims  that  the  rays  greatly  increase  elimination  and  diaphoresis 
without  depressing  the  heart.  The  electric  light  cabinets  are  of  great  value  in 
nephritis  for  this  reason. 

In  the  treatment  of  tuberculosis,  I  know  of  no  more  valuable  agent,  whether 
the  patient  takes  daily  sun  baths  in  the  open  air  or  the  electric  energy  indoors. 
Although  the  rays  of  the  sun  are  of  great  value,  they  are  only  available  in 
summer  or  warm  climates,  as  the  clothing,  especially  from  the  waist  up,  must  be 
removed  to  stimulate  the  physiological  action  through  the  medium  of  the  skin. 
The  results  of  this  action  are  described  in  a  lecture  given  to  the  nurses  of  the 
Henry  Phipps  Institute,  April,  1908,  as  follows:  "These  sun  baths  are  of 
decided  physiological  action,  improving  nutrition,  stimulating  the  heart  and 
respiration,  thereby  aiding  assimilation  and  elimination.  Kellogg  finds  an 
increased  production  of  carbonic  acid,  indicative  of  an  increased  consumption 
of  hydro-carbon  and  carbohydrates.  The  prolonged  effect  of  the  light  upon  the 
circulation  of  the  skin  depletes  congested  abdominal  organs,  at  the  same  time 
stimulating  the  oxygen  storing  capacity  of  the  red  corpuscle,  in  a  short  exposure 
the  whole  blood  stream  will  become  completely  oxygenated,  this  is  possible  if 
only  a  portion  of  the  body  is  exposed  to  the  light.  According  to  Kellogg  the 
collateral  relation  of  the  circulation  of  the  lungs  and  pleura  to  the  skin  cover- 
ing the  chest,  arm  and  back  are  associated  through  the  internal,  intercostals, 
subclavian,  bronchial,  nutrient,  and  the  internal  iliac  arteries.  From  this 
intimate  relation  between  the  skin,  the  lungs  and  pleura,  we  can  readily 
appreciate  the  therapeutic  value  in  the  application  of  light  to  the  chest  in 
tuberculosis.  This  form  of  treatment  is  of  equal  importance  in  treating  tuber- 
culosis of  the  throat,  glands  and  joints. 

The  chemical  action  of  light  not  only  aids  in  the  arrest  of  the  disease  by 
the  increased  hajmoglobin-carrying  power  of  the  red  corpuscles,  the  destruction 
of  pns,  the  suspension  of  the  growth  of  the  bacilli,  the  elimination  of  toxins 
and  its  stimulating  action  on  all  the  nutritive  fimctions,  but  has  a  decided 
physical  influence  upon  the  ingestion  of  foods,  and  the  internal  administration 
of  drugs."  I  have  treated  in  the  past  three  yonm  one  thousand  patients  in  my 
ofdce,  approximating  about  seven  thousand  treatments  with  the  different 
forms  of  electric  light  and  I  have  selected  a  few  to  illustrate  the  value  of  light 
energy  in  disease. 

Case  I.  History: — Female,  aged  31  years.  When  a  child  three  yeai-s  of 
age  she  had  attacks  of  pain  in  both  legs  which  were  more  aggravated  at  night. 
This  occurred  at  frequent  intervals  until  she  was  16  years  of  age.  The  trouble 
then  became  constant  and  continued  until  her  twenty-first  year.  Her  first 
visit  to  my  oflScc  was  made  November  7,  190G.  Her  manner  of  standing  was 
mmt  marked,  she  could  not  bear  her  woiglit  upon  the  solos  of  her  feet  but  was 
comprlled  to  stand  and  walk  on  the  sidrs  of  botli   feet.     On  f)xan)ination.  the 


686  LIGHT  ENERGY  IN  THE  TREATMENT  OF  DISEASE. 

surfaces  of  both  tibia  were  roughened  and  painful  on  pressure,  and  with  pain 
extending  to  the  hips,  but  the  hyperesthesia  was  limited  from  the  ankles  to 
the  knees.  She  had  been  treated  for  her  trouble  during  these  j'ears  of  suffering, 
but  no  relief  was  ever  afforded.  The  treatments  commenced  November  7,  190G, 
and  continued  until  July  5,  1907.  During  this  time  she  had  one  hundred  and 
fijteen  treatments  with  both  the  arc  and  incandescent  lamp  and  fifteen  X-ray 
exposures.  The  latter  were  given  once  a  week  during  the  latter  fifteen  weeks. 
Eelief  was  afCordcd  after  the  second  week,  and  her  condition  continued  to 
improve  until  July,  1907,  when  the  pain  ceased  entirely.  At  this  time  the 
irregular  surfaces  of  the  tibia  were  less  marked,  the  hyperassthesia  had  entirely 
disappeared  and  for  two  months  previous  to  her  last  visit  she  could  assume  a 
normal  position  in  standing  and  walking.  Her  health  had  greatly  improved 
and  her  weight  increased  from  one  hundred  and  eight  pounds  to  one  hundred 
and  twenty-two,  and  she  has  never  had  return  of  the  trouble. 

Case  II.  History: — Male,  aged  39  years.  Health  had  been  good  until 
November,  1906,  when  he  had  pneumonia  and  pleurisy.  His  lung  was  aspirated 
twice,  the  fluid  consisted  of  pus  and  blood.  He  coughed  continually  for  six 
months  with  purulent  expectoration  and  had  frequent  haemorrhages.  First 
visited  the  office  July  12,  1906,  six  months  after  first  taking  ill.  He  was  pale, 
emaciated  and  weighing  one  hundred  and  ^eighteen  pounds,  his  normal  weight 
was  one  hundred  and  fifty-five  pounds,  there  was  dullness  over  lower  lobe  of  right 
lung,  appetite  poor,  nausea,  temperature  from  100°  to  101°,  he  coughed  fre- 
quentl.y,  with  great  pain  on  the  right  side.  The  patient  was  given  25  treatments 
with  the  incandescent  lamp,  commencing  at  first  with  ten  minutes  for  each 
exposure,  and  later  extending  to  30  minutes.  Improvement  commenced  after 
the  first  few  treatments,  cough  became  less  frequent  and  pain  disappeared  after 
the  seventh  visit.  Last  treatment  was  given  October  13,  1907,  the  pfitient  only 
had  one  haemorrhage  during  the  two  months,  he  gained  rapidly  in  weight, 
appetite  improved.     His  weight  at  present  time  is  one  hundred  and  sixty  pounds. 

Case  III.  History: — Male,  aged  60  years.  The  patient  had  for  the  past 
18  daj's  a  severe  pain  on  the  left  side  of  the  face  corresponding  to  the  dis- 
tributive of  the  fifth  nerve.  Loss  of  motion  on  the  same  side  of  tlie  face.  He 
did  not  sleep  niglit  or  day.  The  first  relief  the  patient  had  was  after  he  was 
ten  minutes  under  the  incandescent  lamp,  the  pain  returned  the  following  day 
but  was  again  relieved  by  the  lamp.  It  did  not  return  after  the  second  treat- 
ment. Twenty-three  treatments  were  given  20  minutes  each.  In  the  begin- 
ning the  treatments  were  applied  twice  a  day,  and  after  the  fourth  day,  oncG 
daily.     At  tlie  end  of  four  weeks  the  face  was  restored  to  its  normal  functions. 

Case  IV.  History: — Male,  aged  35  years.  Diagnosis,  tuberculosis.  Tlie 
year  previous  the  patient  was  tapped  for  a  pleural  effusion.  He  had  a  cough 
ever  since  he  first  contracted  pleurisy.  Twenty-six  treatments  were  given  with 
the  arc  and  incandescent  lamp,  commencing  May  13,  1907,  and  ending  July  27, 
1907.  At  that  time  the  patient's  cough  was  relieved  and  he  had  improved  in 
health.  His  original  weight  was  two  hundred  and  ten  pounds  and  at  the  date 
of  last  visit  he  weighed  two  hundred  and  twenty  pounds. 

Case  V.  Hi'Story: — Male,  aged  35  years.     The  first  visit  made  at  my  ofilce 


LIGHT  ENERGY  IN  THE  TREATMENT  OF  DISEASE.  687 

was  May  14,  1907.  June,  1905,  lie  fell  from  a  roof  20  feet  high,  suffering  a 
severe  injury  of  the  spiue.  He  was  confined  to  his  bed  lor  three  mouths  and 
had  to  walk  two  months  on  crutches.  He  had  paralysis  of  the  bowels  and 
bladder.  He  was  given  treatments  by  the  arc  light  15  minutes  to  the  back, 
and  10  minutes  to  the  abdomen.  Treatments  were  given  twice  weekly  for  two 
mouths,  he  improved  each  week  and  with  entire  recovery  of  the  functions  by 
July,  1907. 

CxVSE  YI.  Histonj: — Male,  aged  25  years.  Eczema  of  the  face,  duration 
two  years,  had  entirely  recovered  after  three  treatments  of  the  arc  lamp. 

Case  Vll.  History: — Male,  aged  3  years.  Had  rheumatic  pains  in  both 
knees  for  five  months,  worse  at  night,  associated  with  enlarged  tonsils.  His 
knees  were  swollen.  The  child  was  anaemic,  fretful  and  slept  very  little  night 
or  day.  Fourteen  treatments  were  given  with  the  incandescent  lamp,  with 
complete  recovery.  The  visits  were  made  twice  a  week,  15  minutes  exposure 
to  the  knees  and  10  minutes  to  the  sides  of  the  tonsils.  Beneficial  effects  were 
marked  after  two  weeks  with  relief  of  pain.  Tonsils  bcame  smaller  and  anosmia 
disappeared  after  the  last  treatment.  The  most  interesting  feature  of  this  case 
was  the  disposition  of  the  child.  Instead  of  being  peevish,  the  boy  became  real 
jolly,  took  an  interest  in  his  playthings  and  desired  to  play  with  the  other 
children  which  he  never  did  before. 

Case  YIII.  History : — Male,  aged  40  years.  Carbuncle  of  the  neck,  dura- 
tion one  week.  The  patient  was  given  daily  treatment  with  the  arc  lamp,  six 
treatments  in  all,  with  relief  of  pain  after  the  second  treatment.  At  the  end 
of  the  sixth  treatment  the  carbuncle  had  almost  ceased  to  evacuate.  The 
patient  felt  so  well  that  he  discontinued  the  visits  on  account  of  his  business. 

Case  IX.  History : — Male,  aged  39  years.  Infection  of  the  first  finger  on 
the  right  hand,  duration  three  weeks.  Had  been  incised  twice  the  whole  length 
of  the  finger.  Painful  night  and  day.  Amputation  of  the  finger  had  been 
decided  upon  by  his  physician.  Seven  treatments  were  given  with  the  incan- 
descent lamp,  twenty  minutes  each  daily,  with  complete  recovery  ten  days  later. 
Case  X.  History: — Male,  aged  25  years.  Referred  to  me  by  dentist, 
diagnosed  by  him  as  pyorrhcea.  The  young  man's  jaws  were  so  fixed  that  the 
dentist  could  not  insert  an  instrument  or  swab  to  reach  the  gums.  He  could 
not  open  his  mouth  to  receive  food,  depending  upon  liquid  diet  for  two  days. 
The  pain  was  so  severe  that  he  had  no  rest  for  two  nights.  After  the  applica- 
tion of  the  incandescent  lamp  for  fifteen  minutes,  it  was  possible  to  thoroughly 
cleanse  his  mouth,  with  the  separation  of  his  jnws  three-quarters  of  an  inch. 
His  mouth  was  washed  with  diluted  peroxide  of  hydrogen  &nd  listerin.  His 
first  treatment  was  in  the  morning,  and  the  second  treatment  was  given  the 
Fame  eveninjr.  Pain  was  relieved  after  the  first  treatment,  and  a^'ter  receiving 
the  applicntion  of  the  incandescent  Inmp  the  second  time,  he  could  move  his 
jnws  freelv,  but  was  yet  not  able  to  receive  other  than  liquid  diet.  After  the 
third  trentment  the  following  mnrning,  the  young  man  enjoyed  a  full  meal 
with  an  entire  recovery  after  the  fifth  treatment. 

Cask  XT.  History: — Female,  a^ed  25  yenrs.     JFenstruation  at  nineteenth 
year.     Four  years  ago  she  developed  severe  pains  from  two  to  seven  days  before 


088  LIGHT  ENEliaY  IN  THE  TREATMENT  OF  DISEASE. 

her  periods,  which  generally  lasted  three  days,  and  appeared  every  three  to  six 
weeks.  Period  preceded  by  sick  headache  and  nausea,  and  frothy  vomit. 
Twenty-five  treatments  were  given  with  the  incandescent  lamp  twice  a  week. 
The  vomiting  and  pain  ceased  after  the  first  month,  but  imtil  the  fifteenth 
treatment  she  had  tenderness  over  the  left  ovary.  This  improved  until  it 
ceased  before  the  last  visit. 

Case  XII.  History: — Male,  aged  45  years.  Has  had  a  habit  of  drinking 
three  to  four  glasses  of  beer  daily  for  the  past  three  months.  He  had  tinnitus 
aurium,  vertigo,  coated  tongue,  and  occasionally  headache,  constipation,  tender- 
ness in  the  region  of  the  liver,  complains  of  hearing  voices  talking  to  him,  but 
is  convinced  that  it  is  not  real.  He  was  given  23  treatments  with  the  incan- 
descent lamp.  He  received  relief  after  the  first  few  treatments  and  this  con- 
tinued until  to  the  end  of  the  last  visit. 

Case  XIII.  History: — Female,  aged  19  years.  Stenographer  for  physi- 
cian. She  had  scarlet  fever  in  childhood.  Two  years  ago  she  had  adenoids 
and  tonsils  removed.  Since  she  had  scarlet  fever  she  has  had  periodical  dis- 
charge from  the  ears,  left  ear  more  troublesome.  Patient  had  chronic  suppura- 
tion of  frontal  sinus  existing  since  she  was  first  troubled  with  the  discharge 
from  the  ears.  She  had  a  history  of  periodical  attacks  of  headache  that  were 
relieved  with  belladonna  and  local  treatment.  The  patient  was  left  in  my  care, 
while  her  employer  was  in  Europe,  with  the  understanding  that  I  was  to  refer 
her  to  Dr.  Harlan,  in  Philadelphia,  when  the  occasion  demanded.  On  Decem- 
ber 15,  1906,  the  patient  made  her  first  visit,  she  was  suffering  with  a  severe 
cold  and  headache.  I  gave  her  an  application  of  the  hiph- frequency  current 
with  a  doul)le-pronged  vacuum  tube  rich  in  the  violet  frequencies,  the  treatment 
lasting  five  minutes.  This  was  followed  with  ten  minutes  exposure  every 
other  day  until  she  had  taken  eight  treatments.  Certain  relief  v/as  afforded 
by  these  applications  until  she  developed  an  acute  cold  or  coryza  associated  with 
a  severe  headache.  I  then  applied  the  rays  of  the  arc  lamp  for  ten  minutes 
each  visit.  She  had  taken  24  treatments  with  no  return  of  the  headache  since 
the  second  application.  Fourteen  of  these  exposures  were  made  with  the  arc 
and  ten  by  the  incandescent  lamp.  Ten  minutes  with  tlie  former  and  twenty 
minutes  with  the  latter  and  the  visits  were  made  twice  a  week.  On  May  4t]), 
tlie  patient  snddexdy  developed  a  severe  pain  in  the  mastoid  region,  it  was  pain- 
ful on  pressure  and  slightly  bulging,  dilatation  of  tlie  pupils,  nausea  and  vertigo. 
The  patient  complained  bitterly  of  the  intensity  of  the  pain.  Her  condition 
seemed  so  alarming  th.it  I  advised  her  to  visit  the  speciali;-t  in  Hie  city  w!)ich 
she  did,  but  after  returning  home  the  pain  was  as  intense  as  ever,  and  at  lior 
request  I  applied  the  light  to  the  mastoid  region,  also  permittii);^^  tlie  rays  to 
enter  the  ear.  She  was  relieved  after  twenty  minutes  but  the  pain  returned  the 
same  night.  She  received  daily  treatments  for  five  days,  then  every  other  daj', 
and  finally  tv;ice  a  week  taking  18  exposures,  the  pain  (jntirely  ceased  after  the 
first  week.  She  has  had  very  little  i  rouble  with  t1>o  frontal  headaches  or  Use 
pain  in  the  mastoid  region  Binco. 

Casr  XIV.  His'ory: — Female,  aged  10  years.     The  girl  had  purjrura  on 
both  leg.^  from  ankles  in  the  thighs,  greatly  influenced  by  prrssure,  more  marked 


LIGHT  ENERGY  IN  THE  TREATMENT  OF  DISEASE.  689 

above  the  knees  where  the  garters  bound  the  sldn.  This  was  associated  with 
acute  articular  rheumatism.  Seven,  treatments  were  given  of  fifteen  minutes 
each  daily  for  three  days  then  every  other  day.  Eelief  from  pain  was  stated 
alter  the  fifth  treatment  and  the  disappearance  of  the  purpura  at  the  last 
treatment. 

Case  XV.  History: — Female,  aged  22  years.  Acne  involving  the  face 
lasting  since  she  was  seventeen  years  of  age.  Treatments  consisted  in  the 
application  of  the  rays  of  the  arc  lamp,  using  the  blue  glass  screen  or  filter  to 
control  the  thermal  rays.  Ten-minute  exposures  were  administered  for  the  first 
three  visits,  then  15  minutes  each.  For  the  first  two  weeks  she  was  given  two 
exposures,  then  only  one  a  week.  At  the  end  of  six  weeks  her  face  was  entirely 
clear  and  it  has  not  returned. 

Case  XVI.  History. — Male,  aged  35  years.  Acne,  abscesses  and  keloidal 
scars  on  both  sides  of  the  face  and  neck,  duration  12  years.  The  patient  was 
given  eighteen  treatments  with  the  arc  lamp,  fifteen  minutes  each,  twice  weekly. 
The  first  visit  was  made  at  the  ofiice  March  8,  1907,  and  the  last  visit  was  April 
2Sth.  His  face  was  entirely  clear  at  this  time,  and  had  not  had  a  return  of 
the  trouble  since. 

Case  XVII.  History: — Male,  aged  4  years.  Had  whooping-cough  when 
two  3'ears  of  age,  and  ill  health,  his  mother  states,  dates  from  that  time.  On  his 
first  visit  to  the  office  the  child  exhibited  pronounced  anaemia  and  with  a  history 
of  being  vicious,  at  all  times  irritable,  easily  aroused  to  fits  of  passion  on  the 
slightest  provocation,  punishment  only  aggravated  his  condition,  so  he  was  more 
frequently  indulged.  His  appetite  was  poor  and  perverted  and  he  suffered  con- 
stipation. He  cried  and  complained  with  severe  pain  in  his  abdomen  asso- 
ciated with  frequent  attacks  of  cramp-like  seizures.  On  inspection  his  belly 
was  abnormally  large  and  painful  to  the  touch.  The  first  treatment  was  given 
September  4,  1908,  with  the  incandescent  lamp.  The  light  was  applied  to  the 
abdomen  in  the  region  of  the  greatest  teiidemess  for  fifteen  minutes.  The 
child  refused  to  lie  on  the  table  and  resisted  force  and  attempted  to  kicl:  his 
mother  in  the  face  and  chest,  he  had  to  be  held  on  the  table.  The  second  treat- 
ment was  three  days  later,  he  seemed  to  have  less  pain  since  his  first  visit,  lie 
did  not  resist  being  placed  on  the  table  but  refused  to  have  his  abdomen  exposed 
and  persisted  in  pulling  his  undershirt  down.  The  third  visit  was  made  four 
dayp,  later,  the  cliild  sat  on  my  lap,  ]ilayod  with  my  watch  and  seemed  interested 
with  objects  in  the  office.  The  mother  slated  that  he  complained  of  very  little 
pain,  had  had  no  attacks  of  cramps,  and  the  bowels  moved  without  medicine,  was 
cheerful  during  the  day,  took  an  interest  in  his  playthi]igs  and  slept  well  at 
nights.  He  did  not  objcc  t  to  treatment.  From  September  4th  to  October  14th 
he  had  nine  treatments  commencing  at  first  with  two  visits  a  week,  and  later  one 
weekly.  I  advised  the  mother  to  continue  the  treatments  but  as  her  means  were 
limited  the  visits  were  suspended,  with  the  promise  that  she  would  bring  the  boy 
back  at  the  first  return  of  the  trouble.  I  consider  this  a  very  remarkable  result  of 
the  therapeutic  action  of  light.  At  the  time  of  the  last  visit  the  transformation 
of  the  boy  was  astonishing,  he  wanted  to  play  with  other  children,  fried  to  sing 
and  frhi«ile,  ^x>ok  an  interept  in  pioturp  books,  and  censed  to  bo  dpstniotive. 
6 


690     TESTIMONIES  ON  THE  MUMMY  GROVE  POTTERIES  OF  OLD  PERU. 

His  anocmia  disappeared,  appetite  improved,  the  pain  had  entirely  left.  He 
was  an  entirely  normal  child,  and  was  saved  from  the  possibility  of  becoming  a 
criminal  if  he  lived. 

Case  XVIII.  Ilisiory : — Female,  aged  28  years.  Tubcrenlons  ulcer:ition  of 
the  skin  over  the  knee,  duration  six  years.  Two  sisters  died  of  tuberculosis, 
the  last  one  a  short  time  before  the  trouble  with  the  patient  began.  Tlie  lesion 
appeared  after  an  injury  to  the  Imee  and  did  not  differ  at  first  from  an  ordinary 
inflammation  except  that  it  failed  to  heal.  Ulcers  developed  close  to  the 
original  site,  some  slowly  healed  leaving  angry  looking  violaceous  colored  scars. 
Inspection  at  the  first  visit  revealed  an  irregular-shaped  ulceration  as  large  as  a 
half  dollar  formed  from  two  ulcers  coalescing,  the  edges  were  ragged  and 
dark  in  color,  the  floor  was  superficial  and  discharging  freely.  There  were  scars 
of  previous  lesions  on  the  knee.  The  patient  was  subject  to  eezematous  out- 
breaks. She  was  given  treatment  with  the  incandescent  lamp  twenty  minutes 
each,  having  at  present  twelve  exposures.  The  treatments  were  given  twice  a 
week.  Her  visits  commenced  September  21,  1908.  The  lesions  at  present  are 
now  healed  over  and  have  been  in  that  condition  for  the  past  two  weeks.  Since 
the  improvement  in  the  ulcers  the  eczema  has  become  troublesome  involving 
the  face,  arms  and  legs.  It  looks  as  if  the  healing  of  the  tuberculous  ulcers  has 
possibly  disturbed  the  cutaneous  equilibrium.  It  is  my  usual  custom  to  treat 
discharging  tuberculous  lesions  with  a  number  of  exposures  of  the  electric  light 
before  applying  the  X-rays,  which  was  my  intention  with  this  patient,  but  the 
rapid  improvement  under  the  incandescent  lamp  was  a  very  satisfactory  reason 
for  continuing  this  method. 


BIEDICAL  AND  SURGICAL  TESTIMONIES  ON  THE  MUMMY  GROVE 
POTTERIES  OF  OLD  PERU. 

By  ALBERT  S.  ASIBIEAD,  M.D. 

At  difl'crent  occasions  I  have  called  attention  to  the  representations  of 
mutilation  and  disease  on  faces  and  limbs  in  many  examples  of  anthropomor- 
phous ancient  Peruvian  clay  vessels,  called  by  scientists  "Huacos,"  wine  or 
water  bottles,  found  buried  with  corpses. 

Dr.  Jose  Macedo,  in  the  year  187G,  exhibited  in  Lima  his  famous  collec- 
tion of  these  object".  One  of  these  appeared,  as  he  thought,  to  be  the  symbol 
of  death :  the  face  was  more  like  a  flcshless  cranium  than  a  living  face.  The 
person  represented  v.^as  striking  a  timbrel,  and  at  its  feet  were  figures  dancing, 
playing  wind  instruments;  their  faces  were  funereal  as  also  were  their  vestments. 

Dr.  Palma  has  published  a  huaca  showing  the  face  of  the  man, 
represented,  as  diseased — nose  and  upper  lip  eaten  away.  About  the  body  of 
the  bottle  was  a  bas-relief,  showing  eight  persons  dancing,  holding  hands.  One 
of  these  images  had  a  skull  for  face,  with  hands  raised  in  an  attitude  of  sup- 
plication. I  myself  published  a  plate  given  me  by  Prof.  Mead,  of  the  American 
Museum  of  Natural  History,  New  York,  showing  several  persons  dancing,  while 


TESTIMONIES  ON  THE  MUIMMY  GROVE  POTTERIES  OF  OLD  PERU.     691 

musical  instruments  were  being  played  upon,  and  on  the  ground  were  placed 
several  vessels,  evidently  holding  wine.  One  of  these  figures  had  in  place  of 
a  foot  a  square  block  of  wood.  Evidently  these  dancers  had  relation  to  disease, 
or  crippling,  or  death,  and  were  connected  with  the  huacas  potteries,  for  they 
danced  around  them. 

Dr.  Maccdo  has  four  heads  (huacas)  with  all  the  deformities  of  S3'philis  as 
produced  in  its  tertiary  manifestations.  One  with  its  skin  covered  with 
tubercles  more  or  less  prominent,  which  might  be  verruga  or  some  other  eruptive 
disease.  Another  represented  a  monarch  seated  on  a  hill,  the  left  hand  rested 
on  the  knee,  the  right  one  broken.  A  third  one  was  that  of  a  blind  person 
playing  a  flute,  giving  one  a  clear  idea  of  the  sad  expression  of  a  beggar.  Another 
was  a  huaca  from  Chimbote,  a  careless  idol  as  it  appeared,  its  face  very  grave, 
with  crown  and  earrings  and  necklace  of  spherical  form,  having  in  the  right 
hand  a  human  head,  seized  by  the  hairs,  and  in  the  left  a  cutting  hatchet,  which 
appeared  to  be  the  instrument  that  had  decapitated  the  prisoner. 

Ch.  Wiener  shows  in  his  "Perou  et  Bolivie"  a  subject  of  full  length,  Avith 
disease  of  skin,  for  the  person  was  in  a  grievous  attitude,  scratching  the  body 
with  both  hands.  Wierner  thought  this  represented  syphilis,  but  it  does  not  itch. 
I  myself  published  in  Archives  of  Surgery  a  figure,  similar,  which  Jonathan 
Hutchinson  interpreted  as  MoUuscum  fibrosum.  Wiener  gave  the  same  defini- 
tion for  a  head,  which  represented  squinting  of  the  right  eye  and  with  mouth 
diverted.  This  I  interpreted  as  a  form  of  paralysis.  Wiener  said  that  both 
these  examples  were  derived  from  Puno,  a  syphilitic  region  of  Peru.  Prof, 
Virchow  thought  that  the  first  one  represented  some  form  of  itch,  in  which 
wonderful  interpretation  there  was  not  necessarily  required  much  scientific 
wisdom. 

Dr.  Lehmann-Nitsche,  of  Buenos  Aires,  has  published  a  huaca,  showing 
nose  mutilated,  upper  lip  eaten,  and  with  the  lower  lip  partly  eaten.  This  last 
had  not  been  observed  in  any  Peruvian  vessel  down  to  date.  From  the  photograph 
of  this  image  the  lower  lip  appeared  to  have  lost  a  part;  the  mutilation  was 
distinct. 

Dr.  Palma  has  shown  an  image  with  evident  lower  lip  lost  completely. 
The  person  is  represented  seated  in  an  easy  attitude.  It  has  a  small  part  of  the 
nose  cut  off.  The  two  lips  have  been  barbarously  cut  off,  down  to  their  base; 
the  section  is  lateral  and  very  extensive,  leaving  a  portion  of  the  cheeks,  but 
the  molars  are  completely  uncovered.  The  feet  of  this  im.age  are  amputated 
at  the  ankle  joint.  The  stumps  are  healed  with  suture  transverse.  It  was  the 
first  time  such  an  example  of  amputation  of  both  lips  has  been  described.  The 
other  huaca  of  Dr.  Palma's  was  a  black  huaca  delicately  worked.  It  presents 
the  nose  mutilated  and  deeply  sunken  in;  the  upper  lip  is  cut  off  in  triangle 
permitting  the  teeth  to  be  seen ;  the  lower  lip  appears  sectioned,  also  permitting 
to  be  seen  the  teeth ;  the  feet  of  this  image  arc  not  visible.  In  the  middle  of 
the  forehead  is  noted  a  kind  of  tumor  sunken  in,  and  pared  off  at  its  borders, 
but  prominent  in  its  centre.  On  the  head  are  two  large  tumors,  the  riglit 
larger  and  more  elevated  than  the  left,  like  two  ulcrrations,  one  round,  which 
is  seen  front  face,  the  other  longer  and  seen  posteriorly.     The  left  presents  only 


692     TESTIMONIES  ON  THE  MUiVEVIY  GROVE  POTTERIES  OF  OLD  PERU. 

one  of  these  apparent  ulcerations.  The  abdomen  of  this  image  is  shown  full 
of  lumps  and  depressions,  or  irregular  furrows  in  all  the  parts,  giving  the  illu- 
sion of  tubercles  on  a  potato.  Underneath  the  left  axilla,  radiating  to  the 
costal  wall,  is  noted  a  voluminous  tumor,  rounded  and  fiat  all  over,  except  in 
front,  where  there  is  a  furrow.  In  order  that  this  swelling  may  be  more 
visible,  the  patient  is  shown  with  his  left  arm  pulled  away  and  in  front  or  aside, 
with  his  right  hand.  As}Tnmetrically  arranged  on  the  sides  of  the  patient's 
neck  are  seen  other  buUosities. 

These  lesions  have  never  before  been  observed  in  the  mutilated  anthro- 
pomorphous huacas. 

Dr.  Lehmann-ISTitsche  also  exhibited  a  huaca  with  the  nose  eaten,  and  the 
mouth  lesioned  by  disease,  not  cut.  Another  had  the  point  of  the  nose  lost, 
upper  lip  mutilated  in  the  form  of  triangle  (cut  off),  and  the  eyes  closed.  Is 
he  blind?  The  feet  of  this  person  are  amputated,  sutures  transverse,  stumps 
healed.  He  holds  in  his  right  hand  a  drum.  Here,  evidently,  is  some  relation 
between  the  drum  and  the  sick  dances  and  superstitious  medical  relief,  by  appeal 
to  witchcraft,  to  drive  out  the  evil  spirit. 

Dr.  Lelmiann-Nitsche  also  published  a  figure  lying  on  its  belly;  the  nose 
and  both  lips  lost,  as  also  were  the  feet,  sutures  transverse.  A  similar  one  was 
published  by  myself  in  the  Berlin  Leprosy  Conference  Transactions. 

Dr.  Paima  has  shown  a  huaca  representing  a  woman  lying  down.  Looking 
at  this  huaca  from  behind,  long  hair  is  noted ;  also,  that  the  head  is  supported 
by  a  block  of  wood,  wrapped  up  so  that  it  serves  as  a  pillow.  The  nose  and 
upper  lip  are  cut  off,  for  the  loss  is  triangular-shaped,  letting  the  gimis  and  teeth 
be  seen.  The  feet  are  amputated  at  the  tibio-tarsal  joint.  On  the  face  are  seen 
painted  rays,  in  the  guise  of  ornament.  In  no  other  collection  is  their  such  an 
example  representing  a  patient  in  the  bed. 

Dr.  Ijehmann-Nitscho  also  showed  a  huaca  representing  a  person  on  the 
knees,  with  a  stick  in  the  right  hand,  the  feet  lost  by  amputation  that  had  healed; 
stumps  in  sagittal  suture.  Only  the  nose  was  mutilated.  The  whole  right 
cheek  was  occupied  by  the  drawing  of  a  right-angled  triangle,  which  in  its 
interior  has  rays  that  cross  perpendicularly  forming  squares.  On  the  left  cheek 
are  two  parallel  rays.  On  the  chin  is  a  bug,  like  a  beetle.  "Does  this  represent," 
a'^ks  Dr.  Lehmann-Nitsche,  ''the  disease  which  has  corroded  the  nose?"'  It  may 
be  an  error  of  the  artist,  but  six  fingers  are  made  on  each  hand. 

Dr.  LehraaiLU-Nitsche  has  said:  "I  may  be  permitted  to  express  my 
opinion,  that  much  doubt  exists  as  to  whether  the  mutilations  of  the  nose  and 
upper  lip  have  any  etiological  counection  withi  tlie  feet.  It  appears  to  me  that 
these  cases  treat  of  invalid  beggars,  that  have  acquired  the  diseases  which  arc 
contracted  in  wretchedness." 

Dr.  Lehroann-Nitsche  has  also  published  a  huaca  (Patologia  en  la  alfareria 
peruana),  a  very  rare  exhibit  from  the  Garcia  Meron  collection.  It  represents 
a  beggar  who  prcEents  a  dish  with  his  right  hand  in  the  attitude  of  supplicating 
alms,  whilst  with  the  left  he  carries  a  stick,  like  a  cane,  to  creep  along  with 
more  e.Trsp.     Thii?  vn«r  pre'^rnte  PupcTficially  on   l:lir  infrrior  pnrt.  nimply  the 


TESTIMONIES  ON  THE  AlUilMY  GROVE  POTTERIES  OF  OLD  PERU.     693 

left  leg  entire,  whilst  the  right  one  terminates  in  a  stump.  There  is  no  other 
mutilation  shown  on  the  whole  figure. 

"We  must  admit,"  says  Dr.  Lehmann-Nitsche,  "that  this  beggar  had  lost 
his  leg  by  a  misfortune,  or  that  it  had  been  amputated  according  to  the  art 
of  iEscuJapius  for  some  reason,  but  it  may  be  supposed  that  it  might  have  been 
for  some  disease  of  the  leg,  that  required  him  still  to  carry  it  bandaged,  for  it 
is  easily  recognized  that  there  is  a  dressing  by  the  bandage  being  the  same 
color  as  his  shirt." 

I  myself  have  expressed  the  opinion  that  the  musical  instruments  in  the 
hands  of  so  many  of  the  mutilated  persons  represented  on  the  huacas,  in  sup- 
pliant attitude,  do  not  signify  that  beggars  hold  them  for  reason  of  their  mutila- 
tion, but  rather  that  diseased  persons  make  use  of  them  for  superstitious  relief 
from  their  evil  condition.  This  opinion  is  corroborated  by  the  evidence  of 
the  sick  dances. 

Dr.  Carrasquillo  has  said  that  the  amputations  represented  on  the  huacas 
vases  were  due  to  punishments  for  crime,  but  all  scientists  have  disagreed  with 
this  eminent  South  American  on  this  point.  That  question  has  been  ruled  out, 
yet  it  may  be  interesting  to  refer  to  this  subject  as  surgical  treatment  requiring 
amputation  of  the  feet  is  exhibited  in  so  many  of  these  huacas. 

In  a  huaca  of  the  Gaffron  collection  of  Lima  there  are  sho\vn  lateral  sym- 
metrical mutilations  on  the  wings  of  the  nose,  with  the  head  inclined  down- 
ward and  the  person  contemplating  the  sole  of  the  foot,  which  is  held  by  the  two 
hands.  The  sole  of  the  foot  presents  a  sieve-like  surface  with  numerous 
perforations,  showing  midtiple  perforating  ulcers,  just  like  some  Peruvian 
diseases  might  produce. 

Mr.  Mead,  the  assistant  curator  at  the  Museum  of  Natural  History,  New 
York,  who  furnished  me  with  the  photographs  of  this  pot,  said  he  believed  the 
cavities  in  the  sole  of  the  foot  represented  the  little  holes  left  after  the 
extraction  of  the  sacs  of  the  eggs  of  a  specie  of  insect  called  Musca  de  Arena. 

I  rejected  this  idea,  as  the  nose  and  lip  of  this  subject  were  also  shown 
mutilated,  but  Dr.  Palma,  in  reviewing  this  question,  points  out  that  the  mutila- 
tions of  the  nose  and  of  the  mouth  have  borders  so  very  straight  that  they 
appear  made  with  a  knife,  and  the  lesions  on  the  foot  are  represented  by  many 
semispherical  holes,  excavated  in  the  skin. 

That  the  same  disease  which  produced  the  mutilation  on  the  face,  even  if 
requiring  surgical  relief,  could  have  produced  the  lesions  of  the  foot  is  doubted 
by  Dr.  Palma,  because  uta  principally  does  not  affect  the  feet.  Uta,  as  I  under- 
stand the  word,  is  corroding  ulcer,  and  whether  it  applies  really  to  the  uta  of 
Peru,  as  Dr.  Palma  knows  it,  or  to  some  more  serious  complaint,  which  does 
attack  the  feet  in  the  coca  and  rice  countries,  is  of  small  account.  The  condi- 
tion of  ulceration,  of  gangrene,  of  phagodena,  is  what  I  mean  by  uta,  and 
this  does  attack  the  feet  and  destroys  them,  rots  them  off,  in  Peru  and  Western 
South  America.  The  llagas  of  Pangoa  is  the  worst  kind  of  uta  (corroding 
ulcer),  and  rots  the  feet  off,  unless  amputated,  so  docs  Espundia  of  Bolivia. 

Dr.  Palma  has  referred  to  a  photograph  I  sent  to  Dr.  Grana,  given  me 
by  Prof.  Dorsey,  of  the  Field  Columbian  Museum,  of  Chicago,  of  a  pottery  in 


6;J4     TESTIMONIES  ON  THE  MUMMY  GROVE  POTTERIES  OF  OLD  PERU. 

his  possession,  showing  the  head  thrown  backward,  evidently  by  spinal  curvature, 
and  he  disputes  my  statement  that  tuberculosis  of  the  spine  (caries  of  the 
vertebra)  might  be  responsible  for  the  deformity.  He  makes  the  point  tbat 
uta  is  not  a  skin  tuberculosis,  and  therefore  could  not  be  the  cause  of  this 
curvature.  I  do  not  know  whether  all  the  utas  of  Peru  are  not  tuberculosis, 
but  presume  some  of  them  are.  The  artist-potters  show  here,  at  any  rate,  a 
condition  which  nmst  be  due  to  an  injury  or  to  disease,  and  the  most  plausible 
solution  of  the  latter  problem  would  be  to  consider  it  either  tubercular  or 
syphilitic. 

]Ji-.  Palma  has  published  a  huaca,  which  is  armless,  and  says  that  beneath 
the  shirt  sleeves  of  the  image  may  be  seen  stumps,  showing  that  amputation 
was  performed.  This  image  is  that  of  a  kingly  looking  man,  with  an  unusually 
high  forehead  and  nobleness  of  face.  His  nose  is  finely  moulded — Eoman,  and 
all  his  features  show  him  to  be  a  man  of  power.  There  is  no  evidence  of  disease 
at  all  about  him,  so  we  cannot  even  hint  at  amputation  for  disease.  Perhaps 
tliis  was  a  criminal's  punishment,  yet  he  does  not  look  a  criminal,  but  rather 
like  one  who  was  a  chieftain.  Was  he  taken  prisoner  and  were  his  arms  lost 
in  battle  ?  Xo  one  can  interpret  this  amputation.  It  is,  however,  very  interest- 
ing, for  it  is  rare  to  find  amputation  of  the  upper  members.  This  is  the  only 
one  I  ever  saw.  The  arms  of  this  image  have  been  amputated  above  the 
elbows,  not  merely  the  hands. 

Eegarding  the  question  of  beggary,  as  some  scientists  believe  to  be  repre- 
sented on  the  huacas  potteries,  Dr.  Palma  quotes  from  the  ancient  literature  of 
Peru,  showing  that  the  ancient  laws  provided  against  the  necessity  of  begging. 
Means  were  assured  in  the  communities  for  the  State  care  of  paupers.  He  quotes 
from  Garcilazo,  "As  to  the  order  of  government,  relating  to  the  care  of  widows, 
orphans  and  the  aged  and  diseased.  How  they  furnished  seed  and  put  aside 
tithes  for  the  support  of  village  poor."  Garcilazo  even  asserted :  "There  are  no 
poor  beggars."  Down  to  the  year  loGO,  supplication  for  alms  was  guarded 
against.  In  walking  he  never  saw  an  Indian  begging.  But  only  in  Cuzco  he 
saw  old  women,  who  were  called  "Isabels,"  who  begged,  after  playing  the  buffoon, 
from  liouse  to  house  like  gypsies.  He  quotes  Cieza  de  Leon  to  the  same  argu- 
ment; also  Hcrrera,  as  to  the  government  of  the  Incas  against  beggary,  and 
equity  and  tithing  to  support  the  poor,  part  of  the  land  being  set  aside  to  be 
cultivated  for  the  support  of  the  poor. 

Carrasquillo,  Bastian,  Middendorf,  Sommer  and  others,  have  thought  tliat 
some  of  the  mutilations  on  the  huacas  represented  effects  of  puiiishments 
applied  for  certain  crimes.  Dr.  Palma  has  quoted  from  Zarate  about  the 
servants  in  charge  of  the  lord  of  the  isle  (Incas),  who  had  charge  of  the 
women  having  their  noses  and  virile  members  cut  off.  Ovieda  is  quoted  from 
to  the  effect  that  as  penalty  they  plucked  out  the  eyes  for  some  delinquencies. 
And  from  Gomara,  who  says  that  ancient  Chibchas  cut  off  noses  and  put  out 
eyes  for  certain  faults. 

But  it  is  alleged,  in  refutation,  that  the  Cliibchas  had  no  relation  with 
Peruvians,  that  only  on  ornamentations  of  the  clay  vessels  are  represented  these 
dances,  customs,  scenes  of  the  chase,  decapitations,  etc.,  or  punishments  of  this 


TESTIMONIES  ON  THE  MUMMY  GROVE  POTTERIES  OF  OLD  PERU.     695 

kind,  and  that  in  the  vase  itself  they  recorded  things,  many  of  which  the 
potters  never  had  seen. 

In  the  work  "Monographia  Historia-Americana,"  of  Seuor  Larrabure,  there 
are  reproduced  painted  figures  on  a  great  phite  found  in  a  tomb.  Tlicre  is  seen 
here  a  criminal,  naked,  who  with  the  right  hand  holds  the  nose,  whence  springs 
much  blood.  He  carries  a  rope  at  his  neck,  caught  at  its  end  by  the  police  who 
conduct  him.  He  follows  another  pair,  probably  across  country,  as  appears  from 
some  far  off  hills,  and  there  is  a  bird  flying  over  them.  This  other  punished  one 
is  in  the  same  attitude  as  the  preceding  one,  and  there  are  noticed  also  drops 
of  blood  which  fall  from  his  nose.  It  appears  that  they  have  had  cut  the 
mouth,  prolonging  it  back  to  the  ears.  The  police  conduct  them  with  a  rope, 
and  behind  all  comes  an  official. 

The  plate  is  made  of  ancient  clay,  and  is,  without  any  doubt,  of  value  in 
sustaining  the  hypothesis  of  Dr.  Carrasquillo,  that  criminals  were  mutilated  for 
crimes.  But  it  has  no  relation  to  the  exhibits  of  the  huacas  potteries,  where 
undoubtedly  diseases  of  several  kinds  are  expressed  by  modeling. 

The  chroniclers,  Herrara  and  Garcilazo,  relate  some  interesting  passages, 
which  have  been  exploited  by  Carrasquillo,  and  by  those  who  participate  in  his 
opinion  regarding  the  question,  now  almost  forgotten. 

Dr.  Jose  Torebro  Medina  in  his  work  "La  Imprenta  en  Lima,"  copies  an 
anonymous  resolution  on  the  government  of  the  Incas,  where  is  read:  "If 
they  go  to  be  punished  for  some  transgression  they  are  called  liocliay  carcamayoc, 
which  means  to  say,  'By  which  they  have  incurred  punishment  for  transgres- 
sions,' and  those  wdiich  gave  death  were  in  advance  of  all  and  very  cruel;  to 
some  they  gave  pain  and  to  others  they  cut  off  members,  and  made  other  cruel 
punishments." 

Don  Francis  de  Toledo  al  Key  signalizes  death  as  most  general  punishment, 
though  they  had  also  other  punishments;  he  mentions  nothing  specific.  Anal- 
ogous data,  some  of  much  value,  from  historians  have  served  to  sustain  the 
hypothesis  that  the  huacas  with  mutilations  represented  punished  individuals, 
but  to-day  this  is  not  admitted.  We  do  not  deny  the  punishments,  but  deny 
their  exhibit  on  the  huacas. 

The  question  whether  certain  customs,  or  superstitious  practices  of  the 
Indians,  in  virtue  of  which  they  disfigured  the  features,  might  be  here  gone 
over.  Certainly  such  practices  existed,  and  might  produce  some  alterations 
which  artists  may  have  wanted  to  reproduce  in  clay. 

The  historian,  Garcilazo  (who  is  very  unreliable  as  a  recorder),  cites  the 
following  (speaking  of  Call)  :  "They  dress  thems^elves  and  their  noses,  placing 
in  them  what  they  call  caricuris,  made  of  twisted  nails  of  gold  so  gross  as  a 
finger,  and  others  more  or  less  small." 

Cieza  de  Leon  relates  of  Puerto  Vicjo:  "That  they  draw  out  three  teeth 
of  the  upper  jaw,  and  other  three  from  the  lower,  after  they  have  appeared, 
and  they  draw  out  the  three  teeth,  the  father  from  the  children,  when  they 
are  of  very  tender  age." 

And  speaking  of  the  foundation  of  Guayaquil:  "Immediately  on  cntcrinor 
in,  the  teeth  are  drawn  out  for  sacrifice,  and  according  to  ancient  customs  and 


696     TESTIMONIES  ON  THE  MUMMY  GROVE  POTTERIES  OF  OLD  PERU. 

ia  honor  of  the  wicked  gods  have  they  the  teeth  drawn  out/"^  In  another  place 
he  says :  '"'In  some  of  these  towns  the  caciques  and  chiefs  have  the  teeth  nailed 
with  points  of  gold.  And  the  inhabitants  of  the  village  of  Ancernio  have  the 
nostrils  of  the  noses  opened  to  put  in  something  like  balls  of  fine  gold,  some 
small,  others  large/' 

Augustin  de  Zarate  says,  speaking  of  the  Isle  of  La  Puna,  and  on  firm 
ground,  where  they  have  some  towns  in  which,  for  anger  they  caused  to  the 
Senor  of  Peru,  he  gave  as  penalty  that  they  draw  out  the  teeth  of  the  upper 
jaw,  and  this  they  do  to  this  day.  Men  and  women  go  about  with  their  teeth 
drav.'n  out. 

He  refers  to  a  place  called  Catanez,  a  land  of  much  food,  and  moderately 
populous,  where  all  Indians  who  go  to  war  dress  their  faces  with  nails  of 
gold  in  pieces  on  which  they  hold  things. 

Herrcra  in  his  "Decadas  de  Indias"  writes :  "They  sacrifice  some  of  their 
neighbors  with  whom  they  make  war.  They  believe  in  immortality  of  the  soul. 
Tiie  Incans  also  worship  the  Sun,  drawing  out  three  teeth  from  the  upper, 
and  three  from  the  lower  jaw,  because  they  think  that  this  makes  grateful 
senice  to  God." 

A.  Le  Piuart  cites  that  young  mothers  lose  the  upper  left  canines.  At 
the  time  of  the  first  menstruation,  during  the  feast  given  with  this  object, 
tliey  break  this  tooth  to  show  the  nubility  of  the  girl, 

Jimenez  de  la  Espada,  in  a  v.^ork  on  the  "Iscaicingas,"  describes  a  form 
of  mutilation  of  the  nose.  He  speaks  of  a  very  ancient  people  who  thought 
more  than  of  their  wealth  and  their  corpulence  of  the  strange  disposition  and 
conformation  of  their  face  which  was  provided  with  two  noses  in  the  manner 
of  a  certain  breed  of  pointers,  which  they  judged  to  be  the  natural  thing  and  of 
proper  shape,  and  it  is  of  the  same  kind  of  native  or  believed  to  be  so,  of  the 
chroniclers,  who  spoke  of  the  olfactory  organ  and  of  their  women.  They  are 
great  in  body  and  have  the  noses  torn  in  the  wind  places  and  by  having  them 
of  that  sort  they  are  called  "Iscaicinga"  which  is  to  say  two  noses. 

He  speaks  of  other  people  who  have  bored  the  pulps  of  the  ears  and  pricked 
tliom  with  stalks  or  irons,  who  have  the  cheeks  bored,  and  chin  opened  like  a 
buttonhole  and  lower  lip  with  a  stone  in  it.  They  pierce  the  nose  at  the  gristle 
and  on  both  sides  wear  plumes,  or  thorns  or  egg  shells  and  with  a  piece  of  the 
skin  drawn  out  in  a  long  strip.  He  speaks  of  the  Iscaicingas  making  them- 
selves look  ferocious  by  the  rejmlsiveness  of  their  split  noses,  giving  them  a 
terrible  and  horrible  appearance  to  frighten  their  enemies,  which  is  common 
motive  among  American  savages  and  might  explain  the  strange  noses.  Three 
hypotheses  he  gives  for  these  disfigurements:  (1)  Eeasons  of  sj-mmetry ;  (2)  to 
allow  greater  olfaction;  (3)  to  imitate  the  monkeys.  He  speaks  of  a  huaca 
like  this,  in  the  collection  at  Cuzco,  of  Dona  Rosa  Centano,  and  another  in  the 
Ethnological  Museum  of  Berlin,  which  have  the  noses  divided.  Perhaps  those 
repre-ented  witli  lips  wanting,  showing  the  teeth  of  both  maxillaries,  he  says 
may  be  voluntary  mutilations. 

Even  admitting  tliat  the  two-nosed  deformation  in  a  tribe  was  the  result 
of  legend  transmitted  from  tlie  Pagansos,  it  does  not  appear  credible  that  the 


TESTIMONIES  ON  THE  MUMMY  GROVE  POTTERIES  OF  OLD  PERU.     697 

mutiiation  is  wholly  explained.  There  must  be  some  other  reason,  perhaps 
pathological  or  teratological.  He  mentions  uta  among  the  first,  which  is  "a 
kind  of  endemic  lupus  of  Eastern  Andean  Mountains,  which  principally  de- 
stroys the  middle  part  of  the  upper  lip  and  the  mucous  nasal  cartilages,  and  in 
its  spread  quickly  in  the  face  of  the  patient  gives  an  aspect  like  the  Iscaicinga." 
And  among  the  second,  '*the  anomaly  of  the  leporine  lip  is  not  rare,  the  double 
nose  by  natural  separation  of  the  gristles,  which  ordinarily  are  held  together 
on  the  internal  faces,  except  at  the  point  of  the  nasal  wall.'' 

Besides  these  considerations  of  this  whole  subject,  we  must  also  mention 
what  is  due  to  adoration.  There  are  not  lacking  in  the  sacred  catalogue  of  pious 
Quechnas,  "men  of  the  split  lip,"  "men  of  the  parted  nose,"  '"'ears  of  com,"  or 
"double  corn,"  and  "men  of  the  double  noses."  In  the  Archaeological  Museum 
of  Madrid  there  is  a  splendid  specimen  of  huaca,  representing  an  Iscaicinga. 

The  Ytucales  cut  ofi  the  skin  of  the  nose  with  a  file  without  disuniting 
it  at  the  tip,  they  wrapped  it  up  in  a  peel  of  palm  leaf,  and  kept  it  as  an  emblem 
of  prowess  in  war.  They  gradually  came  to  cut  o2  more  and  more  of  the  skin, 
and  rolled  it  in  a  way  to  form  a  united  arch  at  the  base  near  the  eyebrows. 
To  these  they  gave  the  name  of  Singa  Cuchascas,  or  men  of  the  nose  cut  off. 
The  Cutinanas  made  the  same  for  insignia  of  warriors.  Referring  to 
this  in  1557  it  was  said,  that  in  a  province  of  natives  called  Capilacora  they 
had  an  invenrion  of  noses  not  seen  anwhere  else  in  the  world. 

Among  the  ceremonies  of  ancient  Peruvians  there  are  some  of  religious 
character  which  carried  to  extremity  human  sacrifices,  inspired  by  superstition, 
which  some  have  thought  might  explain  the  representations  made  on  the 
anthropomorphous  huacas. 

Among  the  sacrifices  made  to  their  gods,  however,  they  never  practiced 
mutilations,  which  would  pennit  the  survival  of  the  subject.  Cobo,  3Iolina, 
Las  Casas,  Herrera,  Cieza,  and  others,  corroborate  this.  These  narrate  that  in 
certain  feasts,  they  made  human  sacrifices,  even  interring  persons  alive,  or 
those  to  be  made  ready  were  suffocated  or  punished  by  another  class  of  death. 
Inca  Yupanqui  had  great  feasts,  idolatries  and  offerings  in  the  worship  of  the 
Sun.  For  ten  days  preparations  were  made  with  provisions  of  com,  sheep,  ewes 
and  lambs,  and  fine  clothings,  and  a  certain  number  of  boys  and  girls  for 
sacrifice  to  the  Sun.  Inca  Yupanqui  then  commanded  a  fire  to  be  made  and 
the  ewes  and  lambs  were  beheaded  and  thro^v■n  into  it,  and  the  cloths  and  corn 
v.-ere  offered  all  to  the  Sim,  and  the  boys  and  girls,  which  were  met,  were  well 
clothed  and  adorned,  and  he  ordered  them  to  be  burned  alive  in  that  house 
where  was  the  cult  of  the  worship  of  the  Sun. 

Garcilazo  speaks  of  the  sacrifice  of  men,  women  and  children.  They 
opened  first  the  chest,  while  living,  and  pulled  out  the  heart  and  lungs. 

Francisco  de  Xeres  speaks  of  sacrifices  where  with  the  blood  of  their  own 
children  they  anointed  the  faces  of  idols  and  the  doors  of  the  temple,  and  tops 
of  sepulchres  of  the  dead,  laughing  and  dancing  and  singing,  while  they  go 
willingly  to  death,  those  who  are  to  be  sacrificed,  being  satiated  with  drink 
before  they  cut  off  tlie  heads ;   they  also  sacrifice  ewes. 

Garcilazo  says  some  other  Indians  have  no  such  cruelty  in  their  sacrifices; 


698  SPECIFIC  REMEDY  IN  UROGENITAL  TUBERCULOSIS. 

that,  altlioiigh  they  mix  human  blood  with  their  sacrifices,  it  was  not  by 
death,  but  by  drawing  it  from  the  arms  and  legs,  and  that  they  drew  out  at 
birth  from  the  noses  at  tiie  junction  of  the  eyebrows. 

It  is  undoubted  tliat  those  artists,  who  have  bequeathed  to  us  the  clay 
vessels  representing  individuals  with  mutilations,  constructed  some  models 
symbolizing  superstitious  ceremonials  or  dances  related  with  disease,  and 
patients  in  tlie  state  shown  by  the  huacas  and  models  by  tliis  way  sought, 
by  that  intermediation,  and  by  supplication  to  the  gods  to  be  freed  from,  the 
disease. 

It  is  known  that  medicine  of  ancient  Peru  had  much  that  was  practical 
and  rational,  but  also  there  entered  into  it  a  great  deal  of  witchcrai't,  giving 
fanciful  capacity  to  the  difTerent  superstitions  and  adorations,  in  which  there 
were  dances  and  ceremonies  to  idols,  to  draw  out  the  evil  from  the  body  of  the 
patient.  Thus  the  dance  in  the  bas-relief  of  the  huaca,  I  have  spoken  of, 
would  represent  the  disease  of  the  dance,  Taqui-Onco,  or  perhaps  they  were 
using  it  as  an  idol  to  petition  the  gods  for  the  cure  of  some  other  afBiction.  It 
is  seen  clearly,  there,  that  it  was  not  a  reunion  for  mere  pleasure  by  the  pres- 
ence on  it  of  a  mother  with  her  child,  in  suppliant  attitude,  with  face  very 
much  disfigured,  wh.icli  if  you  look  at  it  with  care,  may  be  divine  as  the  same 
disease  which  applies  to  the  figure  which  crowns  the  jar.  And  in  effect,  "in 
some  parts  there  is  given  a  disease  of  the  dance,  which  is  called  Taqui-Onco^ 
or  facc-onco,  for  whose  cure  they  call  in  witches,  or  go  to  see  them,  and  they 
have  a  thousand  superstitions  and  witcheries  and  other  ceremonies.  (In- 
struction against  the  ceremonies  that  the  Indians  used  conforming  to  the 
time  of  their  infidelity.  Confesonario  para  los  Curas  de  Indies,  con  la 
instruction  contra  sur  Eitos  y  Exhortacion  para  a  yudar  a  bein  morir.  Los 
Eeyes,  ]\I.D.L.,  XXXY.  Eeproducida  en  Eevista  Historica  de  Lima,  Tomo  I.) 
"And,  when  the  lords  were  deceased,  according  to  Cieza,  to  appease  the  ire  of 
the  gods  and  to  petition  them  to  make  them  well,  they  made  other  sacrifices, 
full  of  superstitions,  killing  men,  according  to  what  I  have  related,  holding 
for  greatest  sacrifice  that  which  they  made  with  human  flesh.  And  to  make 
these  things,  they  had  drums  and  hand  bells  and  idols." 

(To  he  concluded  in  the  next  issue.) 


Editorial 


SPECIFIC  REMEDY  IN  THE  DIAGNOSIS  AND  THERAPY  OF 
UROGENITAL  TUBERCULOSIS. 

Dr.  Wiliiklm  Ivaro,  Miinchcncr  incdizinischcn  WocJicnscJirift,  Xo.  37, 
1009,  records  the  treatment  of  urogenital  tuberculosis  both  by  the  ophthalmo- 
reaction and  sulK-utnneous  injections  of  tuberculin,  and  reports  a  number  of 
cases  as  to  the  beneficial  elTccts  and  results  obtained.     He  states  that  we  are,  at 


SPECIFIC  REMEDY  IN  UROGENITAL  TUBERCULOSIS.  699 

the  present  time,  in  doubt  concerning  the  ophthalmo-reaction  and  its  results  are 
uot  delinite  and  therefore  we  have  no  conclusion  that  we  have  tuberculosis  in 
the  urogenital  system.  As  to  the  possibility  of  being  misled  by  the  ophthalmo- 
reaction. Dr.  Casper  in  the  Society  of  Internal  IMedicine,  1908,  reported  a  case  of 
a  woman  who  had  pus  in  the  urine,  the  source  of  which  was  proven  by  the  cysto- 
scopic  examination.  Upon  the  application  of  the  ophthalmo-reaction  a  diagnosis 
of  tuberculosis  of  the  kidney  was  made.  In  spite  of  the  painstaking  clinical 
investigation  they  were  unable  to  demonstrate  the  presence  of  tuberculous 
invasion  in  other  parts  of  the  body,  and  to  his  surprise,  upon  operation,  did  not 
find  any  sign  of  tuberculosis  except  twelve  kidney  stones. 

Similar  observations  have  been  experienced  by  others  and  cases  are  also 
reported  where  the  ophthalmo-reaction  was  negative,  and  upon  operation  the 
kidney  was  found  to  be  tuberculous. 

It  was  also  observed  in  a  woman  28  years  of  age  who  since  her  childhood 
suffered  from  cystic  catarrh  of  the  bladder,  and  who  was  compelled  to  undergo 
an  operation  on  account  of  the  contractions  of  the  bladder.  In  this  case  the 
ophthalmo-reaction  was  negative  and  upon  operation  the  riglit  kidney  was  normal 
but,  however,  a  typical  miliary  tuberculosis  of  the  left  kidney  was  found  in 
spite  of  the  negative  ophthalmo-reaction. 

Another  case  occurred  in  a  young  lady  who  suffered  of  difficult  micturition, 
often  had  pains  in  the  left  side,  and  also  had  pyuria ;  and  in  whom  there  was  a 
suspicion  of  tuberculosis  on  account  of  swelling  of  the  left  Imee.  The  ophthalmo- 
reaction was  negative.  Upon  cystoscopic  examination  the  bladder  was  normal, 
and  upon  further  examination  tubercle  bacilli  were  found  in  the  left  ureter. 
In  all  these  cases  tubercle  bacilli  existed  in  spite  of  the  negative  findings  of  the 
ophthalmo-reaction.  Consequently  the  author  states  that  we  are  unable  to 
draw  conclusions  as  to  the  diagnosis  from  the  ophthalmo-reaction. 

However,  the  author  highly  recommends  tuberculin  injections  and  he  states 
that  they  are  of  great  value  for  the  diagnosis,  and,  moreover,  it  has  proven  of 
value  in  a  large  number  of  cases  and,  therefore,  we  can  rely  upon  it. 

He  also  reports  that  about  three  months  ago  a  young  girl  who  had  for  many 
years  suffered  from  difficult  micturition  and  pain  in  the  region  of  the  right 
kidney.  Her  urine  was  slightly  turbid  and  contained  tubercle  bacilli.  Upon 
cystoscopic  examination  the  bladder  appeared  normal  while  the  opening  of  the 
right  ureter  was  slightly  swollen.  After  a  subcutaneous  injection  of  0.25 
milligram  old  tuberculin  the  patient  experienced  pain  in  both  kidneys  which, 
however,  was  more  pronounced  in  the  left.  At  the  same  time  the  urine  became 
more  turbid  and  contained  tubercle  bacilli.  After  subsidence  of  the  reaction 
he  also  catheterized  the  left  ureter  and  found  tubercle  bacilli  in  the  urine  of 
the  left  kidney.  Drs.  Hock  and  Birnbaura  have  found  the  diagnostic  value  of 
the  subcutaneous  method  so  bcneficinl  that  they  have  employed  it  constantly. 
Another  case  is  reported  in  an  eight  year  old  girl  in  whom  tuberculosis  of  the 
right  kidney  was  suspected.  Under  cystoscopic  examination  the  bladder  was 
normal  except  a  slight  ulceration  of  the  right  ureter.  The  riglit  ureter  was 
catheterized,  and  in  the  urine  pus  and  tubercle  bacilli  were  detected.  The 
patient  received  thirty  injections  of  old  tuberculin  (Koch)  having  the  first  injec- 


700 


CAMPHOE. 


ELECTRICITY  IN  ILEUS. 


tiou  concentrated,  beginning  with  0.0035  milligram  old  tuberculin  and  grad- 
ually increasing  up  to  10  milligrams.  The  result  was  splendid.  The  child 
gained  eighteen  pounds  in  five  months.  After  six  months  the  bladder  was  found 
healthy,  urine  clear  and  no  tubercle  bacilli. 

The  author  advocates  this  treatment  very  strongly  and  that  a  radical 
operation  for  urogenital  tuberculosis  should  not  be  undertaken.  He  says: 
"Only  remove  the  kidney  when  there  is  a  strong  reason  for  doing  so.  The 
tuberculin  injections  are  also  of  value  after  the  patients  have  undergone  opera- 
tion. These  injections  help  to  guard  against  new  infection  of  the  wound  and 
of  the  bladder.  Good  results  have  also  been  obtained  in  the  treatment  of  tuber- 
culosis of  the  testicle.'* 


/Viateria  J'^edica  and  Therapeutics 


CA2£PH0R  IN  DIGESTIVE  INTOXICATIONS 
OF  INFANTS. 
Dr.  Wurtz  states  that  camphor  is  an 
excellent  remedy  in  these  cases.  It  acts 
as  a  tonic  upon  the  heart  and  as  a  stimu- 
lant of  respiration.  When  it  is  adminis- 
tered in  the  form  of  a  powder  it  is  ab- 
sorbed with  difficulty.  The  best  way  to 
give  it  is  in  the  form  of  an  emulsion,  or 
in  hypodermic  injections  in  oil,  every 
three  hours.  The  treatment  was  con- 
tinued until  the  child  was  able  to  support 
proper  food.  In  one  case  as  many  as 
fifty-nine  injections  were  given  within  ten 
days  with  the  effect  of  saving  the  child. 
The  author  believes  that  by  this  means 
many  lives  may  be  saved  in  the  most 
desperate  cases  of  infantile  diarrhceas. 
(Miinch.  med.  Woch.,  1909,  No.  3.) 


DIONIN  IN  KERATITIS  AND  IRITIS. 

Dr.  Chas.  J.  Scott,  of  Parkersburg 
(correspondence),  reports  that  he  is 
using  dionin  in  several  diseases  of  the 
eye  with  the  greatest  benefit;  that  it  is 
not  a  cure  "all"  but  a  very  valuable 
assistant  to  other  remedies. 

Dr.  Scott  states :  "In  all  kinds  of  kera- 
titis I  have  found  it  most  valuable.  My 
plan  of  using  it  is  to  draw  down  the 


lower  lid  and  dust  in  a  piece  of  the  actual 
powder  tlie  size  of  a  pinhead,  that  I  have 
picked  up  on  the  flat  side  of  a  new 
wooden  toothpick.  The  first  time  it  pro- 
duces severe  liyperajmia,  but  when  the 
patient  comes  back  the  next  day  for 
another  treatment  he  is  better.  I  use 
atropin  or  eserin,  and  also  the  cautery, 
where  necessary,  m^akiug  the  dionin  an 
accessory. 

"In  iritis,  the  time  in  which  my  pa- 
tients get  well  has  been  cut  in  half  by  the 
use  of  dionin,  together  with  the  other 
remedies. 

"Of  course,  one  must  use  syphilitic 
treatment  where  the  cause  is  syphilis; 
antirheumatics  where  from  rheumatism, 
etc.     (Merck's  Archives,  Sept.,  1909.) 


ELECTRICITY  IN  ILEUS. 
Dr.  F.  Sejars  occasionally  has  wit- 
nessed good  effects  from  application  of 
electricity  in  ileus,  and  thinks  that  this 
mctbod  should  be  a  routine  measure  in 
hospitals,  at  least.  When  the  occlusion 
is  incomplete,  and  the  result  of  prolonged 
constipation,  electricity,  applied  early,  is 
an  important  aid  in  treatment.  But  in 
occlusion  from  cancer  it  should  be  used 
with  great  caution.     Complete  ileus  con- 


GUAIACOL  AS  AN  ANAESTHETIC. 


INJECTIONS  FOR  ELEMORRHOIDS.    701 


traindicates  more  than  a  single  test  ap- 
plication of  the  electricity,  the  phj'sician 
beiDg  ready  to  proceed  with  a  laparotomy 
at  need.  Whenever  there  is  a  suspicion 
of  appendicitis  or  peritonitis,  electrical 
treatment  is  strictly  contraindicated  and 
dangerous.  Under  other  conditions,  if 
applied  gently,  with  a  medimn  current 
and  without  too  frequent  interruptions, 
it  is  not  dangerous  in  itself,  but  may  be- 
come so  if  too  prolonged  or  too  often 
repeated.  He  refers  especially  to  the 
method  introduced  by  Boudet  of  Paris, 
twenty  years  ago.  (Semaine  Medicale, 
Paris,  Aug.  4,  ^To.  31,  pp.  3G1-372.) 


GTIAIACOL  AS  AW  ANiESTHETIC  AND 
AKTIPHLOGISTIC. 

Dr.  Hecht  reviews  the  history  of 
guaiacol  in  local  treatment  of  neuralgia, 
neuritis,  gout,  chronic  rheumatism  and 
traumatism,  in  the  form  of  a  salve,  and 
for  application  to  the  surface  of  the  chest 
in  lung  pleura  and  febrile  affections.  He 
advocates  a  ten-per-cent.  solution  or 
salve  and  reports  excellent  results  from 
it  in  various  cutaneous  lesions,  including 
erysipelas,  furuncles  and  herpes  zoster. 
There  are  no  untoward  by-effects  unless 
too  large  doses  are  used,  over  1.5  or  3 
grams  (82.5  or  45  grains).  The  author 
regrets  that  guaiacol  is  not  used  more  for 
external  application  as  its  properties 
deserve.  (Therapie  der  gegenwart,  Ber- 
lin, July,  1909.) 


GU^TSHOT  WOUNDS  OF  THE  HEAD, 
TREATMENT  OF. 
Dr.  Paul  F.  Eve  is  fully  impressed  that 
it  is  the  surgeon's  bounden  duty  to  re- 
move the  bullet  in  every  case  where  life 
is  not  too  greatly  jeopardized  and  too 
much  brain  tissue  involved.  Even  should 
there  be  no  cerebral  symptoms,  if  the 
bullet  can  be  extracted  it  should  be  done 
by  all  means,  as  it  is  impossible  for  any 


one  to  tell  the  future  symptoms  which 
may  arise,  or  that  the  bullet  may  not  be 
the  indirect  cause  of  death.  In  every 
case  where  removal  has  been  accom- 
plished, thorough  drainage  should  be  es- 
tablished the  entire  extent  of  the  wound, 
an  antiseptic  dressing  applied  and  the 
head  so  placed  as  to  favor  drainage. 
(So.  Pract.  July,  1909.) 


HYSTERIA,  TREATMENT  OF. 
This  sometimes  involves  a  rather  com- 
plex therapy.  On  the  whole  it  is  sug- 
gestive and  environmental.  The  tem- 
perament, surroundings,  social  status  and 
general  mental  index  must  be  carefully 
taken  into  account.  In  nearly  all  women 
manifesting  a  hysterical  trend,  there  is 
obstinate  constipation  with  anaemia,  or 
autotoxsemia.  Such  cases  do  not  need 
iron.  They  need  exercise  in  the  open  air 
and  sunshine,  and  that  with  a  paucity  of 
clothes  on.  They  need  fruits,  vegetables, 
cascara  sagrada  and  occasionally  calomel 
and  salines.  To  break  the  hysterical 
paroxysm  there  is  notliing  so  effective  as 
a  hj'podermJc  of  apomorphin.  Valerian 
is  one  of  the  best  nerve  steadiers  in  this 
condition,  but  few  physicians  care  to 
incur  the  ill  will  of  good  paying  patients 
by  giving  them  this  nauseous  drug. 
Sodium  bromide  is  a  good  and  effective 
nerve  calmative,  and  usually  produces 
sleep  when  given  in  ten-grain  doses.  No 
habit-forming  drugs  should  be  admin- 
istered to  a  hysterical  woman  only  under 
the  zealous  care  of  the  physician.  (The 
]\[cdical  Summary,  Sept.,  1909.) 


INJECTION  TREATMENT  FOR 
HiEMORRHOIDS. 
Dr.  Edwin  A.  Hamilton,  of  Columbus, 
Ohio,  states  that  the  injection  treatment 
does  not  have  a  wide  application  as  its 
indiscriminate  use  is  followed  by  em- 
bolus, abscess  and  other  complications, 


702 


IODOFORM  AND  ICHTHYOL. 


LUMBAR  PUNCTURE. 


and  relapses  are  prone  to  occur  except  in 
eases  especially  adapted  to  this  method. 
The  instruments  needed  are  a  cone- 
shaped  anal  speculum  with  one  broad 
fcncstrum  and  a  special  copper-tipped, 
long  needle  of  large  caliber  with  an  out- 
side barrel,  which  may  be  screwed  to  the 
needle  proper  to  regulate  the  depth  to 
wliich  it  may  be  inserted.  The  solution 
is  10  per  cent,  carbolic  acid,  90  per  cent, 
oil  of  sweet  almonds.  Neither  water  nor 
glycerine  is  used  in  the  solution,  as  they 
cauFe  pain.  When  the  sphincter  is  nor- 
mal or  hypcrtrophied,  the  hemorrhoids 
are  never  strained  outside  of  the  rectum 
and  treated  there,  but  are  allowed  to  pro- 
trude through  tlie  fenestrum  of  the  specu- 
lum and  attended  to  in  their  normal  loca- 
tion. In  cases  where  the  sphincter  is 
dilated  and  the  hamiorrhoids  are  easily 
replaced  they  may  be  treated  outside  but 
under  no  other  conditions.  From  4  to  8 
drops  are  injected  into  a  ha?morrhoid, 
only  one  injection  being  made  at  one 
treatment.  The  patient  rests  in  the 
recumbent  posture  for  several  minutes. 
No  application  or  dressing  is  applied. 
The  bowels  are  moved  after  the  second 
day.  Subsequent  treatment  may  be  ad- 
ministered at  intervals  of  five  days. 
(jMedical  Eeview  of  Reviews,  September 
25,  1909.)  

lODOFOP.M  AND   ICHTHYOL  IN  PUL- 
MONARY TUBERCULOSIS. 

Dr.  Samuel  Floersherm  says  that  after 
more  than  four  years  of  study  and  pains- 
taking observations,  he  believes  he  can 
safely  state  that  in  iodoform  and  ichthyol 
we  have  therapeutic  agents  which  are  of 
exceedingly  great  value  in  the  treatment 
of  pulmonary  tuberculosis.  The  initial 
dose  of  iodoform  is  from  one-hnlf  to  one 
grain  with  one  or  two  drops  of  ichthyol 
added.  These  are  put  into  capsules  and 
administered  three   times   a   day.     The 


dose  of  iodoform  is  increased  each  week, 
until  tolerance  is  established.  The  ich- 
thyol is  also  increased  until  the  dose 
reaches  four  drops  three  times  a  day. 
When  the  maximum  dose  of  iodoform  has 
been  reached,  continue  it  for  one  or  two 
weeks  and  reduce  it  to  one-half  the  dose, 
and  repeat  as  above  stated.  With  the  ad- 
ministration of  the  drugs  the  usual  strict 
hygienic,  dietetic  and  climatic  measures 
must  be  observed.  In  many  cases,  after 
a  few  weeks  of  this  treatment,  the  pa- 
tients feel  better,  can  eat  and  sleep  better, 
feel  stronger  and  brigiiter  and  gain 
rapidly  in  weight.  Their  cough  becomes 
less  distressing,  the  constriction  around 
the  chest  less  annoying,  and  the  respira- 
tions deeper  and  freer.  The  author  re- 
ports two  cases  in  which  the  results  were 
very  good.  (Medical  Council,  August, 
1909.)  

LUMBAR    PUNCTURE    IN    INJURIES    OF 
THE  HEAD. 

Dr.  P.  Savy  has  treated  a  woman,  43 
years  of  age  who  fell  from  a  second 
story  window.  Sub-conjunctival  ecchy- 
mosis  suggested  the  possibility  of  a  frac- 
ture of  the  base  of  the  skull,  but  no 
operation  was  attempted,  as  the  patient, 
rapidly  recovered.  About  thee  months 
later  the  patient  complained  of  stiffness 
of  the  legs  with  persistent  headache  and 
in  the  course  of  a  few  weeks  other  symp- 
toms indicating  a  meningeal  process  de- 
veloped, and  the  patient  complained  of 
pain  along  the  sciatic  nerves.  Drop  by 
drop  of  blackish  blood  escaped  by  lum- 
bar puncture  and  improvement  soon  fol- 
lowed the  second  and  third  lumbar 
puncture.  About  40  cubic  centimeters 
in  all  of  the  bloody  effusion  was  evacu- 
ated, and  the  symptoms  gradually  sub- 
sided to  complete  recovery  by  the  end  of 
a  month.  The  long  interval  of  latency, 
the  possibility  of  evacuating  the  blood 


MERCURIAL  TREATJklENT  IN  SYPHILIS. 


703 


at  this  late  date,  the  rapid  improvement 
aud  final  recovery,  all  emphasize  the 
importance  of  lumbar  puncture  in  case 
of  injury  to  the  skull.  He  thinks  that 
the  extravasated  blood  did  not  cause  the 
symptoms  so  much  by  compression  as 
by  the  toxic  action  of  the  decomposing 
blood.    (Lyon  Chirurgical,  May  1,  1909.) 


MERCURIAL  TREATMENT  IN  SYPHILIS. 
Dr.  E.  C.  Hay,  Hot  Springs,  Ark.,  dis- 
cusses the  merits  of  each  method  of  its 
administration,  the  internal,  the  inunc- 
tion, and  the  injection  methods  respec- 
tively. The  ingestion  method,  or  mer- 
cury administered  by  the  mouth,  is  one  of 
the  oldest  and  the  one  that  has  been  most 
in  favor,  but  he  is  opposed  to  depending 
on  this  alone  as  it  is  so  feeble  and  slow- 
in  its  action  on  the  disease,  disappointing 
and  discouraging  to  the  patient,  irrita- 
ting to  the  gums  and  the  digestive  tract 
when  given  in  any  adequate  dose,  and  in 
any  case  uncertain  in  its  action.  He 
would  depend  on  it  only  when  the  patient 
is  free  from  all  manifestations  of  the 
disease  and  it  is  only  desired  to  keep  him 
slightly  under  the  influence  of  mercury 
as  a  matter  of  precaution  when  he  is  be- 
ing allowed  to  rest  in  the  intervals 
between  the  more  active  treatments. 
When  giving  mercury  by  the  mouth  ho 
prefers  a  pill  containing  biniodide  of  mer- 
cury, arsenic  and  gold;  it  is  non-irrita- 
ting and  has  been  productive  of  good 
results.  Another  favorite  pill  is  metallic 
mercury  combined  with  lanolin  and  puri- 
fied ox  gall,  one-half  grain  each,  which 
produces  less  gastrointestinal  disturbance 
than  any  other  he  has  used.  The  inunc- 
tion method  is  also  one  of  the  oldest 
methods.  It  is  not  painful  and  is  free 
from  danger  and  is  quick  and  potent  in 
its  action,  but  it  is  often  oI)jectcd  to  by 
patients  because  it  is  apparently  dirty 
and  sometimes  irritating  to  the  skin.     It 


is,  therefore,  often  loft  to  institutional 
treatment  or  treatment  at  resorts  with 
thermal  springs,  etc.  At  Aix  la  Chapelle 
the  mercury  cycle  is  used;  that  is,  the 
mercury  is  rubbed  on  diflerent  portions 
of  the  body  successively,  while  at  Hot 
Springs  it  is  confined  to  the  back,  hip% 
and  sometimes  outer  surfaces  of  the  thigh 
with  just  as  good  results,  besides  being 
cleaner  and  pleasanter.  The  injection 
methods  he  thinks  has  really  no  advan- 
tage over  the  inunction  at  least  when  the 
soluble  preparations  are  used.  The  in- 
soluble preparations  are  the  most  potent 
drugs  we  have  when  given  this  way,  but 
it  is  admitted  by  the  majority  of  writers 
that  their  use  is  very  painful  besides  be- 
ing the  most  dangerous.  He  believes  in 
the  combination  of  all  three  methods,  and 
the  important  points  which  he  wishes  Lo 
emphasize  are  given  as  follows:  "AVhen 
first  instituting  treatment  alter  infection, 
either  inunctions  or  injections  should  be 
employed,  followed  by  internal  medica- 
tion, instead  of  treatment  with  pills  first, 
followed  by  more  heroic  methods,  as  ad- 
vised by  most  of  the  leading  Avriterg. 
The  inunctions,  from  my  experience  and 
observation,  on  an  average,  are  superior 
to  the  soluble  injections,  and  more  lasting 
in  their  effects.  The  insoluble  salts  are 
too  intense  and  profound  to  be  employed 
in  routine,  and  should  be  held  in  reserve 
for  rebellious  cases  in  which  rapid  and 
pronounced  mcrcurizalion  is  desired. 
Finally,  the  long  course  of  treatment  I 
have  advised  should  be  pursued  in  all 
cases.  The  six  cardinal  points  in  the 
therapeutics  of  syphilis  are  to  keep  a  close 
observation  of  the  weight,  kidneys,  bow- 
els, stomach,  gums  and  nervous  sy:=tcm ; 
especially  the  latter,  as  some  patients  will 
never  manifest  any  evidence  of  mercury 
in  the  form  of  stomatitis,  and  the  first 
evidence  you  have  is  a  profound  and 
acute  nervous   prostration."      The   pro- 


704 


SOY  BEAN  IN  INFANT  FEEDING. 


BOOK  REVIEWS 


longed  course  of  treatment  mentioned 
covers  five  years  in  which  the  periods  of 
treatment,  mainly  by  inmictions  or  injec- 
tions, alternated  by  periods  of  rest,  are 
gradually  reduced  from  eight  months  in 
the  first  to  four  or  six  weeks  in  the  fifth 
year.  (Journal  American  Medical  Asso- 
ciation, Aug.  28,  1909.) 


SOY  BEAN  IN  INFANT  FEEDING. 
Dr.  J.  Euhrah,  of  Baltimore,  states 
that  soy  bean  gruel  or  milk,  either  alone 
or  mJxed  with  cow's  milk  is  of  value  in 
feeding  infants  with  marasmus  and  mal- 
nutrition, as  a  substitute  for  milk  in 
diarrhoea,  and  in  intestinal  and  stomach 
disorders  and  in  diabetes  mellitus.  The 
gruel  has  been  prepared  by  soaking  the 
beans  over  night,  stirring  to  remove  the 
envelop  surrounding  the  bean.  Three 
times  the  amount  of  water  is  added  to 
the  beans  and  they  are  boiled  until  a 
smooth  gruel  results.  This  is  strained, 
if  necessary.  This  has  the  odor  and  taste 
of  malt,  but  with  the  addition  of  a  little 


salt  is  well  taken,  especially  after  the 
first  bottle  or  two.  The  gruel  is  retained 
unusually  well  and  seems  to  be  digested 
easily.  The  stools  are  not  more  frequent 
than  with  other  foods;  they  are  light 
brown  in  color,  like  those  from  malted 
milk.  This  soy  bean  gruel  has  nearly 
the  same  food  value  as  milk,  and  for 
certain  children  may  need  further  dilu- 
tion. About  the  same  size  feeding  should 
be  used  as  if  milk  were  being  given;  5 
per  cent,  sugar  may  be  added  to  increase 
the  fuel  value.  The  author  feels  that  if 
properly  used  these  beans  will  be  a  most 
valuable  addition  to  the  dietary  of  the 
sick  infant. 

This  soy  bean  (glycine  hispida)  is  an 
annual  leguminous  plant  wliich  origi- 
nally gi'ew  in  a  wild  state  in  Cochin 
China,  in  the  south  of  Japan,  and  in 
Java.  It  is  now  being  grown  in  various 
sections  of  the  country  and  can  be  ob- 
tained in  the  open  market  like  any  other 
legumin.  (Archives  of  Pediatrics,  New 
York,  July,  1909.) 


5ool<  f^evfews 


MooKHN  JMateria  Medica  and  TnKRAPEUTTC3.  By  A.  A.  Stevens,  A.M.,  M.D.,  Profossior  of 
Therapeutics  and  Clinical  Medicine,  Woman's  Medical  College  of  Pennsylvania;  Lec- 
turer on  Physical  Diagnosis  in  the  University  of  Pennsylvania;  Physician  to  the 
Episcopal  Hospital,  and  to  St.  Agnes'  Hospital;  Assistant  Physician  to  the  Philadelyihia 
General  Hospital;  Fellow  of  the  College  of  Physicians  of  Philadelphia,  etc.  Fifth 
Edition,  Thoroughly  Revised.  In  Conformity  witli  the  Eiglith  Revision  (1905)  of  the 
United  States  Pharmacopoeia.  Philadelphia  and  London:  W.  B.  Saunders  Company, 
1909. 

This  work  is  a  full  and  detailed  treatise  of  the  various  drugs  and  their  application  in 
the  treatment  of  disease.  In  order  to  bring  the  book  up  to  the  jn-csent  advances,  new  articles, 
dealing  with  Scopolamin,  Ethylchlorid,  Theocin,  Veronal  and  Radium  have  been  added,  and 
considerable  new  matter  has  been  introduced  into  the  chapter  on  Radiotherapy. 

The  arrangement  of  the  subject  has  been  most  skillfully  done,  and  the  text  itself  is  a 
model  of  clear  exposition.  The  classification  of  tlio  various  drugs,  en;ihling  the  student  to 
learn  something  of  the  use  and  purpose  of  drugs  at  the  same  time  as  the  details  of  preparation 
and  dosage  are  being  gained,  has  certainly  a  great  advantage.  Especial  mention  should  be 
made  of  the  part  of  the  book  devoted  to  applied  therapeutics,  to  which  is  added  formulte, 
to  make  more  clear  the  therapeutic  ap])lication  of  the  drugs  under  consideration. 

The  general  attractive  character  and  presentation  of  the  remedies  is  very  appealing, 
and  the  index  at  the  I>ack  of  the  book  is  of  great  value. 


Monthly    Cyclopaedia 

AND 

Medical   Bulletin 


Published  the  Last  of  Each  Month 


Monthly  Cyclopaedia  Section 


Vol.  II.  PHILADELPHIA,  DECEMBER,  1909.  No.  12. 


Original  Articles 


Department  in  charge  of  J.  iIADISO^^  TAYLOR,  A.M.,  M.D. 


THE  FAECAL  ORIGIN  OF  SOME  FORMS  OF  POSTOPERATIVE  TETANUS 

(ANORECTAL,  INTESTINAL,  PUERPERAL,  GENITAL,  AND  LOWER 

PELVIC    OPERATIONS)    AND   ITS  PROPHYLAXIS  BY 

PROPER  DIETETIC  MEASURES.' 

(a  preliminary  communication.) 

By   RUDOLPH  MATAS,  M.D., 
Professor  of  Surgery  in  the  jMedical  Department  of  Tulane  University. 

NEW   ORLEANS,  LOUISIANA. 

Notwithstanding  the  vast  increase  in  our  knowledge  of  the  etiology, 
patholog}^,  and  prophylaxis  of  tetanus  since  the  discovery  of  the  drumstick 
bacillus  of  Nicolaier,  twenty-six  years  ago,  a  certain — ^not  fully  determined — 
number  of  postoperative  deaths  from  this  infection  occurs  in  seemingly  clean 
surgical  cases,  which  has  not  been  satisfactorily  accounted  for. 

While  it  has  been  fully  and  irrefutably  demonstrated  that  the  regional 
liability  of  the  exposed  parts  of  the  body  to  tetanus  (feet,  hands,  legs,  forearms, 
arms,  face,  neck,  etc.)  is  directly  proportional  to  the  degree  of  surface  contact 
with  tetanus-bearing  (tetaniferous)  matter  (earth,  manure,  dust),  the  origin 
and  regional  distribution  of  accidental  and  postoperative  tetanus  in  the  con- 
cealed parts  of  the  body  (protected  from  surface  exposure)  has  not  been  suffi- 
ciently investigated. 

Abundant  experience  has  shown  that  while  the  risk  of  tetanus  infection 
can  be  absolutely  eliminated  in  all  operations  upon  sterile  tissues  in  which  a 

iRead  at  the  meeting  of  the  American  Surgical  Association,  held  in  Philadelphia,  June 
.3-5,  1909. 

3  (705) 


706  THE    F^CAL   ORIGIN   OF   POSTOPERATIVE   TETANUS. 

rigorous  postoperative  asepsis  can  he  maintained  until  healing  has  occurred, 
the  liability  to  lockjaw  cannot  be  removed  in  those  regions  in  which  postopera- 
tive asepsis  cannot  be  secured. 

In  order  of  importance  next  to  the  feet  and  hands  and  other  exposed  parts 
of  the  extremities,  the  injuries  and  surgical  operations  in  those  regions  of  the 
body  which  are  most  exposed  to  fcecal  contamination  are  the  most  liable  to 
tetanic  infection.  In  this  category  we  will  place  the  anorectal  region,  perineum, 
female  genito-urinary  tract,  male  genitals,  especially  scrotum,  lower  pelvic 
region,  including  buttocks,  sacrococcygeal  region,  groins,  thigh,  knee,  upper 
leg — on  their  posterior  and  inner  surfaces  especially;  after  operations  on  the 
intestines,  artificial  anus,  etc.,  in  all  of  which  postoperative  faecal  contact  is 
either  constant  or  unavoidable  on  account  of  proximity  to  the  intestine.  In 
considering  this  topographical  distribution  we  are  excluding  the  direct  but 
unconscious  transmission  of  faecal  matter  to  distant  parts  of  the  body  by  the 
soiled  fingers  of  the  patient  himself,  or  of  his  attendants. 

The  careful  attention  to  the  sterilization  of  instruments  and  the  disin- 
fection of  the  hands,  compelled  by  the  rules  of  modern  surgical,  obstetrical, 
and  veterinary  practice,  has  enormously  reduced  the  liability  to  tetanic  infection 
— even  when  those  parts  of  the  body  are  involved  which  are  most  exposed 
to  fgecal  contact — by  eliminating  the  direct  inoculation  of  wounded  surfaces 
with  contaminated  instruments  and  hands.  However,  the  occasional  postopera- 
tive deaths,  which  occur  from  time  to  time  in  the  practice  of  competent  and 
clean  surgeons,  clearly  point  to  another  source  of  danger  which  is  not  depend- 
ent upon  defects  of  technique  or  contaminated  material  {e.g.,  imperfectly 
sterilized  catgut),  but  to  other  sources  of  infection  outside  of,  and  apart  from, 
the  operative  act  itself. 

This  hitherto  unrecognized  or  disregarded  factor  in  the  causation  of  post- 
operative tetanus — at  least  in  regions  liable  to  fiscal  contact — is  the  direct 
contamination  of  the  alimentary  canal  and  its  contents  with  living  tetanus 
bacilli  and  their  spores,  swallowed  in  raw,  uncooked  vegetables,  berries,  and 
other  fruits  which  are  cultivated  in  fertilized  or  manured  (i.e.,  tctanized)  soil 
(Eobinowitsch,  Kolle  and  Hetsch,  Miquel  and  Cambrier,  Kolle  and  Wasser- 
mann,  Thalmann,  Hecker,  et  al.) . 

In  may  be  a  mere  coincidence,  but  it  is  a  fact  tliat  in  all  the  cases  of 
postoperative  tetanus  occurring  after  operations  in  regions  liable  to  fa3cal  contact 
which  have  been  investigated  by  the  author  (two  in  his  own  practice)  the 
patients  had  eaten  copiously  of  uncooked  vegetables  within  twenty-four  and 
thirty-six  hours  before  the  operation.  The  vegetable  menu  in  these  cases 
coincided  with  the  list  of  vegetables  which  have  been  found  in  the  laboratory  to 
be  most  frequently  contaminated  with  tetanus  germs  and  spores,  viz.,  celery, 
lettuce,  chicory,  water  cress,  cabbage,  radishes,  turnips,  carrots,  tomatoes,  and 
other  green  vegetables,  strawberries,  blackberries,  and  other  berries  and  fruits 
which  are  grown  in  the  soil  or  brought  in  contact  with  it,  and  which  are 
largely  consumed  raw  in  an  unavoidably  contaminated  state. 

The  tetanus  bacillus  and  its  spores  are  known  to  survive  the  passage 
through  the  intestinal  canal  of  the  domesticated  animals,  especially  the  her- 


THE    FAECAL  ORIGIN   OF   POSTOPERATIVE   TETANUS.  707 

bivorous  horse  and  cow.  The  dung  of  these  animals  is  a  perpetual  culture 
medium  for  the  tetanic  bacillus,  swallowed  constantl}^  with  the  grass  of  the 
pasture  and  the  fodder  of  the  stable.  Not  only  are  the  bacilli  ejected  alive,  but 
their  virulence  and  activity  are  probably  intensified  by  their  temporary  residence 
in  the  favorable  conditions  of  the  lower  intestinal  tract  (Sormani).  This 
survival  of  the  tetanus  germ  in  a  virulent  state  is  fully  demonstrated  by  the 
experiments  of  Sormani,  Sanchez  Toledo,  Veillon,  Hoifmann,  et  al.,  who  demon- 
strated that  the  diluted  excrement  of  the  horse  and  cow,  injected  subcutaneously 
and  otherwise,  will  kill  rabbits  in  from  five  to  six  days  with  all  the  symptoms 
of  this  disease.  These  and  other  authors  have  fully  demonstrated  that  the  spores 
of  the  drumstick  bacillus  resist  the  action  of  the  digestive  juices;  it  has  also 
been  demonstrated  that  the  tetanus-laden  fgeces  of  the  healthy  horse  and  cow 
are  capable  of  producing  fatal  tetanus  when  brought  in  contact  with  wounded 
surfaces  in  these  animals. 

In  view  also  of  the  fact  that  5  per  cent,  of  all  normal  men  harbor  the 
tetanus  bacillus  or  its  spores  in  an  active  state  in  the  intestinal  canal,  and  that 
the  percentage  of  contaminated  individuals  is  increased  to  20  per  cent,  in 
hostlers,  stablemen,  dairymen,  drivers,  etc.,  (Pizzini),  the  possibility  of  tetanus 
from  fascal  contact  must  always  be  kept  in  mind,  especially  when  operating 
upon  the  anorectal  region,  perineum,  and  genito-urinary  organs  of  both  sexes  in 
unprepared  subjects. 

The  author  fully  recognizes  that  the  normal  defences  of  the  organism 
against  intestinal  infection  are,  in  healthy  individuals,  usually  sufficient  to  pro- 
tect it,  even  if  the  living  tetanus  bacillus  has  been  freely  introduced  into  the 
alimentary  canal  with  the  ingested  food.  It  is  only  through  the  salutary  and 
preservative  influence  of  the  protective  mechanism,  which  largely  neutralizes 
the  most  virulent  infections  in  the  alimentary  canal,  that  we  can  account  for 
the  great  numbers  who  escape  when  operations  are  performed  in  the  recognized 
tetanogenic  regions.  It  is  evident,  however,  that  even  if  tetanus  infection  is 
a  comparatively  rare  postoperative  sequence,  it  is  well  worth  the  observance  of 
the  simple  precautions  required  to  avoid  this  deadly  accident.  Precautionary 
measures  would  be  more  than  justified  if  only  one  in  ten  thousand  operative 
cases  could  be  saved  from  the  almost  certain  death  which  follows  when  this 
form  of  inoculation  occurs  after  operation. 

In  accordance  with  the  preceding  statements  and  his  own  convictions,  the 
author  has  taught,  and  insisted  in  his  own  practice  since  his  last  and  second 
postoperative  death  from  tetanus  occurred  five  years  ago  (perineoplasty  and 
baemorrhoids),  that  no  patient  should  be  brought  to  operation  without  anti- 
tetanic  preparation,  whenever  the  operation  to  be  performed  involved  parts  in 
which  faecal  contamination  was  unavoidable  (haomorrlioids,  fissure,  fistula,  stric- 
ture, perineoplasty,  vaginal  operations,  etc.). 

This  antitetanic  preparation  is  very  simple,  and  consists  in  (a)  purgation, 
three  days  before  the  operation;  (&)  the  suppression  of  all  raw,  uncooked  food, 
especially  green  vegetables,  berries,  and  other  fruit  (for  the  same  period  of 
time  before  the  operation).     In  emergencies,  when  dietetic  preparation  is  impos- 


708  '^^^^    FAICAL   ORIGIN   OF   POSTOPERATIVE   TETANUS. 

sible,  10  cubic  centimeters  of  tetanus  antitoxin  are  injected  subcutaneously  at 
the  time  of  the  operation,  while  the  patient  is  still  under  the  anajsthetic. 

In  conclusion,  it  will  be  noticed  that  what  is  asked  of  the  surgeon  as  a 
preventive  measure  against  tetanus  infection  is,  in  reality,  very  little;  in 
fact,  only  a  little  more  than  any  careful  surgeon  would  prescribe  in  preparing 
patients  for  operations  in  the  abdominal,  anorectal,  genital,  and  lower  pelvic 
regions  of  both  sexes.  It  is  true  that  in  the  matter  of  preparation  some  opera- 
tors are  more  careful  and  exigent  than  others,  but  surely  the  exclusion  of  all 
raw  food,  and  especially  green  vegetables,  berries,  and  friiit  for  three  or  at 
least  two  days  before  an  operation  is  no  hardship  on  the  patient,  when  it  is 
customary  to  prepare  such  patients  by  a  limited  dietary  and  preliminary  purga- 
tion. When,  for  any  reason,  this  simple  dietetic  and  evacuant  preparation  is 
impracticable,  as  in  emergency  cases,  the  administration  of  a  prophylactic  dose 
of  tetanus  antitoxin  at  the  close  of  the  operation,  whenever  it  is  feared  that 
faecal  contamination  of  the  wound  is  unavoidable,  will  impose  no  special  hard- 
ship on  the  patient.  This  is  particularly  true  at  the  present  time,  since  it  has 
become  a  well-recognized  and  general  practice  in  progressive  institutions  to 
administer  a  prophylactic  dose  of  tetanus  antitoxin  to  all  patients  admitted  with 
gunshot,  railroad,  or  other  crushed  and  lacerated  wounds  of  the  extremities 
which  are  especially  liable  to  lockjaw  on  account  of  contamination  with  mud, 
dust,  manure,  or  other  kno\\Ti  sources  of  tetanus  infection. 

References. 

1.  Marcus   Rabinowitch  :      Experimentelle   Untersuchungen    ueber    die    Wirkung   der 

Tetanus    Bacillen    imd    ihrer    Gifte    vom    Magendarmtraktus    aus.,    Arch.    f. 
Hygiene,  1907,  Band  LXI. 

2.  KoLLER  UND  Hetscii  :      Die  Experimentelle  Bacteriologie  und   die   Infektionskrank- 

heiten,  Berlin  and  Vienna,   1908. 

3.  P.    MiQiTEL    ET    R.    Cambbieb:      Traite    de    bacteriologie    pure    et    applique    tl    la 

Medecine  et  .1   I'hygiene,  Paris,   1902. 

4.  Kolle-Wassermann  :      Handbuch    der    Pathogen    Mikroorganismen,    1903,    Band    T. 

5.  Thalmanx:       Zur    Aetiologie    des    Tetanus,    Zeitschrift    f.    Hygiene    u.    Infcktion- 

skrkt.,  1900,  Band  XXXIII. 

6.  Heckeb:      Altes   und  Neues   ueber   die   Infektionsqucllen   und   Uebertragung,   swege 

des  Tetanus;     Schjerning  von  Leuthold  Gedenkschrift,   1006,  Band  I. 

7.  SoRMANi:     Verdhlg.  d.  X  Internat-Congress  f.  Medezine,  etc.,  Berlin,  1S90,  Band  V; 

also   La  Riforma  Medica,    1889    (April). 

8.  Hoffman  :     Ueber  das  Vorkommem  des  Tetanus  Erregers  in  den  Faeces  von  Tieren ; 

Aus  dem  Hyg.  Institut  d.  Univ.  Halle;    Hygien.  Rundschau,   1905,   XV. 

9.  DuFLOCQ:     Logons  sur  les  Bactcries  pathogenes   (Le  Bacille  Tetanique),  Paris.  1907. 

10.  Flugge:      Die    Mikroorganismem,    Leipzig,    1896    (Tetanus    Bacillus)  ;     W.    Kruse, 

Bacillen;     Ch.  III. 

11.  PizziNi:     Revista  d'Igien,  1898,  No.  5. 

12.  L.   CouRMONT  ET  M.  Dyon :     Le  Totanos    (Les  actualitas  Medicales),  Paris,    1899. 

13.  Leblanc,    Cad6ac,    Carougeau:      Pathologic    Chirurgicale    G^nerale    (Encyclopgdie 

Vgtfrinaire,  Paris,   1902,  T6tanos  par  M.   Carogeau). 

14.  Sanchez-Toledo  et  Veillon:     Arch,  de  M6d.  exp.,  Paris,  1890. 


ORGANIC  NERVOUS  DISEASES.  709 


ORGANIC  NERVOUS  DISEASES  FROM  A  PENSION  EXAMINER'S 

STANDPOINT. 

By  d.  J.  McCarthy, 

Professor  of  Medical  Jurisprudence,  University  of  Pennsylvania. 

PHILADELPHIA. 

A  CONSIDERATION  of  the  subject  of  diseases  of  the  nervous  system,  from  a 
pension  examiner's  standpoint,  must  necessarily  concern  itself  with  the  degree 
of  disability  produced  and  the  prognosis  of  the  condition.  The  etiology  and 
the  determining  factors  in  the  production  of  the  disease,  with  a  clear-cut  diag- 
nosis referred  to  a  pathological  basis,  are  essentials  to  a  proper  prognosis.  We 
may  diagnose  nervous  disorders  as  clinical  entities,  or,  on  the  other  hand,  as 
pathological  conditions.  Paralysis  agitans  may  be  paralysis  agitans  and  noth- 
ing more,  as  a  clinical  diagnosis,  or  it  may,  on  the  other  hand,  be  a  symptom 
group  indicative  of  varying  changes  in  the  central  nervous  system  due  to 
arteriosclerosis  or  sclerotic  conditions.  If  we  disregard  the  clinical  diagnosis 
and  study  the  pathological  base  for  the  disease,  we  can  more  easily  arrive  at  a 
more  proper  idea  of  the  future  course  of  the  condition  and  the  degree  of  dis- 
ability to  be  expected.  It  therefore  follows  the  first  essential  is  a  careful, 
complete  history,  and  the  second,  a  careful  and  complete  examination  not  alone 
of  the  nervous  system,  but  of  all  the  other  viscera.  In  a  case  of  partial 
paralysis  due  to  a  slight  thrombotic  lesion,  the  patient  may  be  relatively  well 
and  an  efficient  individual,  or  on  the  other  hand,  in  a  condition  of  hopeless 
invalidism  depending  on  the  condition  of  the  circulatory  and  renal  systems. 
While  a  careful  examination  of  the  heart  and  circulation  with  careful  studies  of 
the  blood-pressure  are  essential,  and  while  we  must  know  not  only  the  presence 
of  actual  disease  of  the  kidney,  but  also  its  efficiency  even  if  not  diseased,  the 
condition  of  the  lungs,  of  the  liver  and  of  the  gastro-intestinal  tract,  must  be 
taken  into  consideration. 

Taking  the  history  of  the  case,  time  and  thoroughness  as  to  details,  in 
order  to  arrive  at  all  the  etiological  factors,  are  absolutely  essential.  And  here 
we  must  differentiate  between  causative  and  determining  factors.  A  man  may 
have  had  a  specific  infection  with  evidence  of  incipient  locomotor  ataxia  which 
might,  and  not  infrequently  does,  exist  for  years  without  the  production  of  pu1)- 
jective  symptoms.  Here  the  cause  of  the  condition  is  unquestionably  syphilis. 
A  sudden  traumatism  with  minor  or  marked  disturbance  of  the  nervous  system 
may  be  the  determining  factor  whicli  causes  the  rapid  development  of  marked 
ataxia,  lancinating  pains,  ocular  symptoms  and  various  visceral  disturbances. 
It  requires  a  careful  history  and  good  clinical  judgment  to  determine  just  how 
far,  and  to  what  degree,  the  accessory  factor  has  acted  in  advancing  the  clinical 
picture.  It  is  often  necessary  to  observe  the  patient  for  some  time  in  order  to 
determine  just  how  far  the  varying  factors  have  been  responsible.  In  this 
respect  the  pension  examiner  is  at  a  decided  disadvantage.  Eelativoly  little 
reliance  can  be  placed  on  stereotyped  statements  of  prognosis  found  in  the 


710  ORGANIC  NERVOUS  DISEASES. 

text-books.  Much  depends  upon  the  general  natural  vigor  of  the  body  and 
more  particularly  of  the  nervous  system.  The  influence  for  a  good  or  a  bad 
heredity,  the  abuse  to  which  the  nervous  system  has  been  subjected,  the  degree 
of  wear  and  tear  on  the  general  system  dependent  upon  the  occupation  and 
nutritional  surroundings  of  the  individual,  and  the  opportunities  for  rational 
and  scientific  treatment,  are  all  factors  which  must  be  taken  into  consideration. 
The  ability  of  the  individual  to  secure  the  proper  treatment  which  includes 
proper  food,  proper  surroundings  and  individual  attention,  may  alter  the 
prognosis  from  relatively  bad  to  a  fairly  good  one.  In  other  words,  in  order 
to  arrive  at  the  proper  conclusion,  the  case  more  than  the  disease  should  be 
carefully  studied. 

As  to  the  individual  diseases,  we  may  take  up  the  group  of  syphilitic  and 
parasyphilitic  diseases  as  a  whole.  The  prognosis  of  an  active  cerebrospinal 
syphilis  depends  upon  how  soon  it  is  diagnosed  and  how  early  it  is  placed  under 
treatment,  and  more  particularly  how  the  case  reacts  to  treatment.  As  a  gen- 
eral rule  it  may  be  stated  that  when  the  nervous  system  is  affected  early  in 
the  course  of  a  syphilitic  infection  that  there  is  a  general  tendency  lor  a  cen- 
tralization of  the  s}Tnptoms  to  one  or  other  portions  of  the  nervous  system. 
While  the  patient  may  recover  under  proper  treatment  from  the  first  attack  of 
meningeal  or  vascular  trouble  referred  to  the  central  nervous  system,  unless 
careful  and  prolonged  treatment  is  adhered  to,  successive  and  more  serious 
trouble  may  be  expected.  If,  on  the  other  hand,  the  case  has  continued  for 
some  time  and  sclerotic  or  destructive  lesions  already  exist,  little  result  is  to 
be  expected.  Tabes  dorsalis  may  be  placed  as  an  incurable  disease.  Its  prog- 
ress may  be  checked  by  mixed  treatment,  some  of  the  s}TQptoms  may  disappear, 
but  after  it  is  established  as  a  clinical  entity,  it  can  be  definitely  stated  that 
the  condition  is  incurable.  This  does  not  mean  that  the  individual  may  not 
by  proper  treatment  be  restored  to  purposive  activity  for  a  period  of  years ;  he 
nevertheless  will  show  on  examination  the  evidence  of  the  destruction  of  the 
posterior  roots  of  the  spinal  cord.  The  same  statement  may  be  made  as  to 
general  paralysis  of  the  insane.  There  is  more  difficulty  in  the  early  diagnosis 
of  this  condition.  In  its  early  stages  it  often  closely  resembles  neurasthenia 
and  psychasthenia.  The  well-developed  cases  are  usually  typical.  It  should 
be  remembered  that  two  conditions  give  an  identical  clinical  picture,  i.e.,  dis- 
seminated cerebral  syphilis  and  chronic  lead  poisoning.  The  diagnosis  of  the 
latter  is  dependent  upon  a  careful  physical,  blood  and  urinary  examination  for 
the  usual  evidences  of  lead;  and  the  former  by  the  therapeutic  test.  The 
only  safe  rule  is  to  try  out  the  therapeutic  test  thoroughly  in  early  cases  of 
general  paresis,  if  we  would  exclude  the  rare  cases  of  cerebral  s^^hilis  which 
gives  an  identical  picture.  At  a  recent  meeting  of  the  Philadelphia  Psychiatric 
Society,  I  exhibited  two  brains  from  cases  of  typical,  clinical  paresis.  In  one 
of  these  the  brain  showed  a  condition  of  active  productive  meningitis  with  an 
extension  into  the  cortex.  An  active  course  of  antisyphilitic  treatment  should 
have  delayed  the  advance  in  the  mental  symptoms,  if  it  did  not  clear  them  up 
entirely.  When  the  case,  however,  is  one  of  true  paresis,  we  may  limit  the 
disease  to  ten  years  at  the  outside,  with  four  to  five  years  as  an  advanced  average. 


ORGANIC  NERVOUS  DISEASES.  711 

At  no  time  after  the  development  of  the  disease  is  the  individual  to  be  con- 
sidered as  fit  for  responsible  or  purposive  work. 

Myelitis. — Acute  myelitis  due  to  an  infection  other  than  syphilis  and  not 
secondary  to  bone  disease  may  cause  temporary  or  permanent  paralytic 
phenomena  dependent  upon  the  extent  or  severity  of  the  pathological  process. 
Minor  states  of  inflammation  which  might  be  grouped  within  the  limits  of  a 
severe  active  congestion  pathologically  may  produce  a  temporary  complete 
paralysis  which  rapidly  disappears  with  rest,  leaving  no  evidence  of  injury  to 
the  cord.  When  there  is  a  distinct  inflammatory  process,  there  is  usually  some 
secondary  degeneration  of  the  motor  columns  with  rigidity  and  a  varying  loss 
of  power.  This  may  disappear  under  hygienic  mechanical  and  hydrothera- 
peutic  measures.  In  the  severer  form  of  myelitis,  recovery  is  only. partial,  and 
the  loss  of  power  may  be  accentuated  by  the  development  of  contractures,  often 
necessitating  surgical  measures  (tenotomy,  tendon  transplantation,  etc.),  for 
their  relief. 

Of  acute  poliomyelitis  which  may  develop  in  adult  life,  the  same  may  be 
said.  ^Much  improvement  is  to  be  expected  even  ia  the  most  severe  and 
extensive  cases,  by  persistent  use  of  massage,  electricity,  mechanical  and  opera- 
tive measures.  The  disability  in  these  cases  depends  on  the  extent  of  involve- 
ment. As  little  as  a  single  muscle  may  be  involved.  In  such  cases,  or  where  a 
single  muscle  group  is  paralyzed,  nerve  or  tendon  transplantation  may,  partially, 
or  completel}^,  remove  the  disability. 

Mexingitis. — Cerebral  meningitis  of  whatever  cause  may  disappear  with 
relatively  little  damage,  or  on  the  other  hand,  may  completely  disable.  Even 
in  epidemic  meningitis,  apparently  full  recovery  may  obtain. 

Depending  on  the  intensity  of  the  process  and  the  degree  of  destruction, 
all  grades  of  disability  may  result.  When  these  are  purely  muscular,  much 
benefit  may  be  obtained  by  the  corrective  measures  above  referred  to  under 
myelitis.  When,  however,  the  damage  is  mental,  or  when  the  higher  special 
cranial  nerves  (such  as  the  optic  and  the  auditory)  are  damaged,  the  results 
are  usually  permanent  and  do  not  yield  to  treatment. 

Tumors  of  the  brain  are  rarely  curable  even  by  operation.  In  a  collection 
of  thirty-four  tumors  in  my  pathological  collection,  only  one  represented  the 
ideal  for  operative  results.  All  the  others  were  either  infiltrating  or  affected  a 
portion  of  the  brain  which  precluded  operative  interference.  The  prognosis  of 
brain  tumors  may,  therefore,  be  said  to  be  unfavorable  to  such  restitution  of 
function  as  to  make  the  individual  a  self-supporting  and  purposive  individual. 
I  do  not  mean  to  imply  that  much  benefit  may  not  be  derived  from  operation, 
but  that  the  results,  as  a  whole,  as  to  absolute  and  permanent  cure  in  the  great 
majority  of  cases  is  disappointing. 

Spinal  tumors  on  account  of  the  early  presence  of  localizing  symptoms, 
offer  a  more  favorable  prognosis.  Even  malignant  isolated  tumors  may  be 
removed  with  complete  and  pennanent  restitution  of  function. 

Cerebral  hsemorrhage,  thrombosis  and  embolism,  in  their  prognosis,  depend 
on  many  factors  which  must  be  studied  in  the  individual  case.  As  a  rule  the 
paralytic  phenomena  remaining  after  three  months  of  treatment,  may  be  taken 


712  THE  CURATIVE  POWERS  IiN  HUMAJS  MILK. 

as  an  index  of  the  permanent  state.  Myotrophic  lateral  sclerosis,  progressive 
muscular  atrophy,  bulbar  palsy,  syringomyelia,  multiple  sclerosis,  primary 
spastic  paraplegia  may  be  classed  as  incurable  and  progressively  disabling 
affections. 


THE  CURATIVE  POWERS  IN  HUMAN  MILK. 

By  J.   MADISON   TAYLOR,  A.B.,  M.U., 

Pediatrist  to  the  Philadelpliia  General  Hospital. 

PHILADELPHIA,    PA. 

Scientific  substitute  feeding  for  infants  is  capable  of  producing  much 
harm.  Judiciously  used  it  has  saved  unnumbered  lives,  but  too  often  both 
physician  and  mother  are  lulled  into  a  false  sense  of  security,  and  breast- 
feeding is  abandoned.  In  my  hospital  and  dispensary  service  (extending  in 
one  place  over  thirty  years)  a  day  seldom  passes  but  instances  occur  where 
mothers  of  the  poorer  classes  "put  their  infants  on  the  bottle"  for  mere  con- 
venience. While  doubtless  this  prevailed  before  the  days  of  easy  and  exact 
substitute  feeding,  it  is  vastly  commoner  now,  to  my  personal  knowledge.  In 
many  cases  this  change  was  made  under  the  advice  or  sanction  of  a  physician. 
To  be  sure,  immediate  effects  often  seem  good  enough;  the  babies  are  fat  and 
happy;  but  what  of  the  remote  effects  on  development  and  immunity,  on  the 
endless  exigencies  of  infection  and  divers  disease  agencies.  Furthermore,  no 
matter  how  perfect  the  mere  chemical  composition  of  percentage  feeding  can 
be  made,  all  clinicians  know  how  difficult  it  is  to  provide  against  the  numberless 
errors  which  creep  in  to  mar  the  integrity  of  the  product  as  a  food.  So  diffi- 
cult is  it  to  rely  on  even  a  specially  trained  nurse  or  an  intelligent,  painstaking 
mother,  that  I  have  personally  pled  with  the  members  of  the  Retail  Druggists' 
Association  to  themselves  undertake  to  furnish  bottled  food,  prepared  with 
all  the  precision  and  precaution  of  which  the  pharmacist  is  so  capable.  They 
say  the  risks  are  too  great,  also  that  it  can  not  be  made  to  pay  in  the  long  run. 

Among  the  poorer  mothers  the  difficulties  of  securing  ice,  guaranteed 
milk,  maintaining  cleanliness  in  containers  and  such  factors,  open  the  door 
for  much  disaster.  A  large  proportion  of  infants  suffer  or  die  from  such  like 
preventable  but  perpetually  recurring  perils.  For  rich  or  poor  it  is  a  well  estab- 
lished maxim  tbat  a  baby  on  breast-milk  will  survive  the  dangers  of  infection, 
either  threatened  or  acquired,  far  better  than  when  even  partial  substitution 
is  practiced.     Much  more  grave  is  the  condition  of  those  fed  only  artificially. 

While  this  axiom  is  well  known,  its  force  is  lessened  in  the  consciousness 
of  far  too  many  physicians  who  have  been  led  to  infer  that  modern  substitute 
feeding  is  so  reliable  a  measure  that  they  can  afford  to  be  lax  with  nursing 
mothers.  The  power  of  physiologic  conviction  dies  readily  in  the  face  of  too 
much  talk  by  "scientific"  authorities.  In  short,  it  is  too  often  the  weakening 
of  mind  or  conscience  in  the  physician  on  which  rest  the  problems  of  infantile 
life,  death  or  impaired  development  and  health,  rather  than  upon  the  selfish- 


THE  CURATIVE  POWERS  IN  HUMAN  MILK.  71 3 

ness,  indolence  or  vanity  of  the  culpable  mother.  I  would,  then,  offer  this 
formulation : 

That  physician,  or  that  mother,  who,  except  for  cogent  reasons,  omits  to 
enforce  or  employ  breast-feeding  thereby  deprives  the  infant  of  the  most 
powerful  agency  for  the  conservation  of  life  and  health.  The  punislmient  falls 
not  upon  the  offender,  but  upon  the  helpless  victim. 

The  purpose  of  this  short  paper  is  to  point  out  a  few  of  the  reasons  for 
the  extreme  desirability  of  conserving  in  all  ways  that  best  of  foods  and,  one 
may  say,  of  immimizing  agencies,  breast-milk.  I  will  give  rapidly  a  few  salient 
points  bearing  on  the  physiology  of  milk,  borrowing,  as  all  do,  but  especially 
from  Sajous's  researches. i  The  investigations  of  A.  Jacobi,  Joseph  Winters, 
Bertillon,  Jones,  J.  Lewis  Smith,  Holt,  Fokker,  Louis  Fisher,  Mayr,  based  on 
statistics  published  in  different  countries  have  shown  that  the  mortality  of 
breast-fed  infants  is  conspicuously  less  than  in  the  bottle-fed.  E.  G.  Holt 
found,  in  1,943  fatal  cases  due  to  degenerative  disturbances,  only  three  per  cent, 
had  been  exclusively  breast-fed;  Jones,  in  Liverpool,  of  718  cases  of  fatal  infant 
diarrhoea  only  thirty  were  exclusively  breast-fed.  "It  is  useless,"  as  Chapin 
remarks,  "to  attack  the  problem  of  artificial  infant  feeding  from  the  standpoint 
of  chemistry  alone."  To  this,  L.  T.  de  M.  Sajous  adds :  "There  is  something 
to  be  thought  of  in  the  composition  of  milk  besides  mere  proteid,  fat,  carbo- 
hydrate, salt,  and  water.  The  additional  factors,  largely  overlooked  until  the 
last  few  years,  include  the  passage  through  the  normal  maternal  milk  to  the 
child  of  special  substances,  inherent  in  the  species,  which  assist  the  offspring 
not  only  in  the  proper  treatment  of  the  food-material  embodied  in  the  milk, 
but  also  in  carrying  on  other  bodily  functions,  including  that  of  protection 
against  infection. 

"That  milk  is  capable  of  conveying  antitoxic  substances  after  these  have 
been  injected  into  the  mother  has  been  known  for  a  number  of  years.  In 
1892  Ehrlich  and  Brieger  demonstrated  this  fact,  in  their  experiments  on  mice. 
The  offspring  of  non-immune  mice  were  suckled  by  other  mice  which  had 
been  immunized  against  the  actions  of  certain  poisons.  It  was  found  that  the 
young  were  thereby  rendered  immune  to  the  poisons  employed,  viz.,  ricin, 
abrin,  and  tetanus  toxin.  This  immunity  steadily  increased  during  the  period 
of  lactation,  persisted  for  some  time  after,  and  then  gradually  disappeared." 

Ehrlich,  in  1892,  performed  his  classic  experiments  showing  the  trans- 
mission of  antitoxic  substances  through  human  milk.  Schmid  and  Pflantz,  in 
1896,  performed  similar  and  interesting  experiments  on  guinea-pigs,  with  milk 
from  a  woman  into  whom  diphtheria  antitoxin  had  been  injected.  They 
enunciated  the  conclusions  that  (1)  antitoxic  substances  found  in  the  blood  of 
parturient  women  exist  also  in  their  milk;  (2)  that  the  quantity  of  antitoxic 
substance  excreted  with  the  milk  is  much  less  than  that  found  in  the  blood. 
La  Torre,  in  1905,  made  similar  observations. 

1  The  facts  presented  are  collected  in  an  admirable  essay  by  Louis  T.  De  M. 
Sajous,  son  of  Charles  E.  de  IM.  Sajous,  appearing  in  the  University  of  Pennsylvania 
Medical  Bulletin,  June,  1909;  also  from  t)H>  "Inlornal  Secret  ions,"  Vols.  I  and  II, 
by  Sajous,  the  elder. 


714  THE  CURATIVE  POWERS  Ix\  HUMAN  MILK. 

Moro  found  that  the  bactericidal  power  of  the  serum  of  the  blood  in  breast- 
fed children  was  distinctly  greater  than  in  those  artificially  fed. 

Some  explanation  of  the  comparative  immunity  of  infants  under  one 
year  to  infections  is  afforded  by  the  observations  of  Ehrlich,  Moro  and  A.  C. 
Abbott.     Sajous  says  in  this  connection: — 

"As  Halban  and  Landsteiner  have  shown,  the  bactericidal  power  of  the 
blood  of  newborn  infants  is  relatively  deficient,  and  it  seems  not  unlikely  that 
this  deficiency  should  be  made  up  by  the  transmission  of  protective  bodies  from 
the  mother.  Under  these  conditions  the  antitoxic  status,  if  I  may  so  express 
it,  of  the  infant's  blood  should  correspond  more  or  less  closely  with  that  of  the 
maternal  blood,  this  implying,  as  a  consequence,  that  the  infant  should  react 
to  the  various  morbid  influences  to  which  it  is  exposed  in  a  manner  more  or 
less  similar  to  the  mother  herself.  In  support  of  this  proposition  it  may  be 
urged  that  the  infections  to  which  the  infants  below  one  year  seem  less  sus- 
ceptible than  children  past  that  age  are  also  diseases  which  occur  infrequently 
among  adults — a  fact  which  suggests  a  similar  cause  for  this  infrequency 
during  these  two  periods  of  life.  This  would  involve  the  conclusion  that  breast- 
fed infants  acquire  these  diseases  less  often  than  the  artificially  fed.  That 
such  is  probably  the  case  is  suggested  by  Fischer's  statement  that  he  has 
'rarely  met  with  infectious  diseases  in  healthy  breast-fed  infants,'  and  Mayr's 
observation  that  of  ten  nurslings  exposed  to  measles,  only  one  contracted  the 
disease." 

Finally  the  subject  of  the  bactericidal  properties  of  the  milk  itself,  on 
which  some  convictions  were  held,  but  much  uncertainty  prevailed  till  lately. 
It  has  now  been  carefully  studied  in  connection  with  the  problem  of  the 
effects  of  heat  on  the  composition  of  milk  during  sterilization  and  pasteuriza- 
tion.    I  quote  in  full  from  L.  T.  de  M.  Sajous's  able  paper  to  the  end : — 

"Human  breast  milk  is  often  put  down  as  sterile;  this  is  not  strictly  the 
case,  though  its  bacterial  content  is  very  usually  made  up  of  organisms  of  low 
virulence,  as  the  staphylococcus  albus  and,  less  commonly,  aureus.  Cow's  milk, 
on  the  other  hand,  is  not  only  not  sterile  when  it  leaves  the  animal,  containing 
as  it  does  frequently  streptococci  and  tubercle  bacilli,  but  is  subsequently  given 
numerous  opportunities  for  further  contamination  before  it  reaches  the  arti- 
ficially fed  infant.  G.  W.  Goler  found  by  careful  tabulations  of  the  deaths  in 
early  childliood  in  Eochester,  N.  Y.,  that  'the  infantile  death  rate  bore  a  close 
relation  to  the  average  number  of  bacteria  per  cubic  centimeter  found  in  the 
municipal  milk  supply.'  This  brings  out  clearly  the  importance  of  the  bacteri- 
ological study  of  milk,  and  the  need  of  precautions  to  minimize  the  effects  of 
any  pathogenic  bacteria  it  may  contain.  It  is  of  no  less  significance  in  connec- 
tion with  breast-feeding,  since  milk  transferred  directly  from  the  breast  to  the 
infant's  digestive  tract  has  naturally  the  least  possible  opportunity  to  become 
infected  from  the  exterior.  Provided  the  mother's  breasts  be  not  diseased, 
human  milk  is  therefore  a  safe  food  relatively  so  far  as  the  bacterial  content  is 
concerned,  while,  conversely,  the  use  of  cow's  milk  affords  more  or  less  time  for 
the  multiplication  of  bacteria  before  it  is  consumed. 

"Fokker,  a  number  of  years  ago,  reached  the  conclusion  that  milk  possessed 


THE  CURATIVE  POWERS  IN  HUMAN  MILK.  715 

an  inhibitory  influence  on  bacteria  similar  to  that  of  the  blood  serum.  He 
inoculated  specimens  of  raw  milk  and  of  milk  sterilized  by  heat  with  lactic- 
acid-forming  organisms,  and  observed  that  the  formation  of  acid  with  conse- 
quent coagulation  of  the  milk  took  place  more  rapidly  in  the  sterilized  milk 
than  in  the  raw  milk.  He  therefore  believed  that  the  latter  possessed  an 
inhibitory  power  which  the  sterile  milk  had  lost  through  being  heated.  His 
results  were  contradicted  by  Basenau,  but  on  insufficient  grounds,  and  they  have 
been  supported  by  later  investigations.  Experiments  were  made  to  bring  out 
the  behavior  of  the  organisms  of  typhoid  fever  and  cholera  when  introduced 
into  cow's  milk,  but  the  results  were  so  contradictory  that  they  are  of  no  value 
for  our  present  purpose.  In  1901  Hunsiker  published  conclusions  based  on 
an  extensive  series  of  observations  on  the  bactericidal  properties  of  cow's  milk. 
He  found  that  fresh  milk  usually  had  germicidal  power,  but  that  it  varied 
markedly  in  degree  in  the  milk  obtained  from  different  animals,  and  even  some- 
times with  different  milkings  from  the  same  animals.  He  also  noted  that  the 
germicidal  influence  was  strongest  at  70°  F.,  being  weaker  but  of  greater  dura- 
tion at  temperatures  below  this;  that  it  lasted  on  the  average  from  three  to 
six  hours  at  70°  F.,  at  most  twelve  hours;  and  that  an  exposure  of  forty 
minutes  at  149°  F.  destroyed  it  completely. 

"Hunsiker's  findings  were  confirmed  and  amplified  in  1908  by  Evans  and 
Cope.  They  obtained  raw  sterile  milk  directly  from  the  cow,  treated  portions 
of  it  by  heating  to  various  grades  of  temperature,  and  other  portions  by  freez- 
ing, inoculated  the  specimens  with  various  organisms  after  bringing  them  all 
back  to  room  temperature,  and  then  observed  the  rapidity  of  multiplication  of 
these  organisms  by  making  counts  at  frequent  intervals.  Their  results  are  of 
great  interest.  At  the  end  of  four  hours  the  lactic  acid  bacillus  showed  an 
increase  of  6  per  cent,  in  the  raw  sterile  milk,  55  per  cent,  in  the  frozen  milk, 
250  per  cent,  in  the  sterile  milk  heated  at  55°  C,  1000  per  cent,  in  the  milk 
heated  at  68°  C,  3500  per  cent,  in  the  milk  heated  to  the  boiling  point,  and 
2500  per  cent,  in  a  bouillon  control.  The  inhibitory  activity  thus  shown  to 
exist  in  raw  milk  they  found  to  last  only  four  to  eight  hours,  after  which  the 
bacteria  in  the  different  specimens  proliferated  with  approximately  equal 
rapidity.  At  the  end  of  twenty-four  hours  the  counts  made  in  the  difl'erent 
specimens  varied  so  little  that  it  might  almost  seem  as  if  they  had  all  been 
subjected  to  the  same  treatment  from  the  beginning.  Among  other  organisms 
upon  which  the  antibacterial  effects  of  milk  were  tested  by  these  investigators 
were  streptococcus  pyogenes,  the  micrococcus  aureus  or  staphylococcus,  and  the 
bacillus  coli  communis.  The  results  obtained  were  essentially  the  same  as  with 
the  lactic  acid  organism,  except  in  that  an  actual  bactericidal  effect  was  pro- 
duced in  the  raw  sterile  milk,  the  number  of  bacteria  showing  at  the  end  of 
four  hours  a  decrease  instead  of  a  limited  increase.  The  reduction  in  the  case 
of  the  streptococci  amounted  to  3.5  per  cent.,  in  the  staphylococci  20  per  cent., 
and  in  the  colon  bacilli  40  per  cent.  At  the  eighth  hour,  the  streptococci  were 
further  slightly  reduced,  but  after  this  underwent  rapid  increase;  the  staphy- 
lococci had  already  begim  to  increase  at  the  eighth  hour,  while  the  colon  bacilli 
were  about  100  times  as  numerous  at  this  time  as  they  had  been  at  the  fourth 


716  THE  CURATIVE  POWERS  IN  HUMAN  MILK. 

hour.  In  the  Bpecimens  of  milk  heated  at  certain  temperatures  before  being 
inoculated  no  reduction  in  the  number  of  bacteria  was  produced,  except  in  the 
case  of  the  streptococci  in  milk  previously  heated  at  55°  C.  In  the  boiled  milk 
the  organisms  always  underwent  rapid  proliferation  from  the  start. 

'These  experiments  show  that  there  exists  in  raw  milk  a  well-marked 
bactericidal,  or  at  least  inhibitory,  power,  which,  however,  is  of  short  duration. 
The  latter  fact  would  seem  to  be  of  some  importance  in  connection  with  the 
artificial  feeding  of  infants.  Few  infants  are  enabled  to  take  their  cow's  milk 
within  eight  hours  or  even  twelve  hours  after  it  has  left  the  animal.  They 
receive  it,  then,  after  its  inhibitory  influence  on  bacteria  has  largely  disappeared. 
Whatever  microorganisms  may  have  been  acquired  by  the  milk  during  its 
journey  from  the  cow  to  the  infant  have  begun  to  multiply  at  once,  and  the 
longer  the  period  elapsed,  the  greater  the  danger  becomes.  The  infant  then 
has  to  depend  exclusively  upon  its  own  defensive  activities  for  checking'  bacterial 
proliferation,  i.e.,  upon  the  HCl  and  pepsin  of  its  gastric  juice.  Moreover, 
Netter  states  that  the  proportions  of  both  total  and  combined  hydrochloric  acid 
are  less  in  the  gastric  contents  of  children  below  two  years  of  age  than  in  adults. 
If  the  quality  of  the  infant's  gastric  juice  be  impaired  for  any  reason,  as  in  the 
case  of  inherent  weakness  or  exposure  to  unhealthy  surroundings,  or  under  the 
influence  of  hot  weather,  it  is  directly  exposed  to  bacterial  mischief,  whereas  if 
the  milk  still  possessed  antibacterial  power  when  ingested,  this  additional  pro- 
tective influence  would  be  present  during  the  period  of  digestion,  and  doubtless 
in  many  cases  be  a  deciding  factor  in  the  preservation  of  comparative  health  as 
against  disease. 

"The  importance  to  the  infant  of  keeping  under  control  the  organisms  in 
its  gastro-intestinal  tract  need  not  be  emphasized  when  we  recall  the  great 
prevalence  and  fatality  of  disorders  of  this  tract,  especially  in  the  summer 
months.  Babies  fed  on  cow's  milk  kept  for  a  number  of  hours  and  subjected 
to  a  temperature  favorable  to  microorganismal  growth  are  very  prone  to  develop 
one  of  the  forms  of  acute  or  subacute  infectious  gastro-enteritis  (which  may  be 
used  as  a  general  term  for  several  more  or  less  diversely  classified  diseases,  as 
summer  diarrhoea,  cholera  infantum,  etc.).  In  the  more  acute  affections  of  this 
type,  symptoms  directly  due  to  the  toxic  products  generated  by  bacteria  are  seen. 
The  organisms  found  have  been  various  and  their  relationship  to  the  different 
disease  conditions  have  not  as  yet  been  fully  worked  out,  but  it  is  known  that  the 
bacillus  of  Shiga  is  often  present,  also  a  variety  of  the  colon  bacillus  which  has 
acquired  virulence,  and  not  infrequently  the  streptococcus.  As  Euhriih  states, 
'nearly  all  the  cases  and  nearly  all  the  deaths  are  in  bottle-fed  babies,' 

"Breast-fed  infants  receive  milk  that  is  comparatively  free  of  bacteria  and 
with  whatever  bactericidal  power  it  may  possess  undiminished  by  lapse  of  time. 
Cozzolino  found  that  in  human  milk  the  growth  of  the  colon  bacillus  was  limited 
during  fourteen  to  forty-eight  hours,  whereas  in  cow's,  goat's,  and  ass's  milk 
abundant  growth  occurred.  If  these  experiments  are  valid,  we  have  further 
evidence  in  favor  of  the  protective  activity  of  maternal  milk. 

"The  conclusions  suggested  by  these  facts  are  as  follows : — 

"1.  The  prevailing  custom  of  considering  only  the  nutritional  values  of 


RELATIOJSS  OF  RECTAL  DISEASE  TO  GEJSIERAL  HEALTH.  7 17 

milk  and  other  forms  of  food  used  in  the  artificial  feeding  of  infants  is  partly 
responsible  for  the  great  mortality  that  prevails  among  them,  especially  during 
the  first  year, 

"2.  The  protection  of  the  infant  against  infection  depending  in  no  small 
degree  upon  bactericidal  and  antitoxic  substances  physiologically  supplied  to  it 
in  the  maternal  milk,  the  protective  properties  of  any  artificial  food  should 
receive  attention  as  well  as  its  nutritional  values. 

"3.  All  phases  of  the  problem  indicate  that,  of  the  various  modes  of  feed- 
ing, direct  maternal  nursing  affords  the  greatest  protection  to  the  infant;  it 
follows,  therefore,  that 

"4.  We  should  do  all  in  our  power  to  promote  the  abandonment  of  artificial 
feeding  and  thus  reduce  greatly  the  mortality  among  infants." 


RELATIONS  OF  RECTAL  DISEASE  TO  GENERAL  HEALTH. 
By  ERNEST  LAPLACE,  M.D., 

PHILADELPHIA. 

The  modern  aspect  of  medicine,  brought  about  by  the  relation  of  micro- 
organisms to  the  human  body,  taken  as  a  soil,  has  awakened  the  highest  interest 
in  the  functions  of  the  rectum,  and  the  necessity  of  keeping  these  functions 
within  strict  physiological  limits.  That  the  body  should  maintain  itself  in  a 
fair  state  of  health,  not  only  should  the  various  glands  and  blood-making 
organs  have  their  physiological  integrity  but  the  serum  should  retain  its 
opsonin-producing  power  and  the  polynuclear  leucocytes  should  abound,  to 
digest  easily  the  invading  microorganism  weakened  by  the  opsonin.  That  this 
auto-protective  system  should  remain  unimpaired  it  is  necessary  that  the  sym- 
pathetic nervous  system  as  well  as  the  cerebro-spinal  system  continue  in  a  normal 
state. 

]\Iy  object  is  to  briefly  show  the  intimate  connection  of  the  sigmoid 
and  rectum,  with  the  sympathetic  and  cerebro-spinal  nervous  S5''stem.  Under 
various  rectal  disorders  the  nervous  system  becomes  thoroughly  demoralized, 
predisposing  the  patient  to  many  reflex  troubles.  Second,  I  will  demonstrate 
the  great  absorbing  power  of  the  rectum,  for  gases  and  fluids  and  thereby  show 
the  toxic  influence  of  constipation  upon  the  general  system,  in  weakening  the 
autoprotective  powers  of  the  economy,  the  opsonins  and  phagocytes. 

The  cerebro-spinal  system  gives  the  muscles  of  the  rectum  branches  from 
the  sacral  plexus,  while  the  superficial  perineal,  a  branch  of  the  pudic,  supplies 
the  levator  ani  and  the  skin  in  front  of  the  anus.  The  inferior  ha^morrhoidal, 
sometimes  existing  independently  from  the  sacral  plexus,  supplies  the  lower  end 
of  the  rectum  and  anus.  Tlie  pudic  is  controlled  by  the  same  part  of  the  cord 
as  the  sciatic.  Hence  irritation  from  a  fissure  or  ulcer  located  within  the  anus 
may  be  transferred  down  the  limbs  to  some  distant  parts.  The  intimate  rela- 
tion of  this  nerve  to  the  genito-urinary  organs,  e.vplains  the  frequency  with 
which  disorders  of  urination  are  associated  with  rectal  affections.     Tt  is  tlirough 


718  RELATIOJS'S  OF  RECTAL  DISEASE  TO  GE:NERAL  HEALTH. 

the  sjTnpathetic  system,  however,  that  a  more  profound  impression,  is  produced 
upon  the  general  econom}^,  from  the  rectum.  The  sympathetic  nerve  in  this 
region  comes  from  the  mesenteric  and  hypogastric  plexuses.  It  also  receives 
branches  from  the  lumbar  and  sacral  plexuses.  From  this  intimate  connection 
of  the  rectum  with  the  sympathetic,  it  follows  that  any  constant  irritation  in 
this  region  is  betrayed  to  the  sympathetic  system  as  a  8}Tiiptom  which  I  have 
called  the  pain  of  the  sympathetic;  that  is,  a  constant  degree  of  low  shock  com- 
monly called  a  condition  of  general  depression.  During  this  state,  in  reality 
a  minor  condition  of  shock,  all  the  functions  of  the  body  are  lowered,  and  the 
patient's  resistance  to  disease  lowered.  This  condition,  obscure  in  itself,  has 
been  sometimes  diagnosed  as  neurasthenia,  a  name  often  too  handy  to  cover  the 
symptoms  resulting  from  an  overlooked  constant  insult  to  the  sympathetic 
system. 

Haemorrhoids,  anal  fissure,  fistula  in  ano,  prolapse  of  rectum  therefore 
undermine  the  system  by  the  actual  sensation  of  pain  through  the  cerebro-spinal 
system  and  as  markedly  by  the  depression  or  minor  condition  of  constant 
shock  through  the  sympathetic,  resulting  in  anemia,  hence  a  diminished  poly- 
nuclear  leucocytosis ;  that  is  diminished  auto-protection  of  the  body  against 
infections,  and  diminished  function  of  the  glands  for  internal  secretions.  I 
have  seen  many  patients  who  had  become  neurasthenics,  and  were  cured  when 
relieved  of  internal  haemorrhoids.  I  have  especially  gathered  observations  of 
four  cases  of  ulcer  of  the  stomach,  in  whom  haemorrhoids  had  existed  for  five, 
eight  and  nine  years,  who  persistently  neglected  the  treatment  of  the  haemor- 
rhoids and  whose  general  debility  was  followed  by  chronic  dyspepsia  and  this 
by  ulcer  of  the  stomach.  In  one  instance  the  patient  still  refused  operation 
for  the  ulcer:  it  perforated  and  death  followed.  In  the  other  three  cases  a 
gastro-enterostomy  was  performed  and  the  haemorrhoids  were  removed. 

I  have  also  found  hamiorrhoids  associated  with  various  forms  of  malignant 
growths.  Of  course  we  know  that  any  part  of  the  body  if  constantly  irritated 
is  prone  to  degenerate  into  a  malignant  condition,  the  constant  irritation  pre- 
disposing the  spot  to  cancerous  infection.  Another  factor  comes  from  the 
constant  depression  of  the  sympathetic,  which  we  know  is  a  predisposing  cause 
for  cancer  elsewhere  in  the  body. 

A  tubercular  fistula  in  ano,  aside  from  its  local  significance  is  a  constant 
source  of  possible  tubercular  infection  to  the  rest  of  the  economy,  and  should, 
therefore  be  promptly  removed. 

But  by  far  the  most  common  affection  of  the  rectum  and  that  which 
directly  and  indirectly  results  in  the  most  harm  to  the  economy  is  constipation. 
This  condition  so  universally  spread,  has  never  received  the  attention  it  deserves, 
and  the  future  will  reveal  more  and  more  its  baneful  effects  on  the  human  race. 
Mere  talk,  advice  and  warning  on  the  subject  does  not  suffice,  we  should  convince 
ourselves  on  this  matter,  and  convince  our  patients  by  the  following  plain  facts : 
The  rectum  is  a. reservoir  for  freces — true,  but  nature  has  endowed  it  with  a 
quality  as  dangerous  as  it  may  be  useful — that  is,  absorption. 

The  absorbent  vessels  of  the  rectum  are  much  more  numerous  than  are 
generally  supposed.     The  lymphatics  run  backward  between  the  two  layers  of 


RELATIOI^S  OF  RECTAL  DISEASE  TO  GENERAL  HEALTH.  719 

the  meso-rectum,  in  which  there  are  four  or  five  glands,  through  the  sacral  to 
the  lumbar  glands.  The  veins  are  the  superior,  middle  and  inferior  haimor- 
rhoidal.  The  superior  hasmorrhoidal  vein  returns  the  blood  to  the  portal  vein 
and  liver,  while  the  middle  and  inferior  hsemorrhoidal  vein  return  the  blood  to 
the  internal  iliac  vein.  Hence  the  passage  through  the  liver  and  through  the 
general  circulation  of  fluids  and  gases  from  the  rectum.  This  absorbent  prop- 
erty has  been  recognized  and  utilized  in  therapeutics  for  rectal  feeding.  It  is 
wonderful  to  contemplate  how  long  and  how  efficiently  this  can  be  done.  Some 
three  years  ago,  I  had  a  patient  who  had  an  ulcer  of  the  stomach  with  repeated 
hffimatemesis,  and  marked  cardio-vascular  disease.  An  operation  on  the  stomach 
was  impossible,  he  was  treated  by  rectal  feeding  alone  during  eight  weeks, 
without  loss  of  weight.  It  is  well  known  to-day  that  the  Murphy  gradual 
instillation  of  normal  salt  solution  in  the  rectum  is  a  most  valuable  adjimct  to 
our  surgical  therapeutics  in  peritonitis.  As  many  as  eight  quarts  of  normal 
salt  solution  have  been  absorbed  in  twenty-four  hours  without  discomfort  to 
the  patient.  This  fluid  passes  into  the  lymphatics  and  veins.  If  the  abdominal 
cavity  be  drained,  a  large  amount  of  this  fluid  modified  by  the  serum  of  the 
blood  is  poured  into  the  dressings. 

Ether  is  freely  administered  by  the  rectum  with  resulting  anassthesia. 
Oxygen  is  absorbed  by  the  rectum  in  the  treatment  of  asphyxia. 

These  statements  give  us  an  idea  of  how  absorbent  the  rectum  is,  and 
therefore  how  easily  can  be  absorbed  into  the  system  the  deleterious  fluids  and 
gases  of  fffical  matter  which  are  allowed  to  stagnate  in  the  rectum.  What 
clinician  can  tell  us  to-day  the  number  of  ailments  to  which  the  body  is  pre- 
disposed by  constipation.  The  toxic  fluid  and  gases  are  certainly  absorbed  in 
direct  proportion  to  the  hardness  of  the  isecal  matter  of  constipation.  Their 
efl'ect  upon  the  internal  secretions,  upon  the  opsonins  and  upon  the  phagocytes 
has  but  lately  been  studied,  and  the  full  damage  produced  by  them  is  not  yet 
known.     Some,  however,  are  the  following: — 

Auto-intoxication,  as  manifested  by  a  furred  tongue,  bad  taste,  foul  breath, 
nausea,  thirst,  sallow  complexion,  certain  skin  afi'ections  (acne,  urticaria,  etc.), 
anaemia,  weak  pulse,  lassitude,  anorexia,  insomnia,  loss  of  memory,  inability  to 
concentrate  the  mind,  infantile  convulsions,  and  other  phenomena.  Surgeons 
have  learned  from  experience  that  when  a  patient  has  a  sudden  rise  of  tempera- 
ture which  cannot  be  accounted  for  by  infection,  the  best  thing  to  do  is  to 
administer  a  cathartic  or  high  enema,  and  thoroughly  empty  the  bowel,  a  pro- 
cedure which  is  followed  by  a  prompt  reduction*  of  the  temperature,  proving 
that  local  absorption  was  the  cause  of  the  trouble. 

Headaches  of  various  degrees  of  intensity;  among  women  sick  headaches, 
which  may  occur  periodically  and  are  not  relieved  until  free  catharsis  is  resorted 
to.  ISTeuralgia  is  a  frequent  result  of  constipation.  Loomis  called  it  "a  cry  of 
the  nerves  for  better  blood."     It  may  occur  in  any  part  of  the  body. 

A  constant  auto-intoxication  leads  to  imperfect  nutrition  of  the  cellular 
elements  of  the  body.  The  first  to  suffer  are  those  of  the  lowest  order,  the 
fibro-elastic  tissues  which  outer  into  the  composition  of  the  various  fasciji?  and 
suspensory  ligaments  of  the  viscera.     As  these  cellular  elements  weaken  under 


720  RELATION'S  OF  RECTAL  DISEASE  TO  GENERAL  HEALTH. 

the  influence  of  auto-intoxication,  they  no  longer  possess  sufficient  power  to  sus- 
tain the  various  viscera  and  ptosis  occurs,  gastroptosis,  enteroptosis,  coloptosis 
— all  of  which  aggravate  the  condition  by  increasing  the  svmnathetic  shock  or 
depression  of  the  system,  by  decreasing  the  physiological  efficiency  of  these 
various  organs  by  diminishing  the  peristaltic  action  of  the  colon,  allowing  it  to 
assume  a  V-like,  or  hammock-like,  or  festooned  position,  wherein  fajcal  matter 
accumulates,  leading  to  further  intoxication.  Thus,  we  see  that  the  initial 
habits  of  constipation  which  may  at  first  result  merely  from  removable  causes, 
leads  to  a  genuine  vicious  circle:  that  is,  intoxication,  coloptosis,  fscal  reten- 
tion or  impaction,  which  in  its  turn  accentuates  the  auto-intoxication.  I  have 
at  present  a  case  in  point.  A  wealthy  merchant  of  Philadelphia,  sixty-five 
years  of  age,  had  suffered  for  many  years  with  symptoms  of  neurasthenia,  head- 
aches, foul  breath,  pains  in  back,  in  abdomen.  No  appetite,  vomiting.  He  had 
been  treated  by  several  prominent  clinicians  of  Philadelphia,  who,  having  recog- 
nized his  habits  of  constipation,  had  prescribed  purgatives,  etc.,  which  would 
relieve  him  awhile,  but  he  soon  fell  into  his  former  condition.  Fearing  that  he 
was  developing  a  malignant  trouble  in  the  abdomen,  requiring  an  operation,  he 
applied  to  me  for  help.  Clinical  and  X-ray  examination  failed  to  show  malig- 
nant disease.  Gastroptosis,  however,  was  diagnosed  and  also  a  festooned 
transverse  colon.  Purgatives  would  cause  an  overflow  from  the  transverse 
colon  into  the  descending  colon  or  rectum,  but  would  not  empty  the  transverse 
colon,  which  remained  full  after  the  purgative  as  well  as  before  it.  It  then 
occurred  to  me  that  my  patient  suffered  with  chronic  auto-intoxication  in  spite 
of  the  course  of  treatment  to  which  he  had  been  submitted  during  the  several 
years  past.  To  relieve  this  condition  I  practiced  on  him  the  operation  of 
appendicostomy,  whereby  a  fistula  of  the  caliber  of  the  appendix  was  made  in 
the  right  inguinal  region.  Through  this  fistula  he  introduces  an  ordinary  male 
catheter  and  washes  out  his  colon  two  or  three  times  a,  week,  removing  thereby 
all  possibility  of  absorption  of  putrefactive  fluids  and  gases  from  the  dependent 
colon.  A  snugly  fitting  abdominal  supporter  relieves  the  s}Tnptoms  of 
enteroptosis.  After  three  months  treatment  he  has  apparently  rejuvenated 
many  years  and  enjoys  excellent  health. 

My  firm  conviction  is  that  many  obscure  troubles  can  be  traced  to  an 
etiology  more  or  less  similar  to  the  case  just  related  and  more  attention  should 
be  directed  to  constipation  as  an  immediate  or  remote  cause. 

It  was  not  my  intention  to  give  an  exhaustive  study  of  any  one  phase  of  the 
many  diseases  of  the  rectum.  I  wished  in  a  very  concise  way  to  point  out  some 
of  the  remote  consequences  of  rectal  affections  based  upon  anatomical  physio- 
logical and  pathological  relations  of  this  organ  to  the  general  economy — an 
importance  not  sufficiently  given  to  the  subject ;  I  simply  meant  to  emphasize 
the  necessity  of  giving  the  rectum  and  its  functions  the  real  claim  it  has  in 
keeping  the  body  in  its  physiological  equilibrium  of  health,  preventing,  thereby 
many  subsequent  complications,  which  in  their  turn  may  be  incurable. 


CATARACT.  721 

CATARACT. 
(Two  Demonstration  Lectures.) 

By  CHARLES  A.  OLIVER,  A.M.,  M.D., 

PHILADELPHIA, 


(second  lecture) 


* 


Treatment. — The  removal  of  cataract  can  be  secured  only  by  operation. 
The  fact  that  a  few  undoubted  instances  of  spontaneous  disappearance  of  the 
condition  have  been  observed,  does  not  militate  against  the  force  of  this  state- 
ment. Eeported  instances  of  its  cure  by  means  of  drugs,  or  by  massage  are  mis- 
leading, and  usually  emanate  from  persons  or  institutions  that  are  devoted  to 
the  purpose  of  mere  monetary  gain.  It  is  probable  that  the  temporary  visual 
improvement  which  is,  at  times,  obtained  by  such  patients,  is  due  to  the  instilla- 
tion of  a  mydriatic,  for,  if  the  opacity  be  central,  dilation  of  the  pupil  may  be 
rendered  sufficiently  large  to  remove  the  iris  from  before  the  clear  periphery 
of  the  lens,  thus  permitting  vision  through  the  unobstructed  portion  of  the 
lens.  Unfortunately,  however,  the  improvement,  which,  at  best,  is  but  teni- 
porar}^,  lasts  only  during  the  time  of  the  effects  of  the  drug. 

The  development  of  cataract  may  be  retarded  by  careful  use  of  the  eyes, 
by  repeated  correction  of  any  existing  anomaly  of  refraction,  and  by  constant 
care  of  the  patient's  general  health.  In  this  connection,  it  is  interesting  to 
note  that  the  present  average  age  of  operated-upon  cases  in  this  portion  of  the 
world  (Philadelphia),  has  gradually  length.sned  nearly  a  decade  in  the  past 
half  century. 

Operations. — At  present,  ther*^  are  two  operative  methods  of  treating  cata- 
ract :  one  by  absorption  and  the  other  by  extraction.  The  first  is  applicable  to 
soft  cataracts  only,  and  is  consequently  limited  to  those  cases  that  are  found 
in  young  subjects.  It  has  for  its  object  the  bringiDg  of  tlie  aqueous  humor  into 
contact  with  the  lens-fibers  by  means  of  an  artificial  opening  made  in  the 
anterior  capsule  of  the  lens.  This  is  accomplished  by  entering  a  needle  tip, 
especially  prepared  for  the  purpose,  through  one  of  the  peripheral  quadrants 
of  the  cornea,  and  incising  those  portions  of  the  anterior  capsule  of  the  lens  tliat 
are  situated  opposite  tlie  pupillary  area. 

The  pupil  should  have  been  primarily  dilated  as  much  as  possible  with  some 
efficient  mydriatic.  Care  should  be  taken,  particularly  in  very  young  subjects, 
that  the  capsular  incisions  are  not  made  too  extensively,  and  that  they  do  not 
penetrate  too  deeply  into  the  lens-structure,  in  order  that  the  lens-mass  may 
not  be  disturbed  too  greatly.  For  developmental  reasons,  it  is  best  to  wait  until 
the  subject  is  about  a  year  old  before  any  operative  procedures  are  attem[)tcd. 

General  anesthesia  is  not  necessary.     The  instillation  of  a  few  drops  of  a 


*  Delivered  before  the  Junior  and  Senior  Classes  in  the  Woman's  Medical  College 
of  Pennsylvania.  (See  November  number  of  this  journal  for  the  first  lecture  of  this 
series. 


722  CATARACT. 

two-per-cent.-strength  solution  of  hydrochlorate  of  cocain  into  the  conjunc- 
tival cul-de-sac,  is  sufficient  to  render  the  operation  painless.  The  patient 
should  be  placed  in  a  recumbent  position  and  the  eyelids  should  be  separated  by 
a  speculum  or  by  an  elevator  and  the  fingers  of  an  assistant.  After  the  pro- 
cedure, a  few  drops  of  a  one-per-cent.-strength  solution  of  sulphate  of  atropiii 
should  be,  as  a  rule,  instilled  into  the  conjunctival  cul-de-sac,  and  iced  com- 
presses applied  until  i\\Q  eye  becomes  free  from  any  signs  and  s\Tnptoni3  of 
operative  irritation. 

If  no  complications  arise  and  there  be  sufficient  reason,  the  operation  can 
be  repeated  as  soon  as  the  absorption  of  the  loosened  cataractous  masses  seems 
to  have  been  accomplished  as  much  as  possible,  and  the  bulk  of  the  remaining 
lens-mass  itself  has  become  stationary.  The  incisions  in  the  second  and  in  any 
subsequent  operations,  may  be  made  more  freely,  as  the  danger  of  swelling  oi 
the  lens-fibers,  with  the  possibility  of  the  production  of  so-called  secondary 
glaucoma,  is  lessened ;  this,  in  measure,  being  due  to  the  diminished  volume  of 
the  lens-m.aterial  and  the  lower  grade  of  reaction.  If  there  is  a  dense  central 
mass,  it  had  better  be  removed  separately  through  a  peripheral  incision  while 
the  subject  is  under  the  influence  of  a  general  antEsthetic.  If  the  lens  sub- 
stance escapes  as  a  milky  fluid  when  the  capsule  is  cut,  it  should  be  immediately 
evacuated  through  a  small  peripherally  placed  corneal  incision.  In  uncom- 
plicated cases,  the  absorption  of  the  cataractous  masses  is  generally  accomplished 
in  eight  to  ten  weeks'  time.  In  some  instances,  the  lens  material  is  so  hard 
that  it  can  be  only  removed  safely  and  satisfactorily  in  its  entirety,  in  its 
capsule,  with  a  hook,  a  loop,  or  a  spoon. 

The  principal  complications  of  the  procedure  are  iritis,  and,  as  just  noted 
—secondary  glaucoma.  The  first  is  supposed  to  be  caused  either  by  pressure 
or  "chemical  irritation"  exerted  by  the  lens-matter  on  the  iris.  As  a  rule,  it 
may  be  prevented  by  keeping  the  pupil  well  dilated  with  some  powerful 
iridoplegic  or  cycloplegic  or  combination  of  cycloplegics.  If  the  second  form 
of  complication  appears,  as  much  of  the  lens-matter  as  may  be  proper  at  the 
time,  should  be  immediately  removed  by  extraction  through  a  linear  incision, 
and  the  softened  lens-masses  carefully  and  gently  coaxed  out  along  the  groove  of 
a  Daviel  spoon  or  a  grooved  spud.  Care  should  be  taken  to  avoid  ectogenous 
infection  from  the  related  and  adjacent  mucous  membranes. 

In  traumatic  cataract,  the  patient  should  be  placed  in  bed  as  early  as  pos- 
sible. Iced  compresses  should  be  applied  either  constantly  or  intermittently  to 
the  eye  in  order  to  reduce  inflammatory  reaction,  and  atropin  should  ht 
instilled  at  regular  inten-als,  so  as  to  prevent  the  occurrence  of  iridic  inflamma- 
tion. Ordinarily,  under  such  a  plan  of  treatment,  the  lens-substance  will  be 
gradually  absorbed  without  any  complicating  disturbances.  The  danger  of 
secondary  glaucoma  with  its  accompanying  signs  and  s\Tnptoms,  should  never  be 
lost  sight  of,  and  intra-ocular  tension  should  be  repeatedly  tested. 

In  operating  upon  shrunken  cataracts  or  upon  membranous  opacities,  it 
is  not  so  essential  to  provoke  absorption  of  the  remaining  cataractous  material 
as  it  is  to  obtain  a  clear  space  in  the  toughened  and  opaque  capsule  or  capsular 
and  lenticular  remains  through  which   vision  can  be  gotten.     The  operation 


CATARACT.  723 

is  ordinarily  performed  by  means  of  two  needle  tips  that  are  passed  rather 
obliquely  through  the  cornea,  one  near  to  the  nasal  side  of  the  cornea  and  the 
other  as  close  to  the  temporal  border  as  judiciously  possible.  This  done,  both 
are  pushed  backward  into  the  chosen  portion  of  the  mass  and  the  points  of  the 
instruments  separated  from  one  another  in  such  manner  that  no  traction  is 
exerted  upon  the  iris  and  the  ciliary  body,  thus  producing  a  clear  hole  in  the 
membrane.  If  this  be  impossible,  various  modifications  of  procedure  known  as 
iridotomy,  iridectomy,  capsulotomy  and  capsulectomy,  either  separately  or  in 
combination,  may  be  usefully  employed  in  different  ways  for  the  same  purpose. 

Simple  linear  extraction  is  applicable  to  the  removal  of  both  the  soft  and 
the  membranous  varieties  of  opacity.  It  is  preferred  by  many  operators  to  dis- 
cission, and  may  be  employed  in  any  case  in  which  the  lens-substance  is  suffi- 
ciently soft  to  flow  through  a  small  peripherally  placed  wound. 

The  operation  is  performed  as  follows :  After  a  speculum  has  been  inserted, 
or  the  eyelids  separated  by  an  assistant,  the  globe  is  grasped  by  a  fixation-for- 
ceps, and  the  point  of  a  keratome  or  the  tip  of  a  von  Graefe  knife  is  entered 
into  the  anterior  chamber  through  the  cornea,  usually  about  two  or  three  milli- 
meters' distance  from  the  limbus.  If  the  former  instrument  is  used,  its  tip 
is  passed  directly  through  the  corneal  membrane,  but,  as  soon  as  the  point  enters 
the  anterior  chamber,  the  cutting-blade  of  the  instrument  is  laid  upon  a  plane 
which  is  parallel  to  that  of  the  iris.  It  is  then  pushed  forwards  until  the 
corneal  woimd  has  obtained  a  length  of  several  millimeters.  It  is  then  slowly 
withdrawn,  in  order  to  prevent  the  aqueous  humor  from  coming  away  too 
quickly,  with  the  possibility  of  a  prolapse  of  the  iris.  If  a  von  Graefe  knife  is 
used,  the  movements  given  to  the  instrument  must  be  carefully  performed,  in 
order  to  avoid  wounding  the  iris-tissue.  The  point  of  a  cystitome  is  then  passed 
into  the  anterior  chamber  through  the  same  corneal  wound,  care  being  taken 
not  to  injure  the  iris.  Free  incision  into  the  anterior  capsule  of  the  lens  is 
then  made  with  it.  After  the  incisions  have  been  accomplished,  the  cystitome 
is  withdrawn,  and  the  loosened  lens-matter  is  evacuated  by  means  of  a  Daviel 
spoon  or  a  grooved  spud.  If  necessary,  the  operation  may  be  done  with  the 
addition  of  an  iridectomy.  In  this  event,  the  corneal  incision  is  made  nearer 
the  limbus  of  the  cornea  and  should  be  made  somewhat  longer.  After  the 
withdrawal  of  the  knife,  the  tips  of  an  iris-forceps  are  introduced  into  the 
anterior  chamber  and  a  fold  of  iris  directly  over  the  sphincter  of  the  pupil  is 
grasped  and  gently  drawn  through  the  wound.  The  extended  portion  of  the 
iris  is  then  cleanly  snipped  off  with  a  pair  of  fine  scissors.  Cystotomy  and 
extraction  of  the  lens-massings  then  follow,  as  just  detailed. 

As  it  frequently  happens  that  lens-matter  is  left  behind,  a  number  of  opera- 
tors practice  its  removal  by  suction-syringes  of  special  construction.  The  pro- 
cedures, however,  have  never  obtained  general  favor. 

The  operation  for  the  removal  of  a  hard  cataract  consists  essentially  of 
three  steps:  the  making  of  a  corneal  incision  of  sufficient  size  to  permit  of  the 
passage  of  the  lens;  tlie  performance  of  an  incision,  or  a  series  of  them,  into 
the  anterior  capsule  of  the  lens  (cystotomy)  in  order  to  allow  the  egress  of  the 
lens-matter  through  it;    and  the  delivery  of  the  lens-substance  from  the  eye- 


724  CATARACT. 

ball  itself.  Before  the  actual  operation  is  performed,  certain  preliminar}'  details 
should  be  carefully  attended  to.  Care  should  be  taken  that  the  conjunctival 
membrane  and  the  lacrymal  passages  are  free  from  the  presence  of  pyogenic  or 
other  harmful  bacteria.  A  general  warm  bath  should  be  given  to  the  patient 
the  night  before  the  procedure.  His  head  is  to  be  cleansed  with  castile  soap 
and  water.  The  bowels  should  be  relieved  by  a  gentle  laxative,  in  order  tliat 
they  may  not  be  disturbed  for  the  first  few  days  after  the  operation. 

The  instruments,  with  the  exception  of  the  knives,  which  should  be  im- 
mersed in  alcohol  for  at  least  twenty  minutes  prior  to  their  use,  should  be 
boiled.  After  their  cleansing  has  been  completed,  they  should  be  kept  in  a 
tray  of  alcohol,  during  the  entire  operation,  being  dipped  for  a  few  moments  in 
a  tray  of  sterile  water  just  as  they  are  being  picked  up  for  use.  Care  must  be 
exercised  not  to  use  any  differentiating  anilin  dye  for  either  the  immersion  or 
the  cleansing  fluids  when  they  contain  bichlorid  of  mercury,  as  the  staining 
materials  may  injure  the  epithelium  and  the  deeper  structures  of  the  cornea. 

The  patient  having  been  properly  prepared  and  the  field  of  operation  hav- 
ing been  cleansed  and  excluded  from  external  contamination  for  a  couple  of 
hours  previously  by  a  few  turns  of  a  roller  bandage,  the  eyebrows,  eyelashes, 
eyelids,  and  adjacent  parts  should  be  thoroughly  washed  with  a  saturated  solu- 
tion of  boric  acid.  The  lids,  whenever  possible,  should  be  gently  everted  and 
the  upper  and  the  lower  cul-de-sacs  flushed  with  the  same  character  of  solution. 
Several  drops  of  a  two-per-cent.-strength  solution  of  hydrochlorate  of  cocain 
are  then  introduced  into  the  conjunctival  sacs  at  five-minute  intervals,  for 
about  fifteen  minutes  before  the  operation,  care  being  taken  that  the  eyelids  are 
kept  closed  and  that  a  clean  towel  is  thrown  over  the  field  of  operation.  If 
possible,  the  patient  should  lie  flat  on  his  back  in  the  bed  that  he  is  to  occupy. 
If  circumstances  do  not  permit  of  this,  he  should  be  placed  upon  some  form 
of  operating  chair  or  table.  The  source  of  light  should  be  situated  so  that 
there  shall  be  a  field  of  uniform  illumination  upon  the  exact  points  to  bo 
operated  upon.  If  the  sui-geon  be  ambidextrous,  he  may  place  himself  in  front 
of  the  patient  or  behind  him  in  accordance  with  comfort  and  existing  circum- 
stances. A  trained  assistant  should  be  present  and  assume  such  a  position  that 
he  may  be  able  to  hand  the  instruments  to  the  surgeon  or  receive  them  from  him 
with  such  skill  and  rapidity  that  the  operator  may  be  able  to  keep  his  vision 
fixed  upon  the  field  of  operation  during  the  successive  stages.  Prior  to  any 
procedure,  it  is  well  for  the  surgeon  to  speak  kindly  and  quietly  to  the  patient 
for  a  few  moments  to  gain  his  confidence,  and  at  the  same  time  inform  him  of 
certain  movements  of  the  eyes  that  may  be  necessary  during  the  operation. 
The  patient  should  be  cautioned  against  holding  his  breath  and  straining,  and 
should  be  told  to  resist  all  desire  to  close  his  eyes  forcibly.  By  these  few 
injunctions,  quietly  and  authoritatively  given,  the  most  intractable  subjects  may 
be  rendered  obedient ;  the  soothing  words  thus  given,  often  bearing  fruit  to 
the  surgeon  a  hundred-fold. 

All  these  minor,  but  essential,  preliminaries  being  satisfied,  the  eyelids  are 
to  be  separated  by  a  wire  lid-elevator  held  in  the  hands  of  a  skilled  assistant, 
who  is  capable,  if  necessary,  to  momentarily  remove  the  instrument  without 


CATARACT.  725 

any  damage  to  the  organ.  The  patient  is  asked  to  look  dovm.  The  globe  is 
firmly  and  gently  held  in  any  desired  position  without  any  pressure  upon  it, 
by  lightly  taking  a  fold  of  bulbar  conjunctiva  about  two  or  three  millimeters' 
distance  from  the  corneal  limbus  within  the  grasp  of  a  fixation- forceps  held  with 
one  hand,  while  with  the  other  the  corneal  section  is  made.  The  knife  most 
generally  employed  is  the  one  which  was  introduced  by  von  Graefe.  It  con- 
sists of  a  long,  straight,  narrow  blade  converging  at  its  far  extremity  into  a 
sharp  point.  Unless  contraindicated,  the  primary  puncture  should  be  made 
just  within  the  margin  of  the  clear  cornea  at  the  outer  extremity  of  a  horizontal 
line,  which,  as  a  rule,  would  pass  three  millimeters  below  the  summit  of  the 
membrane.  The  cutting  edge  of  the  knife  should  be  situated  upward  and  its 
point  is  to  be  directed  towards  the  center  of  the  cornea.  After  the  tip  of  the 
knife  has  been  made  to  enter  the  anterior  chamber,  it  should  be  carried  directly 
across  the  chamber  and  re-entered  into  the  opposite  side  of  the  corneal  tissue 
at  any  point  desired.  The  section  is  then  completed  by  an  upward  movement 
of  the  knife  so  regulated  that  the  corneal  incision  is  kept  true  and  smooth 
throughout  its  entire  extent.  At  this  stage,  the  elevator,  in  uncomplicated 
cases,  is  removed,  and  not  used  again.  The  first  stage  of  the  operation  being 
completed,  the  surgeon  next  addresses  himself  to  the  performance  of  the  second 
stage,  or  that  of  capsulotomy,  or  so-called  cystotomy.  Directing  the  patient  to 
look  down  and  without  any  fixation-instrument  in  position,  if  possible,  he 
introduces  a  cystitome,  with  the  heel  of  the  cutting  point  first,  between  the 
lips  of  the  corneal  wound,  and  inser.ts  the  point  of  the  instrument  into  the 
anterior  capsule,  without  dislocating  the  lens,  in  such  a  manner  as  to  be  able 
to  make  a  series  of  as  free  incisions  as  he  may  believe  desirable  and  in  such 
positions  as  he  may  consider  the  best  in  each  individual  case.  These  having 
been  obtained,  the  cystitome  is  withdrawn  in  such  a  way  that  the  iris  is  not 
wounded  during  the  withdrawal.  The  avenue  of  escape  for  the  lens  having 
been  made,  it  remains  to  practically  complete  the  operation  by  the  performance 
of  the  third  stage,  or  that  of  the  delivery  of  the  lens.  The  surgeon  should, 
with  the  ball  of  the  finger-tip  of  one  hand  placed  upon  the  sclera  just  below 
the  lower  edge  of  the  cornea,  and  a  spatula  held  in  the  other  hand,  and  placed 
upon  the  sclera  just  above  the  corneal  section,  make  a  series  of  delicate,  yet 
steady,  upward  and  forward  pressures  and  counter-pressures  until  just  one- 
half  of  the  lens  has  engaged  in  the  corneal  wound,  when,  by  a  series  of  dex- 
trous and  slightly  tilting  and  upward  motions  from  side  to  side,  the  lens  will 
emerge  without  any  accident,  and  the  corneal  flap  will  fall  smoothly  into  place. 
Should  the  pupil  not  be  round,  and  should  any  lens  debris  be  seen,  the  eyelids 
are  to  be  closed  and  a  light  gentle  rotary  motion  is  to  be  made  upon  the  globe 
through  the  upper  eyelid  by  the  fingers.  If  there  be  any  cortex  remnants,  the 
stump  of  the  flap  is  to  be  slightly  depressed  and  the  masses  gently,  though  as 
completely  as  possible,  washed  out  of  the  anterior  and  the  posterior  chambers 
by  free  irrigation  from  varying  positions  with  warm  sterile  water  or  boric- 
acid  solution  carefully  projected  from  a  bulb  syringe  without  the  introduction 
of  any  instrument  into  the  chambers. 

After  the  lens  has  been  delivered,  and  everything,  such  as  blood-clots  and 


726  CATARACT. 

remaining  lens  material,  which  might  prevent  the  proper  union  of  the  lips  of 
the  corneal  woimd,  have  been  removed,  the  conjimctival  cul-de-sac  is  flushed 
clean  with  a  warmed  solution  of  boric  acid,  and  the  pupil  and  corneal  flap  are 
seen  to  be  in  proper  positions.  At  times,  it  may  be  well  to  instil  a  drop  or  two 
of  a  neutral  solution  of  sulphate  of  atropin  or  scopolamin.  The  eyelids  of 
both  eyes  are  then  gently  closed  and  held  together  by  a  couple  of  narrow  strips 
of  isinglass  plaster.     Xo  pressure  should  be  made  upon  the  eyeballs. 

A  few  carefully  adjusted  and  smoothly  applied  turns  of  gauze  bandage  over 
squares  of  sterilized  gauze  properly  covered  by  pledgets  of  absorbent  cotton 
should  be  made  without  disturbing  the  patient.  Strict  injunction  to  remain 
quiet  for  at  least  twenty-four  hours'  time,  should  be  given ;  any  necessary  desires 
being  properly  cared  for  by  competent  attendants. 

If  no  pain  be  complained  of,  the  dressings  should  be  allowed  to  remain  for 
a  period  of  twenty-four  hours,  at  the  end  of  which  time  they  can  be  removed, 
the  eye  inspected,  and  the  conjunctival  cul-de-sac  gently  flushed  with  a  warmed 
solution  of  boric  acid.  If  all  has  gone  well,  it  will  be  found  that  the  anterior 
chamber  has  re-established  itself  and  that  the  eye  is  quiet.  If  there  be  any 
injection,  if  the  pupil  is  small,  or  if  any  signs  of  inflammatory  reaction  be 
present,  a  drop  or  two  of  sulphate  of  atropin,  or,  better,  hydrochlorate  of 
scopolamin  should  be  instilled.  At  the  end  of  forty-eight  hours'  time,  the 
dressing  over  the  sound  eye  may  be  removed,  but  that  on  the  operated  eye, 
which  can  be  made  lighter,  should  be  allowed  to  remain  for  another  day,  when 
plain  smoked  glasses,  or,  if  unobtainable,  a  suitable  shade,  can  be  worn. 

To  prevent  tendency  to  prolapse  of  the  iris  and  to  favor  smooth  healing  of 
the  corneal  incision,  it  is  essential  that  the  patient  should  rest  absolutely  quiet 
in  bed  for  the  first  forty-eight  hours.  If  he  be  old  and  feeble,  more  latitude 
can  be  given  to  his  movements,  which  must  be  accomplished  by  the  aid  of  care- 
ful attendants.  At  the  end  of  the  second  day,  a  bed-rest  may  be  employed,  and 
on  the  third  day,  if  the  healing  has  been  uncomplicated  (which  under  the  cir- 
cumstances will  be  so  almost  without  exception)  the  patient  may  be  allowed 
to  sit  up.  Eor  the  first  twenty-four  to  forty-eight  hours,  the  diet,  which  is  to 
be  regularly  given,  should  be  liquid  and  semi-solid.  On  the  third  day,  the 
bowels  may  be  opened  by  a  gentle  laxative.  After  this,  liberal  nourishment  is 
to  be  ordered. 

The  operation  which  has  just  been  described,  is  what  is  known  as  simple 
extraction,  or  extraction  without  iridectomy,  and  should  be  the  one  chosen  in  all 
cases  in  which  there  are  no  contraindications. 

Many  operators,  however,  still  make  use  of  an  iridectomy  before  they  expel 
the  lens,  justly  claiming  for  this  method  that  it  enables  them  to  get  rid  of  any 
remaining  cortical  matter  much  more  readily.  They  also  state  that  it  prevents 
prolapse  of  the  iris  and  that  the  lens  may  be  extruded  through  a  smaller  wound. 
The  sole  difference  in  the  procedure  consists  in  removing  a  wedge-shaped  piece 
of  iris  tissue  after  the  corneal  section  has  been  made.  To  do  this,  the  tips  of  a 
pair  of  iris  forceps  are  introduced  through  the  corneal  section,  so  as  to  reach  the 
sphincter  pupillae.  The  inclosed  iris  tissue  is  gently  grasped  at  the  pupillary 
border  and  steadily  withdraMTi  through  the  center  of  the  wound.    The  extruded 


CATARACT.  727 

portion  is  excised  by  a  single  clip  mude  with  an  iris  scissors.  The  free  edges 
of  the  coloboma  thus  made,  are  smoothly  set  into  position  by  an  applicator  or 
a  flat  spatula. 

Those  who  prefer  extraction  without  iridectomy,  urge  that  the  advantages 
of  a  round,  mobile  pupil  make  it  the  operation  of  choice.  The  contraindica- 
tions are :  an  unripe  cataract,  increased  intra-ocular  tension,  a  small  rigid  pupil, 
and  an  intractable  patient. 

Despite  the  most  careful  precautions,  prolapse  of  the  iris  occurs  in  a  few 
cases  of  simple  extraction,  usually  appearing  during  the  first  twenty-four  or 
forty-eight  hours.  If  it  be  small,  it  may  be  let  alone.  If  it  be  considerable, 
and  the  lips  of  the  wound  remain  ununited,  the  line  of  corneal  incision  may  be 
opened  and  the  prolapsed  portion  of  the  iris  excised  with  an  iridectomy  scissors. 
Should  the  prolapse  occur  after  the  corneal  wound  has  united,  it  is  best  either 
to  wait  until  about  the  tenth  day,  when  a  formal  iridectomy  can  be  made,  or, 
if  not  productive  of  any  irritation,  and  the  pupil  is  not  much  distorted,  the 
prolapsed  portion  can  remain  undisturbed;  cicatrization  and  flattening  sub- 
sequently taking  place. 

In  certain  cases  in  which  complications  are  feared,  or  when  it  is  advisable 
to  hasten  the  maturity  of  the  cataract,  an  iridectomy  known  as  "preliminary 
iridectomy,"  can  be  performed  some  time  before  the  extraction  of  the  lens  is 
made.  If  it  is  desired  to  ripen  the  lens  after  the  iridectomy  has  been  per- 
formed, the  anterior  capsule  of  the  lens  may  be  triturated  with  a  spatula  either 
directly  applied  to  it  or  indirectly  through  the  cornea.  Rapid  swelling  and 
opacification  of  the  lens-fibers  are  said  to  follow  these  procedures,  and  the 
extraction  in  many  cases  is  made  possible  in  several  weeks'  time  after  the 
operation.  The  lens-substance,  however,  in  these  cases,  seem  to  have  obtained 
an  undue  degree  of  friability,  which  may  be  detrimental  to  its  complete  removal. 
In  this  class  of  cases  it  is  much  better  to  remove  the  lens  in  its  capsule. 

Eegular  removal  of  the  lens  in  its  capsule,  as  is  practiced  in  some  countries, 
is  a  preferred  and  invaluable  plan  of  procedure  in  the  hands  of  expert  operators. 

Many  surgeons  assert  that  simple  extraction  with  the  section  made  as  much 
as  possible  in  the  avascular  cornea  gives  the  best  results  in  "l)lack  cataract." 

Many  of  the  accidents  occurring  during  cataract  extraction  are  the  results 
of  want  of  skill.  Loss  of  vitreous  humor  can  be  often  prevented  by  the  cmjiloy- 
ment  of  fine  sutures  placed  in  the  cornea.  Should  the  sclera  collapse  during  a 
cataract  extraction  procedure,  the  lens  may  be  safely  removed  within  its  capsule, 
by  the  use  of  a  wire  loop.  Propulsive  haemorrhage  is,  fortunately,  a  rare  com- 
plication. It  is  almost  alwaj's  ruinous  to  the  63^6.  It  is  best  met  by  local  and 
general  methods  that  are  adapted  to  each  individual  case.  In  some  instances, 
it  happens  that  the  patient's  condition  is  such  that  a  successful  result  can 
scarcely  be  expected:  Deafness,  loss  of  self-control,  and  great  stupidity  are  all 
harmful  and  even  injurious  at  times. 

Although  planned  with  the  utmost  exactness,  it  sometimes  happens  that 
the  size  of  the  lens  is  misjudged  and  the  corneal  section  is  made  too  small.  If 
this  occurs,  the  incision  should  be  lengthened  by  one  or  two  clean  snips  witli  a 
pair  of  scissors.     Should  prolapse  of  the  vitreous  humor  take  place  during  the 


728  CATARACT. 

delivery  of  the  lens,  the  lens  had  better  be  carefully  removed  with  a  loop  or  a 
siMon,  and  if  necessary,  an  iridectomy  performed.  Prolapse  of  the  vitreous 
humor  occurring  after  the  extraction  of  the  lens,  is  much  less  serious  for  the 
time  being.  It  interferes,  however,  with  the  proper  coaptation  of  the  lips  of 
the  wound,  and  renders  inflammatory  reaction  more  liable;  while  in  many 
cases  it  becomes  a  most  harmful  factor  for  the  future  welfare  of  the  organ. 

Usually,  there  is  some  discomfort  for  a  few  hours  after  even  an  uncom- 
plicated operation.  Should  this  continue  and  be  at  all  marked,  the  bandage 
should  be  removed  and  the  eye  inspected.  At  times,  great  relief  can  be  obtained 
by  gently  pulling  down  the  lower  eyelid  and  permitting  exit  to  an  accumulation 
of  tears,  or  comfort  offered  to  the  patient  by  allowing  a  faultily  placed  eyelash 
or  lid  border  to  fall  into  proper  position.  If  the  eyeball  appears  the  least 
injected  and  the  slightest  signs  of  iris  reaction  be  present,  atropin  or  scopola- 
min  should  be  immediately  instilled  into  the  conjunctival  cul-de-sac.  If  sup- 
puration appears,  it  usually  takes  place  before  the  third  or  fourth  day,  and  is 
traceable  to  infection,  which  is  generally  due  to  lacrymal  disease.  In  a  few 
instances  it  is  dependent  upon  a  lack  of  nutrition  to  the  eye.  If  it  is  due  to 
the  former  complication,  it  is  best  combated  by  cauterization  of  the  edges  of 
the  corneal  incision,  the  instillation  of  sulphate  of  atropin,  and  the  use  of  hot 
compresses.  The  latter  form  is  best  cared  for  by  attention  paid  to  the  general 
health. 

Both  eyes  should  not  be  operated  upon  at  one  sitting,  in  order  that  any 
unforeseen  and  harmful  local  and  systemic  complications  arising  after  the  pri- 
mary procedure,  may  be  given  opportunity  for  avoidance  during  or  after  the 
second  operation.  Several  weeks'  interval  at  least  should  be  allowed  to  elapse 
between  the  two  extractions  even  when  the  cataracts  are  about  equally  mature. 

An  eye  whose  lens  has  been  removed  is  termed  aphakic.  In  order  to  render 
the  vision  of  such  an  eye  useful,  the  organ  must  be  provided  with  an  artificial 
lens  corresponding  in  relative  strength  to  the  crystalline  lens  that  has  been 
removed  from  it,  plus  a  cylindrical  one  to  correct  any  astigmia  which  may  result 
from  cicatrization  of  the  corneal  incision.  To  this  artificial  lens,  a  convex 
spherical  one  of  two  or  three  diopters'  strength  for  use  during  near  work,  must 
be  added.  As  cicatrization  is  generally  not  completed  until  from  four  to  six 
weeks  after  the  operation,  it  is  better  to  postpone  ordering  permanent  glasses 
until  after  that  period  of  time. 

No  case  can  be  considered  as  having  been  successfully  operated  upon  until 
at  least  three  to  six  months  after  the  actual  procedure. 

The  old  methods  of  depression  and  reclination  (couching),  have,  by 
reason  of  coarse  and  destructive  after  results,  been  practically  abandoned,  except 
in  a  few  appropriate  cases  among  the  old  and  the  decrepit,  in  whom,  for  example, 
sight  is  legally  required  for  a  brief  period  of  time. 

Erythropsia,  or  colored  vision  from  changes  in  color-perception,  is  said 
by  some  to  be  the  result  of  after-images.  It  may  follow  both  the  simple 
and  the  combined  forms  of  extraction,  especially  the  latter,  even  several  years 
after  the  procedure.  It  is  quite  common  in  some  countries — particularly  in 
India. 


ASSOC.  U.  S.  rEJSSION  EXAMINING  SURGEONS. 


CANCER. 


729 


Editorial 


TRANSACTIONS  OF  THE  NATIONAL  ASSOCIATION  OF  U.  S.  PENSION 
EXAMINING  SURGEONS. 

We  are  pleased  to  present  in  our  columns  this  month,  the  first  two  papers, 
one  by  Dr.  Ernest  Laplace,  Professor  of  Surgery  in  the  Medico-Chirurgical 
College,  and  the  other  by  Dr.  D.  J.  McCarthy,  Professor  of  Medical  Juris- 
prudence in  the  University  of  Pennsylvania,  of  the  series  read  at  the  last  annual 
meeting  of  the  National  Association  of  U.  S.  Pension  Examining  Surgeons, 
at  Atlantic  City.  The  balance  of  the  articles,  all  likewise  by  writers  of  excep- 
tional merit,  will  be  published  at  the  rate  of  two  or  three  per  month,  until  the 
supply  shall  have  been  exhausted.  These  papers  will  no  doubt  be  appreciated 
by  the  members  of  the  Association,  to  all  of  whom  the  Monthly  Cyclop.5:dia 
will  be  sent  as  long  as  the  articles  appear,  as  well  as  by  our  subscribers. 


C>?clop£edid  of  Current  I^iterature 


ACETONE    TREATMENT    OF   INOPERABLE 
CARCINOMA. 

Eight  cases  of  inoperable  carcinoma  are 
reported  by  the  writer,  treated  with  ace- 
tone as  first  used  by  Gelhorn.  The  pa- 
tients had  passed  beyond  the  reach  of 
any  radical  operation,  and  in  some  cases 
the  cancer  had  consumed  the  greater 
part  of  the  cervix  and  vagina.  The 
treatment,  in  a  simple  and  harmless  way, 
has  given  these  patients  a  period  of  com- 
parative ease  and  comfort.  The  treat- 
ment is  of  value  only  in  inoperable  cases, 
and  does  not  give  a  permanent  cure,  but 
ameliorates  the  chief  symptoms  and 
makes  the  life  of  the  patient  endarabk". 
The  terrible  odor,  discharge,  and  haemor- 
rhages are  all  relieved,  and  when  they  re- 
turn the  treatment  can  be  given  again 
without  harm.  The  haemorrhages,  septic 
absorption,  and  odor,  are  all  stopped. 
D.  W.  Tovey  (Medical  Record,  November 
6,  1909). 


ARTERIOSCLEROSIS,  NATURE  OF. 

The  dominant  primary  event  in  the 
arteriosclerotic  process — syphilitic,  senile, 
or  functional — is  a  localized,  or,  it  may 
be,  a  diffuse  weakening  of  the  arterial 
wall,  and  especially  of  the  media.  This 
induces  strain  on  the  remaining  coats; 
and,  if  this  be  not  excessive,  that  strain 
leads  more  especially  to  connective  tissue 
overgrowth,  and  the  development  of  the 
characteristic  lesions  of  arteriosclerosis. 
J.  Gr.  Adami  (American  Journal  Medical 
Science,  October,  1909). 

CANCER,  THYROIDECTOMY  AND. 

After  years  of  careful  observation  of 
many  cases  of  carcinoma  and  sarcoma,  in 
all  stages,  the  author  has  come  to  the 
conclusion,  looking  on  the  thyroid  gland 
as  the  flywheel  of  body  growth  and 
metabolism,  that  this  organ  is  very  liable 
to  overwork,  that  tlie  body  metabolism 
in  this  manner  is  liable  to  become  over- 


730 


CLUB  FOOT,  CURE  OF. 


ETHYL  CHLORID  AS  AN  ANAESTHETIC. 


driven,  and  that  so  the  thyroid  may  be 
a  causative  factor  in  the  origin  and  con- 
tinuation of  malignant  disease.  Holding 
these  views,  he  long  had  it  in  contempla- 
tion to  perform  more  or  less  complete 
excision  of  the  thyroid  in  inoperable 
carcinoma  as  the  best  means  of  elimina- 
ting or  ameliorating  a  disturbing  factor 
in  the  diseased  organism  of  the  carcino- 
matous. Five  cases  are  reported,  in 
which  this  was  done,  and  there  seems  to 
be  no  doubt  that  partial  removal  of  the 
thyroid  had  an  influence  on  these  ■ 
growths.  It  seems  to  have  a  deterrent 
effect  on  the  rate  of  growth  of  the  pri- 
mary tumor;  the  secondary  glands,  too, 
seem  to  be  favorably  affected,  as  in  these 
cases  there  was  a  softening  change  in  the 
glands,  and  they  were  much  less  painful. 
In  all  cases  the  pain  was  quickly  relieved. 
The  patients,  instead  of  losing  weight,  as 
they  were  doing  before  the  operation, 
put  on  weight.  Another  thing  noted  in 
all  these  cases  was  a  distinct  slowing  of 
the  rate  of  the  pulse.  The  second,  third, 
and  fifth  patients  were  operated  on  at  a 
much  earlier  date  than  the  first  and 
fourth,  and  it  would  appear  to  be  best 
to  intervene  as  early  as  possible,  not 
waiting  until  the  patient  is  too  low  and 
weak.  W.  Stuart-Low  (Lancet,  October 
16,  1909). 

CLUB  FOOT,  CURE  OF,  IN  INFANCY,  WITH- 
OUT OPERATION. 

Practically  all  cases  of  congenital  club 
foot  are  curable  without  operation,  if 
taken  in  hand  before  the  child  is  six  weeks 
old.  The  younger  the  infant  at  the 
time  of  instituting  treatment,  the  better. 
The  results  are  better  than  if  treatment 
is  postponed  until  operation  becomes 
necessary. 

The  routine  treatment  consists  of 
manipulation,  followed  by  a  plaster  band- 
age, every  two  weeks,  progressively  over- 


crowding the  foot;  as  soon  as  the  foot 
offers  no  resistance  to  overcorrection,  and 
maintains  the  normal  position  naturally, 
continued  manipulation,  a  tin  splint,  to 
be  worn  at  night,  or  a  brace,  if  the  child 
is  old  enough  to  walk.  Eelapses  are 
bound  to  occur  under  any  form  of  treat- 
ment, if  the  aftercure  is  neglected;  the 
patient  should  be  kept  under  close  ob- 
servation for  one  year  after  apparent 
complete  recovery.  Albert  Ehrenfried 
(Boston  Medical  and  Surgical  Journal, 
Xovember  18,  1909). 

DYSENTERY,  AMCEBIC,  TREATMENT  OF. 

The  rest-supportive  treatment,  consist- 
ing of  rest  in  bed,  a  milk  diet,  the  use 
of  mild  irrigations  and  bismuth  subni- 
trate  in  heroic  doses,  has  been  given  by 
the  authors  with  by  far  the  most  sat- 
isfactory results.  Surgical  interference 
is  indicated  if  the  improvement  does  not 
rapidly  follow  the  above-mentioned 
method.  W.  E.  Decks  and  W.  F,  Shaw 
(Medical  Record,  Xovember  13,  1909). 

ETHYL  CHLORID  AS  A  GENERAL  ANES- 
THETIC. 

Ethyl  chlorid  is  regarded  by  the  writer 
as  a  comparatively  safe  and  reliable  gen- 
eral anaesthetic,  which  is  most  suited  for 
operations  for  removal  of  adenoids  and 
tonsils  in  children.  It  is  simple  of  ad- 
ministration, and  does  not  require  an  ex- 
pert, or  one  of  large  experience,  to  give  it. 
The  patient  is  under  the  influence 
quickly,  is  out  almost  immediately  on 
completion  of  the  operation;  there  are 
no  unpleasant  or  dangerous  effects  from 
its  use,  either  during  or  after  the  opera- 
tion. This  anaesthetic  is  not  only  espe- 
cially applicable  in  operations  in  the 
throat,  but  should  be  used  in  most  other 
operations  performed  on  children.  When 
the  inhaler  is  kept  over  the  patient's  nose 
and  mouth,  he  can  be  kept  under  the 


HEART  MASSAGE. 


LUPUS  VULGARIS. 


731 


ansesthetic  as  long  as  desired.  It  is  only 
when  that  is  removed  that  the  patient 
regains  consciousness  more  quickly  than 
with  other  anaesthetics.  When  long  op- 
erations are  necessary  on  the  nose  or 
throat,  the  writer  advised  first  putting 
the  patient  under  ethyl  chlorid,  and  then 
continuing  deep  anaesthesia  with  ether, 
using  the  drop  method.  E.  M.  Sill 
(Medical  Record,  October  23,  1909). 

HEART  MASSAGE  IN  SURGERY. 

Heart  massage  is  an  established  method 
of  resuscitation,  ten  successful  cases  hav- 
ing been  reported  by  ten  operators. 
Heart  failure  is  rarely  primary  in  chloro- 
form anaesthesia,  it  is  therefore  essential 
that  respiration  be  invoked  by  artificial 
means  in  conjunction  with  heart  massage. 
Artificial  respiration  alone  will  not  in- 
augurate heart  contractions  nor  maintain 
blood-pressure.  The  best  results  have 
been  obtained  by  the  subdiaphragmatic 
method.  The  most  frequent  indication 
for  its  use  is  in  chloroform  narcosis  with 
cessation  of  respiration  and  circulation. 
In  other  conditions  of  heart  failure, 
secondary  to  respiratory  failure  and  not 
dependent  upon  organic  changes  in  the 
heart,  the  method  is  applicable.  Fur- 
ther use  of  the  method  will  widen  its  field 
of  usefulness. 

The  possibility  of  resuscitation  bears 
a  definite  relation  to  the  time  that  has 
elapsed  between  the  cessation  of  the  heart- 
beat and  massage.  The  briefer  the  inter- 
val the  more  rapid  is  the  response  to 
heart  massage.  C.  S.  White  (Surgery, 
Gynaecology  and  Obstetrics,  Oct.,  1909). 

HERNIA.  ETIOLOGY  OF. 

Protest  is  made  against  the  current 
household  practice  of  applying  an  inelas- 
tic band  to  the  infants'  abdomen,  as  it 
tends  to  push  the  viscera  downward,  and 
to  produce  a  tendency  to  hernia.     Nor- 


mally, the  infant  abdomen  forms  an  in- 
verted cone,  as  it  were,  with  the  largest 
circumference  near  the  costal  arch;  the 
inguinal  region  is  comparatively  empty 
of  contents,  the  walls  are  depressible. 
With  the  tight  ''belly-band"  the  viscera  are 
forced  down  into  this  region,  and  the  ab- 
dominal wall  here  is  stretched  taut,  and 
offers  resistance  to  the  finger.  The 
writer  does  not  accept  the  possibility  of 
a  truly  congenital  hernia;  the  hernia  is 
always  acquired  later,  he  asserts,  and  the 
conditions  produced  by  the  traditional 
''belly-band"  favor  its  production  when 
the  region  is  exposed  to  mechanical  stress 
in  later  life.  C.  Widmer  ( Correspondenz- 
Blatt  fiir  Schweizer  Aerzte,  October  1, 
1909 ;  Journal  of  the  American  Medical 
Association,  November  6,  1909). 

LTIPUS  VULGARIS,  NEW  PRINCIPLES  FOR 
TREATMENT  OF. 

The  writer  gives  an  illustrated  de- 
scription of  a  method  of  treating  lupus 
which  is  simple,  and  yet  seems  to  cure 
in  a  comparatively  short  time.  In  spite 
of  its  numerous  disadvantages,  excision 
of  the  lupous  patch,  he  declares,  is  still  the 
most  effectual  method  of  treating  lupus, 
but  he  believes  that  all  its  essential 
features  can  be  obtained  by  undermin- 
ing the  patch  under  local  anaesthesia. 
Two  parallel  incisions  are  made  through 
the  skin  down  to  the  muscles,  allowing 
the  entire  skin  to  be  separated  from  the 
muscles  below,  to  form  a  bridge  flap. 
Iodoform  gauze,  dipped  in  Peruvian  bal- 
sam is  then  drawn  through  beneath  the 
flap  to  prevent  its  growing  down  again. 
The  lupous  patch  is  tlms  medicated  from 
above  and  below,  and  the  lupus  soon 
heals,  leaving  apparently  normal  skin,  ex- 
cept that  it  is  inclined  to  be  more  pig- 
mented than  normal.  The  tint  has  grown 
constantly  more  and  more  like  that  of 
normal    skin    in    the   course   of   the   six 


732     NAUSEA  FOLLOWING  AN/ESTHESIA. 


PLEURISY  AND  PNEUMONIA. 


months  his  patients  have  been  under  ob- 
servation. This  undermining  treatment 
has  been  applied  in  four  cases  to  date, 
but  only  for  lupus  on  the  limbs.  There 
is  no  bleeding,  no  need  for  assistance, 
no  danger,  and  no  defect  is  left.  The 
after-treatment  is  painless,  the  gauze  not 
being  changed  until  granulation  has  oc- 
curred over  the  whole  raw  surface,  which 
is  generally  in  about  a  week;  the  Peru- 
vian balsam  facilitates  the  removal  of  the 
gauze,  and  the  cure  is  complete  in  one  or 
two  months.  The  cosmetic  result  is  ex- 
cellent, and  extensive  areas  can  be  treated 
in  this  way,  as  desired. 

The  conditions  in  the  face  are  less 
favorable  for  the  undermining  technic, 
and  for  this  the  writer  has  been  ex- 
perimenting with  magnesium  arrows, 
stuck  through  into  the  subcutaneous  tis- 
sue, such  as  he  uses  in  treatment  of 
cavernous  angioma  not  adapted  for  ex- 
tirpation. The  result  in  the  lupus  cases 
was  prompt  and  beneficial.  An  opening 
is  made  with  a  tenotome,  and  the  little 
stick  of  magnesium  is  pushed  from  di- 
rectly under  the  patch  or  into  its  depths. 
This  method  has  boon  applied  in  only 
one  case,  but  with  the  exception  of  a  few 
isolated  nodules,  the  extensive  lupus,  al- 
most covering  the  face,  has  healed,  leav- 
ing merely  a  firm,  reddish  scar.  Payr 
(Deutsche  Zcitschrift  fiir  ('liirurgie,  Bd. 
C,  S.  1-G45;  Journal  of  the  American 
Medical  Association,  November  13, 1909). 

NAUSEA  FOLLOWING  AN.ffiSTHESIA,  PRE- 
VENTION OF. 

The  author  ui'gcs  the  patient  to  drink 
an  abundance  of  water  for  two  days  pre- 
ceding the  operation,  and  receive  saline 
enemas  every  few  hours  after  the  opera- 
tion, to  lessen  the  thirst,  nausea  and 
shock.  When  not  contraindicatod  by  the 
operation,  it  is  sometimes  advisable  when 
ether  mucus  has  been  swallowed  to  allow 


the  patient  to  drink  all  the  water  desired 
as  soon  as  consciousness  returns ;  if  this  is 
vomited,  the  stomach  is  washed  out,  and  if 
it  is  retained  the  ether  mucus  is  diluted. 
Another  method  advocated  by  Kelly,  that 
is  often  successful  in  preventing  nausea 
and  vomiting,  following  ether  narcosis, 
is  to  wash  out  the  stomach  thoroughly  at 
the  conclusion  of  the  operation,  and  then 
leave  in  the  stomach  six  ounces  of  a  satu- 
rated solution  of  magnesium  sulphate. 
L.  F.  Watson  (Old  Dominion  Journal  of 
Medicine  and  Surgery,  September,  1909), 

NITROGLYCERIN  IN  CHRONIC  MYOCAR- 
DITIS. 

In  the  experience  of  the  author,  one- 
drop  doses  of  1-per-cont.  solution  of  nitro- 
glycerin, given  with  digitalis,  every  two 
or  three  hours,  are  practically  inert;  but, 
if  from  34o  to  ^o  of  a  grain  be  given 
every  minute,  for  twenty  or  thirty  doses, 
brilliant  results  will  be  obtained,  days  be- 
fore the  effect  of  digatilis  can  possibly  be 
expected.  In  oedema  of  the  lungs  the 
toleration  for  this  drug  is  most  extraor- 
dinary', and  relief  from  dyspnoea  is  uni- 
formly obtained  before  the  physiologic 
effects,  such  as  flushing  of  the  face  and 
throl)bing  headache,  are  produced.  Two 
cases  of  myocarditis  are  reported,  with 
cardiac  failure  and  oedema  of  the  lungs, 
one  witliout  and  tlie  other  with  valvular 
lesion,  in  which  nitroglycerin  was  of  the 
greatest  service.  S.  B.  Ward  (Albany 
Medical  Annals,  jSTovember,  1909). 

PLEURISY  AND  PNEUMONIA  IN  INFLAM- 
MATION OF  INTRA-ABDOMINAL  OR- 
GANS. 

Pleurisy  and  pneumonia  are  much  more 
frequently  caused  by  infectious  diseases 
within  the  abdomen  than  has  hitherto 
been  believed.  The  right  side  is  more 
frequently  involved  than  the  left.  It  is 
the  duty  of  surgeons  to  constantly  bear 


POSTOPERATIVE  PSYCHOSES. 


RENAL  TUBERCULOSIS. 


733 


this  in  mind,  and  carefully  examine  their 
patients  for  pleural  and  pulmonary  com- 
plications during  the  course  of  intra- 
abdominal affections,  and,  after  opera- 
tions. The  frequency  of  abdominal  in- 
fection as  a  cause  of  pleural  effusion  and 
pneumonia  calls  for  a  painstaking  exam- 
ination of  the  intra-abdominal  organs  in 
each  case  in  which  the  signs  of  intra- 
thoracic inflammation  exist.  The  infec- 
tion of  the  pleura  and  lung,  following 
intra-abdominal  inflammation  is  conveyed 
through  the  diaphragm,  omentum,  and 
mesentery,  by  way  of  the  lymphatics. 
"Ether  pneumonia"  does  not  exist,  and 
the  term  anaesthetic  pneumonia  should  be 
entirely  discarded.  If,  during  the  course 
of  an  intra-abdominal  affection,  pneu- 
monia or  pleurisy  should  be  discovered, 
they  constitute  no  contra-indication  to 
operation,  but,  on  the  other  hand,  ur- 
gently call  for  drainage  of  the  primary 
focus  of  suppuration.  G.  Paul  LaEoque 
(International  Journal  of  Surgery,  Sep- 
tember, 1909). 

POSTOPERATIVE   PSYCHOSES. 

Postoperative  psychoses,  seen  often  in 
childhood  and  the  aged,  occur  also  in 
women  in  the  prime  of  life,  most  fre- 
quently between  the  ages  of  thirty- 
five  and  forty-five.  Anaesthesia,  physical 
shock,  the  kind  or  severity  of  the  opera- 
tion are  not  effective  causative  agents. 
Infection,  auto-intoxications,  drug  in- 
toxication, are  important  factors,  but 
there  are  many  psychoses  entirely  inde- 
pendent of  them.  Mild  aberrations  of  a 
transitory  nature  are  very  common.  An 
unstable  nervous  system,  and  especially 
undue  anxiety  and  worry  about  the 
operation  and  the  trouble  which  leads  to 
the  operation  are  the  most  potent  fac- 
tors in  bringing  about  profound  nervous 
sequelae.  Prognosis  is  favorable.  Pro- 
phylaxis consists  in  quieting  and  reassur- 


ing the  patient.  In  this  connection,  the 
nurse  is  most  important.  Care  should 
be  taken  to  avoid  any  legal  or  forensic 
complications  by  frankly  dealing  with 
the  family  from  the  onset  of  the  trouble. 
H.  A.  Kelly  (Surgery,  Gynecology  and 
Obstetrics,  November,  1909). 

RENAL  TUBERCULOSIS,  DIAGNOSIS  OF. 

The  subjective  symptoms  of  renal  tu- 
berculosis are  usually  those  of  a  cystitis. 
A  causeless  cystitis,  or  a  cystitis  that  be- 
gan so  imperceptibly  that  the  patient 
cannot  definitely  fix  the  time  when  it 
really  started ;  a  cystitis  in  a  person  who 
had  the  history  of  former  tuberculous 
troubles;  a  cystitis  that  is  rebellious  to 
treatment,  or  especially  painful;  all 
these  should  make  one  suspicious  that  he 
may  have  to  do  with  a  tuberculous  pro- 
cess. The  development  of  tuberculosis 
in  guinea-pigs  that  have  been  inoculated 
with  the  sediment,  demonstrates  abso- 
lutely the  tuberculous  nature  of  a  urinary 
infection,  as  does  also  the  finding  of  red- 
staining,  acid-fast  bacilli  in  catheter 
specimens  of  the  urine.  We  are  prac- 
tically sure  of  the  tuberculous  nature  of 
a  process  when  we  can  find  no  organisms 
in  a  purulent  urine. 

The  rarity  of  tuberculous  cystitis,  ex- 
cept as  it  is  secondary  to  renal  tubercu- 
losis, warrants  us  in  almost  making  a 
diagnosis  of  renal  tuberculosis  whenever 
a  tuberculous  urine  is  found. 

The  most  accurate  way  of  telling  which 
kidney  is  involved  is  by  cystoscopic  ex- 
amination. The  changes  in  the  bladder 
about  the  ureteric  orifice,  or  the 
changes  in  the  ureter  itself  will  usually 
make  clear  which  kidney  is  involved. 
Occasionally  these  changes  may  not  be  de- 
cisive, and  catheterization  of  the  ureters 
may  be  necessary  to  dctenninc  whicli  is 
involved.  One  should  usually  catlietcrize 
the   supposedly   well   ureter,   to   demon- 


734 


TUBAL  PREGNANCY. 


TYPHOID  FEVER. 


strate  definitely  that  the  process  is  uni- 
lateral, and  that  the  well  kidney  is  func- 
tionally competent.  The  danger  of  this 
is  very  small  when  it  is  carefully  done. 
A.  L.  Chute  (Boston  Medical  and  Surg- 
ical Journal,  November  4,  1909). 

TUBAL  PREGNANCY. 

The  diagnosis  of  tubal  pregnancy  be- 
fore hemorrhage  has  occurred  is  impos- 
sible, according  to  the  writer.   The  diag- 
nosis of  a  tubal  mole  from  some  other 
conditions  is  difficult,  but  nearly  all  the 
conditions  which  may  reasonably  be  mis- 
taken for  a  tubal  mole  equally  require 
prompt  operation.     Slight  haemorrhage 
from  perforation  of  a  pregnant  tube  is 
often  accompanied  by  death  of  the  foetus 
and    rapid    absorption    of    the    effused 
hlood.       When     great     intraperitoneal 
hemorrhage  has  taken  place  from  per- 
foration of  a  pregnant  tube  operation  is 
urgent  and  simple.     The  danger  from 
delay  in  operating  is  greater  than  that 
coming    from   the    inexperience    of   the 
operator,  if  only  he  be  one  who  under- 
stands antisepsis.    After  perforation  of 
a  pregnant  tube  the  amnion  may  pro- 
trude into  the  peritoneal  cavity,  and  the 
child  grow  free  among  the  bowels,  cov- 
ered only  by  its  amnion.    In  that  case 
the  placenta,  as  it  grows,  may  become 
implanted    on    almost    any    abdominal 
viscus,  and  cover  a  large  area.    In  such 
cases  it  is  probable  that  after  the  pri- 
mary preparation  the  mother  runs  hardly 
any  risk  imtil  after  the    death    of  the 
child.     In  such  cases,  operation  while 
the  child  is  viable  is  an  extremely  dan- 
gerous one,  and  is  more  dangerous  the 
more  advanced  the  pregnancy.  The  dan- 
ger is  from  hemorrhage  resulting  from 
separation  of  the  placenta.    The  experi- 
ence of  more    recent    operators    shows 
that  it  is  nevertheless  safer  to  remove 
the  placenta  than  to  leave  it    to  come 


away.  The  methods  of  preventing  such 
haemorrhages  which  have  proved  suc- 
cessful are:  (a)  the  removal  when  pos- 
sible of  the  viscera  to  which  the  placen- 
ta is  attached;  and  (b)  extensive  proph- 
ylactic ligature  of  the  arteries  supplying 
the  placental  site.  If  the  operation  is 
postponed  until  after  the  death  of  the 
child,  some  time  afterward  the  circu- 
lation through  the  placenta  ceases,  and 
it  becomes  thrombosed.  If  an  operation 
is  now  done  the  placenta  can  be  peeled 
off,  without  hemorrhage,  and  the  opera- 
tion is  simple  and  safe.  When  the 
pregnancy  is  underneath  the  peritoneum 
there  is  danger  of  rupture  at  any  period 
of  the  pregnancy.  Therefore  in  this 
case  the  sooner  operation  is  done  the 
better.  G.  Herman  (Clinical  Journal, 
July  7,  1909). 

TYPHOID  FEVER  OF  SHORT  DURATION. 

Some,  at  least,  of  the  fevers  which 
formerly  would  have    been    considered 
febricula  or  simple  continued  fever  are 
in  reality  typhoid  fever.    In  the  present 
state  of  our  knowledge  it  would  be  rash 
to  assert  that  all  mild  fevers  in  this  lati- 
tude, for  which  no  other  cause  can   be 
found,  are  typhoid  in  nature,  but  tlie 
writer  asserts  that  there  have  been  no 
series  of  cases  of  mild  fevers  in  Bellevue 
Hospital  in  the  last  five    years    which 
could  not  be  proved  to  be  either  typhoid 
fever  or  some  easily  recognized  disease, 
as   bronchitis,   gastro-intestinal    disturb- 
ance, etc.    This  investigation  also  brings 
out  the  fact  that  a  great  deal  of  confusion 
exists  in  the  literature  concerning  the 
milder  forms  of  typhoid  fever,  and  em- 
phasizes the  urgent  need,  from  the  epi- 
demiological standpoint,  of  a  more  thor- 
ough study  of  these  forms.  ISTo  statistics 
have    been    accumulated,    since    exact 
methods  of  diagnosis  have    come    into 
general  use,  to  show  the  relative  propor- 


ULCERATION  OF  THE  RECTUM. 


BOOK  REVIEWS. 


735 


tion  of  the  mild  to  the  severe  cases  of 
typhoid  fever.  Doubtful  cases  should 
be  treated  as  typhoid  fever  until  the 
cause  of  the  disease  can  be  found.  \Yar- 
ren  Coleman  (American  Journal  Medi- 
cal Sciences,  June,  1909). 

ULCERATION  OF  THE  RECTUM,  CHRONIC. 

Patients  who  are  suffering  from  ulcer- 
ative colitis  should  be  treated  by  medical 
means  in  the  earlier  stages  of  the  dis- 
ease, because  many  of  the  patients  with 
sporadic  cases  can  be  cured,  if  they  are 
taken  in  hand  at  once.  The  general 
treatment  is  to  prevent  the  accumulation 
of  discharges  in  the  rectum,  to  soothe 
the  irritated  state  of  the  bowel,  and,  if 
possible,  to  prevent  the  multiplication  of 
the  infective  micro-organisms  in  the  mu- 
cous membrane.  The  patient  is  to  be 
kept  in  bed,  and  a  drachm  dose  of 
magnesium  sulphate  administered  every 
hour,  with  the  object  of  promoting  a  flow 
of  l}Tnph  toward  the  intestinal  walls, 
which  will  perform  the  same  function  as 
does  the  increased  flow  of  blood  through 
an  inflamed  part,  produced  by  the  appli- 
cation of  a  fomentation.  The  rectum  is 
also  to  be  well  flushed  out  daily  with 


an  enema  of  boric  lotion,  or  salt  solu- 
tion, at  a  temperature  of  105°  F.,  while 
every  other  day  the  enema  is  altered  to 
one  containing  10  grains  of  silver  nitrate 
in  a  pint  of  distilled  water.  If  these 
means  fail,  they  should  not  be  persevered 
with  in  the  hope  of  improvement,  as  the 
condition  is  progressive,  and  becomes 
more  serious  with  lapse  of  time,  but 
should  be  discarded.  Mercury  may  then 
be  given  in  the  form  of  calomel,  in  a 
single  dose  of  10  grains,  followed  by 
three  to  five  grain  doses,  if  the  drug 
seems  to  cause  improvement.  Ten  grain 
doses  of  tannigen  are  sometimes  useful, 
and  chlorodyne  is  serviceable  when  there 
is  much  tenesmus.  It  can  be  given  in 
10  minim  doses,  with  20  grains  of  bis- 
muth oxycarbonate  in  an  ounce  of  chloro- 
form water.  Some  advise  the  use  of 
quinine  in  a  single  15  grain  dose  of 
quinine  sulphate,  repeated  in  four  hours, 
if  the  temperature  has  not  fallen,  fol- 
lowed by  5  grain  doses  until  the  symp- 
toms subside.  Enemata  containing  1  or 
2  drachms  of  salol  dissolved  in  oil  of 
turpentine,  and  added  to  each  pint  of  hot 
water  also  highly  recommended.  D'Arcy 
Power  (Practitioner,  August,  1909). 


8ool{  Reviews 


Experimental  Piiaemacology.    A  Laboraton'  Guide  for  tlie  Study  of  the  Phj'siologic  Action 

of  Drugs.     By  Charles  Wilson  Greene,  Ph.D.,  Professor  of  Physiology  and  Piiarmacolog}', 

University    of    Missouri.      Third    Edition,    with    37    Illustrations.      Seventy-six    Pages. 

Philadelphia:      P.   Blakiston's  Son  &   Co.,    1909.     Price,   Cloth,   $1.00. 

In  this,  the  third  revised  edition  of  his  useful  work,  Dr.  Greene  emphasizes  the  need 

of  laboratory  instruction,   if   proper  understanding  of  the   principles   of   pharmacology   are 

to  be  acquired.     He  gives  explicit  directions,  suitable  to  the  needs  of  the  student,   for  the 

carrying  out  of  the  various  experiments  he  advocates.     lie  leaves  the  decision  as  to  the  results 

obtained  to  the  experimenter,  however,  a  disadvantage,   in  our  opinion.     On  the  whole,  the 

book    is    an    excellent    one,    when    the    work    of    the    student    is    carefully    super\'ised    by 

instructors. 

The  Psychic  Treatment  of  Nervols  Disorders.  By  Dr.  Paul  Dubois,  Profes.sor  of  Neuro- 
pathology at  the  University  of  Berne.  Translated  by  Smith  Ely  JellifTe,  M.D.,  Ph.D.. 
Visiting   Neurologist,   City   Hospital;     Instructor   in   Materia   Medica   and   Therapeutics, 


736  BOOK  REVIEWS. 

Columbia  University,  Isew  York;  and  William  A.  White,  M.D.,  Superintendent  Govern- 
ment Hospital  for  the  Insane,  Washington,  D.  C;  Professor  of  Nervous  and  Mental 
Diseases,  Georgetown  University.  Sixth  Revised  Edition.  Octavo;  485  Pages.  New 
York:     Funk  &  Wagnalls  Company,  1909.     Price,  $3.00,  net. 

The  sixth  edition  of  Dr.  Dubois's  work  sustains  the  enviable  reputation  acquired  by 
its  predecessors.  The  author  is  not  only  a  psychologist  of  the  first  order,  but  also  a  com- 
petent neurologist.  As  a  result,  the  work  not  only  instructs  the  physician  who  wishes 
to  become  familiar  with  the  rapidly  developing  psychotherapy,  but  it  gives  him  a  sound 
foundation  for  the  proper  appreciation  of  any  pathological  condition  that  may  underlie  a 
mental  aberration  he  might  be  called  upon  to  treat.  It  is  admirably  translated,  and  placed 
on  the  market  at  a  very  reasonable  price. 

Epocii-makixg  Contributions  to  Medicine,  Surgery,  and  the  Allied  Sciences;  Being 
Reprints  of  those  Communications  which  first  Conveyed  Epoch-making  Observations  to 
the  Scientific  World,  together  with  Biographical  Sketches  of  the  Observers.  Collected 
by  C.  M.  B.  Camac,  M.D.,  of  New  York  City.  Octavo  of  435  Pages,  with  Portraits.  W. 
B.    Saunders   Company,   1909.     Artistically   Bound,    $4.00,   net. 

Dr.  Camac  has  rendered  a  veritable  service  to  the  profession  by  supplying  it  with  the 
present  work.  It  is  not  only  of  value  from  the  historical  standpoint,  but  it  constitutes 
a  valuable  reference  book,  where  authors  may  find  exact  information  concerning  the  initial 
steps  of  each  great  medical  advance.  Lister  (antisepsis),  Harvey  (the  circulation  of  the 
blood),  Auenbrugger  (percussion  of  tlie  chest),  Laennec  (auscultation  and  the  stethoscope), 
Jenner  (vaccination  against  small-pox),  Morton  (anesthesia),  and  Holmes  (puerperal 
fever),  are  the  m.asters  and  their  immortal  contributions  given  in  the  present  volume.  It 
is  to  be  hoped  that  the  author  will  continue  his  labors  with  Pasteur,  Koch,  and  tlie  many 
other  innovators  of  modern  times,  as  his  subjects.  The  work  is  beautifully  gotten  up  and 
illustrated;     much  credit  is   due  to  the  publishers  on   this  score. 

Medical  Sociology.     A  Series  of  Observations  Touching  Upon  the  Sociology  of  Health   and 
the  Relations  of  Medicine  to  Society.     By  James  Peter  Warbasse,  M.D.,  Surgeon  to  the 
German  Hospital,  Etc.     New  York  and  London:     D.  Appleton  &  Company,  1909. 
It  is   a  good   sign  when   members  of  the   medical   profession   write   systematically   upon 
the  more  sociologic  questions  involved  in  their  calling.     In  the  book  before  us  we  have,  from 
the  pen  of  a  w-ell-known   surgeon  of   Brooklyn,   twenty-five  chapters   dealing  with   the   soci- 
ology of  health,  and  thirty-five  upon  medical   science  and  medical   art.     It  is  an  eminently 
sane,   wholesome  presentation  of  a   number  of  cognate   topics,  and   well   worth   perusal,   not 
only  by  all   physicians,  but  by  intelligent  laymen,  as  well. — J.  M.  T. 

Further  Advances  in  Physiology.  Edited  by  Leonard  Hill,  ]\I.B.,  F.R.S.  Cloth;  440 
Pages,  with  Illustrations.  New  York:  Longmans,  Green  fc  Co.,  1909.  Price,  $4.20. 
The  present  work  is  the  second  in  a  series  in  which  the  recent  advances  in  physiology 
are  set  forth  by  a  number  of  physiologists,  each  taking  a  special  subject.  While  the  first 
volume  dealt  with  metabolism,  secretion,  and  excretion,  mainly,  the  present  volume  deals 
especially  with  circulation,  respiration,  the  neuro-muscular  sj'stem,  and  vision.  Benjamin 
Moore  studies  the  equilibrium  of  colloid  and  crystalloid  in  living  cells;  Martin  Flack,  the 
heart;  Thomas  Lewis,  pulse  records  in  their  relation  to  the  events  of  the  human  cardiac 
cycle;  Leonard  Hill,  the  vascular  system  and  blood-pressure;  Arthur  Keith,  the  mechanism 
of  respiration  in  man;M.  S.  Pembrey,  the  physiology  of  muscular  work;  N.  H.  Alcock, 
the  physiology  of  nerve:  Joseph  Shaw  Bolton,  cortical  localization  and  the  functions  of 
tlie  cerebrum. 

Although  the  book  is  primarily  intended  for  workers  in  physiology,  it  is,  nevertheless, 
of  value  to  the  pathologist  also,  since  it  gives  him  a  deeper  view  into  many  functions 
which  should  be  clearly  understood  in  their  normal  state,  to  render  the  recognition  of 
abnormal  conditions  possible. 


Monthly    Cyclopaedia 

AND 

Medical   Bulletin 


Published  the  Last  of  Each  Month 


Medical  Bulletin  Section 


Vol.  II.  PHILADELPHIA,  DECEMBER,   1909.  No.  12. 


Clinical   Lecture 


URAEMIA.' 


By  JOHN  V.  SHOEIMAKER,  M.D.,  LL.D., 

Professor  of  Materia  ]\Iedica,  Therapeutics,  Clinical  Medicine,  and  Diseases  of  the  Skin, 
in  the  Medico-Chirurgical  College  and  Hospital  of  Philadelphia. 

Gextlemex  :  This  patient,  age  64  years,  was  brought  into  the  hospital 
by  the  police  patrol  last  evening,  with  a  history  of  having  found  him  on  the 
pavement  in  an  unconscious  condition.  We  have  since  learned  from  his 
family  that  he  has  never  had  an  attack  of  epilepsy  or  of  syncope  at  any  time,  but 
that  during  the  last  week  he  complained  daily  of  headache,  languor,  dizziness, 
anorexia,  constipation  and  slight  oedema  of  the  ankles  and  feet.  However, 
he  pursued  his  regular  occupation  as  a  blacksmith;  which  he  has  followed 
for  over  twenty-five  years.     We  were  unable  to  ascertain  his  family  liistory. 

Social  History. — lie  is  married,  and  is  the  father  of  four  healthy  sons  and 
two  daughters.  His  habits  have  not  always  been  very  good.  Nearly  every 
Saturday  afternoon  and  evening  he  went  to  the  saloon  and  returned  to  his 
home  in  an  intoxicated  condition.     His  favorite  drink  being  whiskey. 

Hospital  Records. — On  admission  his  pulse  was  120  per  minute;  tem- 
perature 100%°  F. ;  respiration,  .'30  per  minute.  The  skin  felt  hot  and  dry  to 
the  touch ;  respiration,  panting  in  character  witli  a  ui'inifcrous  odor  on  the  breath 
and  slight  muscular  twitching  of  the  arms  and  legs.  The  pupils  were  noi'mal 
and  reacted  to  light.  The  patient  was  cathcterizod  and  nine  ounces  of  urine 
were  removed,  which  showed,  on  examination,  a  large  amount  of  albuniiii  and 
many  hyaline  and  granular  casts. 

Diagnosis. — 'J'hc  diagnosis  of  nra}mia  in  this  particular  case  is  quite  easy. 
But  in  cases  whore  no  history  can  be  obtained,  and  tlie  symptoms  are  more 


Delivered  in  the  Clinical  Amphitheatre  Medico-Cliinirgical   ]Io.s|)ital. 

(737) 


738 


UR.EMIA. 


obscure  it  is  often  very  difficult  to  make  a  correct  diagnosis.  In  tliis  patient 
the  symptoms  are  quite  typical  and  the  history  strongly  points  to  uraemia.  A 
differential  diagnosis  of  apoj^lexy,  opium  poisoning,  meningitis,  hysteria, 
alcoholism  and  diabetic  coma  should  be  made  in  all  such  cases.  We  have,  for 
your  convenience  in  studying  these  different  diseases,  placed  on  the  blackboard 
the  tables  showing  the  most  important  differential  points. 
Differential  Diagnosis : — 


Uncmia. 

1.  History  of  Bright's  disease. 

2.  Coma  follows  convulsions. 

3.  No  paralysis. 

4.  Albumin  and  casts  in  urine. 

5.  CEdema. 

0.  Pupils  normal. 

Uraemia. 

1.  History    of    Bright's    disease. 

2.  Coma  preceded  by  other  symptoms. 

3.  Pupils  normal. 

4.  CEdema. 

5.  Respiration  hurried. 

UrcPmia. 

1.  History    of    Bright's    disease. 

2.  QCdema. 

3.  Waxy  countenance. 

4.  Albumin  in  urine. 

5.  Delirium  usually  mild  or  absent. 

Urcrm  ia. 

1.  History    of    Bright's    disease. 

2.  Albumin  in  urine. 

3.  Reflexes  absent. 

UrcFmia. 

1.  Presence  of  albumin   in   urine. 

2.  Waxy  countenance. 

3.  Urinous  odor. 

4.  (Edema. 

Urwmic  Coma. 

1.  History    of    Bright's    disease. 

2.  Albumin  in  urine. 

3.  Skin  is  not  harsh  and  dry. 

4.  No   characteristic  emaciation. 


Apoplexy. 

1.  History  of  disease  of  the  arteries. 

2.  Coma  precedes  convulsions. 

3.  Paralysis  and  spasm  of  one  side. 

4.  Normal  urine. 

5.  No  oedema. 

6.  Pupils  unequal  or  dilated. 

Opium  Poisoning. 

1.  No  previous  history. 

2.  Coma  comes  on  gradually. 

3.  Pupils  contracted  and  do  not  respond  to 

light. 

4.  No  oedema. 

5.  Respiration  slow,  deep,  and  full. 

Meningitis. 

1.  History  of  injury  or  disease. 

2.  No  oedema. 

3.  Flushed  face. 

4.  Normal  urine. 

5.  Wild  delirium. 

Hysteria. 

1.  History  of  hysteria. 

2.  Urine  pale  and  abundant. 

3.  Reflexes  pale  or  exaggerated. 

Alcoholic  Coma. 

1.  Absence  of  albumin. 

2.  Flushed  face. 

3.  Alcoholic  odor. 

4.  No  oedema. 

Diaiefio  Coma. 

1.  History  of  diabetes. 

2.  Sugar  in  urine. 

3.  Skin  is  harsh  and  dry. 

4.  Emaciation. 


Etiology  and  PatlioJogi/. — Urfemia  is  a  condition  which  is  caused  by  the 
retention  of  toxic  substances  within  the  blood  which  ought  to  be  excreted  by 
the  kidney.  "We  have  as  yet  not  separated  these  substances  and  their  nature  is 
therefore  obscure.  This  condition  is  most  common  in  Bright's  disease  but  it 
may  occur  in  gout,  scarlet  fever,  typhus  fever,  yellow  fever  and  cholera  in. 


PAINFUL  HEEL.  739 

which  the  kidneys  and  the  blood  may  be  affected.  The  etiology  and  pathology 
of  this  condition  is  based  upon  theories.  It  is  claimed  by  authorities  that  it  is 
due  to  the  presence  in  the  blood  of  urea,  uric  acid,  ammonium  carbonate  and 
water.  These  poisonous  substances  increase  the  toxicity  of  the  blood-serum 
and  this  is  responsible  for  the  sjTnptoms  manifested.  Another  theory  advanced 
is  that  uraemia  is  due  to  anaemia  or  oedema  of  the  brain.  This  theory  explains 
the  nervous  S}'mptoms  such  as  coma  and  convulsions. 

Treatment. — After  studying  the  condition  of  the  patient, — and  we  had 
sufficient  reason  to  suspect  uraemia, — we  placed  the  patient  in  an  electric  pack 
and  put  on  the  tongue  three  grains  of  calomel  which  he  soon  swallowed.  An 
hour  in  the  electric  pack  produced  profuse  perspiration,  and  partial  conscious- 
ness was  restored.  The  electric  pack  was  then  removed  and  the  patient  wrapped 
in  heavy  woolen  blankets,  which  kept  up  the  perspiration.  He  also  had  a 
copious  action  of  the  bowels.  Mild  diuretics  were  now  indicated  and  we  gave 
him  a  dram  each  of  liquor  ammonii  acetatis  and  spiritus  setheris  nitrosi  in  a  cup 
of  hot  water  every  two  hours.  H3^odermatically,  he  received  one  minim  of 
spiritus  glycerylis  nitratis  every  three  hours  to  lower  the  increased  arterial 
tension.  This  drug  also  acts  as  a  valuable  diuretic  in  these  cases.  Liquor 
ferri  et  ammonii  acetatis  may,  in  a  few  days,  be  employed  as  a  diuretic  and 
tonic.  The  following  combination  in  a  capsule  serves  me  well  in  such  nephritic 
cases  as  this  one: — 

IJ   Spiritus   glycerylis   nitratis tnxx, 

Sparteinse    sulphatis     gr.  v. 

Phenylis    salicylatis     3j. 

Misce.     Fiant  capsulse  No.  xx. 
Signa:     One  capsule  four  times  daily. 

The  diet  must  consist  of  liquids  only,  and  milk  should  be  the  chief  article 
of  food  for  the  next  few  months. 

Prognosis. — By  careful  treatment,  rest  in  bed,  with  proper  diet,  I  believe 
the  patient  will  entirely  recover  from  this  attack.  Usually  these  patients  die 
in  less  than  two  years.  Many  die  within  four  months'  time  after  an  attack 
of  uraemia. 


Original  Articles 


PAINFUL   HEEL. 
By  C.  F.  WAHRER,  M.D., 

FORT  MADISON,  IOWA. 

Under  this  affection  we  may  find  quite  a  variety  of  pathological  condi- 
tions, some  of  a  gouty  and  rheumatic  origin  in  the  patients  beyond  early  life, 
but  in  the  younger  we  may  as  well  look  for  gonorrliceal,  and  in  the  ill  nourished, 
for  neuralgic  troubles. 


740  PAINFUL  HEEL. 

The  patients  thus  alHicted  complain  of  an  intensely  acute  pain  which  in 
some  is  almost  unbearable,  in  others  to  that  degree  as  to  necessitate  the  use  of 
canes  or  even  crutches. 

The  average  pliysician  looks  at  once  for  flat-foot  or  some  form  of  talipes, 
calls  it  rheumatism,  or  a  sprain,  does  it  up  in  tight  bandages,  enforced  with 
the  numerous  liniments,  only  to  be  defeated,  just  as  his  predecessor  was,  and 
in  nearly  all  such  cases  there  was  a  predecessor  or  two.  Such  patients  usually 
have  been  the  rounds,  before  they  come  to  you,  and  I  want  to  put  you  on  your 
guard,  so  when  they  come  to  you,  they  will  find  one  doctor  prepared  for  them. 

Had  it  not  been  for  my  Osier  when  my  first  patient  came  to  me,  I  should 
have  met  my  Waterloo,  but  Osier  was  the  only  one  in  my  then  rather  good 
library  of  excellent  authors  who  mentioned  the  matter  of  painful  heel.  Tie 
classed  it  then  under  the  neuralgias,  though  mentioning  that  it  was  often 
rheumatic  or  gouty.  Older  authors  spoke  of  these  affections  as  pododynia, 
plantar  neuralgias,  including  rather  too  much. 

Eeceiitly  Isaac  D.  Steinhard,  in  the  i\rarch  27,  1909,  Neiv  York  Medical 
Journal,  reports  thirty  cases  in  which  he  claimed  a  clear  etiology  in  all  of  his 
cases. 

In  the  young  whites  he  generally  found  gonorrhoea  the  cause,  while  in  the 
older  patients  he  found  gout  and  rheumatism  the  more  frequent  cause.  A  few 
were  due  to  tramnatism.  In  practically  all  he  found  an  exostosis  in  shape  of 
a  spicula  of  bone,  which  caused  the  pain,  when  stepping  upon  the  foot.  Of 
course  he  employed  surgical  means  for  relief,  which  in  his  cases  was  usually 
successful. 

jVIy  experience  with  six  cases  was  not  similar  to  his,  as  all  my  cases  proved 
to  be  neuralgic  in  origin,  were  so  treated,  and  all  recovered.  None  relapsed, 
the  first  case  occurring  twenty  years  ago,  the  last  one,  one  and  one-half  years  ago. 
This  may  be  a  mere  matter  of  coincidence,  which  for  the  purposes  of  my  paper 
does  not  matter,  as  every  reader  of  this  article  must  make  his  own  diagnosis, 
my  main  object  being  to  put  you  on  your  guard,  when  these  cases  come  to  you, 
so  you  will  not  be  diagnostically  asleej),  or  napping. 

jMay  I  digress  a  moment  here  and  preach  a  sermonette  on  not  only  the 
importance  of  a  correct  diagnosis,  but  of  the  great  importance  of  what  are 
wrongly  called  "little  things."  There  are  no  such  things  as  little  things  in 
medicine.  One  such  a  little  thing  as  a  gonococcus  can  raise  the  devil  for 
several  generations,  if  you  will  just  let  him  alone  a  little  while,  just  don't 
diagnose  him  for  a  week  or  two.  and  he  will  be  a  million  legions,  yea  he  will 
be  as  many  as  were  promised  the  tribes  of  Israel,  as  the  sands  of  the  seashore, 
and  then  some.  A  wart  may  be  a  very  insignificant  thing  unless  it  is  a  can- 
cerous wart,  then  it  ceases  to  be  little,  it  will  interest  you  more  than  3-ou  can 
manage,  1  fear.  jSTowhere  does  the  scriptural  saying  mean  more  than  in 
medicine— "He  that  is  faithful  in  little  things,  etc."     So  back  to  our  heel. 

If,  after  careful  examination,  we  find  we  have  a  gonorrha3al  origin,  let  it 
so  be  treated.  If  gouty  or  rheumatic,  then  anti-arthritics  will  be  the  remedies, 
in  which  galvanism  will  play  no  small  part.  If  the  exostosis  is  found,  surely 
no  other  remedy  will  take  the  place  of  the  knife  and  chisel.     But  if  we  find,  as 


PAINFUL  HEEL.  741 

I  did,  in  all  iny  cases,  that  they  are  neuralgic,  wliicli  from  my  limited  experi- 
ence, and  rather  extensive  experience  of  others,  as  found  in  the  literature,  then 
we  must  institute  anti-neuralgic  treatment,  which  is  about  as  difficult  a  thera- 
peutic feat  as  we  have. 

If  the  patient  is  ani^mic,  under-nourished,  worked  down,  nervous,  suffer- 
ing from  indigestion,  constipation,  and  the  usual  round  of  complaints  of  the 
neuralgics,  then  it  takes  a  full  knowledge  of  the  patient's  condition  to  be  able 
to  know  what  is  best  to  do. 

But  here,  as  well  as  in  many  other  worrisome  cases,  industry  and  the 
exercise  of  good  judgment  will  help  you  out,  and  finally  bring  your  patient 
sufferer  relief.  Before  resorting  to  positive  remedial  measures,  attention  must 
be  given  to  the  patient's  shoes,  if  they  are  well-fitting,  if  the  heels  are  broad 
and  square,  or  if  the  patient  has  a  slovenly  habit  of  walking,  whether  there  are 
any  calluses  or  corns  or  other  lesions  on  the  feet.  All  these  little  details  have 
their  full  weight  in  insuring  success  or  their  neglect  be  followed  by  failure. 

Now,  having  the  preliminary  matters  all  attended  to,  we  may  proceed  to 
our  neuralgic  heel.  Out  of  my  patients  only  one  was  a  man,  the  others,  women. 
The  first  two  were  sisters,  one  married,  the  other  single.  The  man  was  about 
fiftA'-six  years  old.  The  last  one  a  young  lady  of  twenty.  Not  one  of  these 
was  normally  nourished.  All  were  more  or  less  anaemic.  And  every  one 
was  habitually  constipated.  To  begin  the  treatment  all  were  given  castor  oil, 
one  ounce  every  morning  and  then  gradually  diminished  until  only  one  easy 
mushy  stool  was  had  every  day.  It  is  claimed  that  castor  oil  is  itself  an  anti- 
neuralgic,  and  even  if  not,  it  will  aid  to  clear  out  the  more  or  less  septic  canal, 
and  thus  aid  digestion,  and  also  help  to  assimilate  the  other  drugs  given. 
Galvanism  should  be  at  once  applied  and  continued  two  or  three  times  a  week 
until  cured.  Acetanilid  combined  with  quinine,  arsenic,  strychnine  and  iron 
generally  docs  effective  work,  when  given  in  rather  generous  doses.  Of  course 
each  patient's  dose  must  be  determined.  A  course  of  treatment  like  this  will, 
in  the  majority  of  cases  soon  bring  relief,  and  by  persistence,  a  cure.  Slight 
relapses  are  common,  but  continued  treatment  will  again  be  successful.  The 
co-operation  of  the  patient  is  aljsolutcly  necessary.  This,  owing  to  the  previous 
failures  with  other  treatments  is  not  always  easy  to  obtain,  because  the  average 
patient  with  this  trouble  is  usually  somewhat  skeptical.  I  wish  to  emphasize 
that  the  border  line  between  the  rheumatisms  and  the  various  neuralgias  is  not 
always  etiologically  nor  pathologically  as  distinct  as  we  could  wish,  and  it  is 
not  always  the  fault  of  the  practitioner  because  the  diagnosis  is  not  pedantically 
exact.  So  when  in  doubt,  and  success  in  treatment  not  very  brilliant,  it  is 
sometimes  well  to  give  both  anti-rheumatics  and  anti-nouralgics,  because  some 
of  these  serve  equally  well  in  both  affections. 

This  may  be,  or  appear  as,  a  confession  of  weakness,  but  tlie  best  of  us 
must  confess  to  this  at  times.  If  any  one  is  inclined  to  sneer,  lot  him  a?k 
himself  what  are  the  exact  indications  for  the  various  forms  of  nasal  catarrh, 
or  how  many  cases  of  hay  fever  ho  has  cured,  not  to  mention  his  therapeutic 
resources  in  carcinoma  and  sarcoma. 

Remember  this  is  by  no  means  to  imitate  the  shotgun  idea  of  putting  in  a 


742      TESTBIONIES  ON  THE  MUMMY  GROVE  POTTERIES  OF  OLD  PERU. 

little  of  everything  so  as  to  make  sure  that  something  may  hit  something,  for 
such  methods  are  to  be  deprecated.  But  my  recommendation  is  to  be  used 
only  in  such  cases  where  it  is  reasonably  certain  that  the  neuralgia  is  of  a 
rheumatic  nature,  or  that  the  two  diseases  are  co-existing  in  the  same  patient. 

For  instance,  we  know  that  galvanism  is  very  useful  in  both  neuralgia  and 
rheumatism;  so  are  acetanilid,  some  of  the  salicylates,  gelsemium,  salicin,  and 
indirectly,  arsenic,  strychnine  and  the  chalybeates. 

In  practically  all  these  patients  we  have  depraved  condition  of  the  general 
health,  and  we  will  make  but  indifferent  progress  if  we  do  not  at  once  begin  to 
look  to  that,  and  so  inform  the  patient.  Therefore,  the  very  first  thing  to  do  is 
to  clean  out  the  alimentary  canal  and  keep  it  clean.  To  this  end  the  regula- 
tion of  the  diet  may  contribute  much,  the  main  thing  in  these  cases  is  usually 
to  get  these  people  to  eat  enough,  as  most  of  them  are  underfed,  and  metabolism 
is  perverted.  Otherwise  stated  we  must  take  the  broader  view  in  these  special 
cases,  and  not  look  to  drugging  alone  to  do  for  us  what  only  a  most  comprehen- 
sive and  wise  management  can  accomplish. 

If  we  had  a  specific  for  each  symptom,  then  the  reign  of  the  lazy  physician 
would  soon  be  inaugurated.  And  if  so,  the  laity  would  soon  commit  the  symp- 
toms and  their  remedies  to  heart  and  physicians  would  soon  pass  to  the  rear  and 
patent  medicine  houses  and  the  embossed  tablet  with  its  cousin,  the  blown-in- 
the-glass-only-genuine  panacea  would  rule  the  world.  To  the  industrious 
physician  who  is  willing  to  read  and  delve  in  medical  lore,  these  rare  things 
will,  in  time,  become  an  open  book.  There  are  only  a  few,  we  hope  who  are 
still  looking  for  remedies  for  dropsy,  when  they  should  be  making  a  urinalysis 
looking  for  renal  incompetence,  or  using  the  stethoscope  for  cardiac  compensa- 
tion; of  those  who  are  asking  the  correspondence  editor  of  the  penny  medical 
journals  for  remedies  to  cure  leucorrhcea,  when  they  should  examine  their 
patients  for  endometritis  or  look  for  a  latent  gonorrhcea.  I  say,  there  are  only 
a  few  such,  but  when  you  look  for  tliem,  you  would  be  surprised  how  many 
there  still  are. 

So  don't  forget  when  a  patient  comes  to  you  with  a  painful  heel  that 
there  is  no  special  remedy  for  it,  until  you  have  found  the  exact  pathology  for 
that  particular  heel. 

MEDICAL  AND  SURGICAL  TESTIMONIES  ON  THE  MUMMY  GROVE 
POTTERIES  OF  OLD  PERU. 

By  ALBERT  S.  ASHMEAD,  M.D. 

(Continued  from  November  issue.) 

Herrera  says,  "that  the  greater  part  of  these  dances  are  of  idolatrous 
kind,  because  thus  they  venerate  their  idols  and  huacas.  For  these  dances 
they  have  different  instruments,  some  flutes  and  a  kind  of  bugle;  others  like 
tambourines ;  others  like  horns ;  and  all  used  to  sing,  one  or  two  chanting  their 
verses  and  the  rest  repeating  and  striking  their  drum,  holding  each  other  by 


TESTIMONIES  ON  THE  MUMMY  GROVE  POTTERIES  OF  OLD  PERU.     743 

the  hands  and  crying  out  the  first ;  and  men  and  women  responding ;  and  at 
other  times,  drinking  the  wine  which  was  made  from  com  and  other  things, 
until  they  fell  down  drunk." 

"Of  these  superstitious  cures,  vestiges  still  remain  in  the  mountains  of 
Aina  (Ayacucho)  and  of  Chanchamayo.  There  are  patients  coming  from  there 
who  had  a  disease  like  Uta,  or  Apaicha,  inoculated  after  a  contact  with  the 
nests  of  a  mosquito,  whose  venom  originates  the  evil.  The  best  remedy  to  cure 
the  patient  is  to  take  the  nests  and  roast  them  and  pulverize  them  and  apply  on 
the  Uagas  (ulcers)  of  this  Uta,  then  collect  the  powder  which  falls  to  the 
ground  and  scatter  it  to  the  wind,  saying  at  the  same  time:  'Go  away  quick, 
Apaicha,  I  have  not  done  more  than  to  break  your  pot,  go  quickly.'  "  Compare 
this  with  what  Herrera  says  of  the  pious  priests,  who  have  science  to  cure 
and  divine.  "In  order  to  assist  a  patient  they  have  a  thousand  farces ;  grasp- 
ing a  stick  of  a  tree  which  no  one  but  the  pious  one  knows  its  virtue,  they  rub 
it  in  the  windpipe,  pounding  and  even  drawing  blood,  they  sigh  and  roar,  and 
shake  and  kick,  and  make  a  thousand  squeamishnesses ;  they  sweat  them  for 
two  hours  and  at  the  end  they  make  in  the  mouth  like  phlegm,  very  thick,  and 
a  little  hard  ball  and  black  in  the  middle  of  it,  which  those  of  the  house  of  the 
diseased  carry  to  the  field,  and  throwing  it  away  say:  'Go  there.  Demon, 
Demon,  go  there/  " 

And  among  the  Indians  of  Hispaniola  is  related  the  same:  "They  go  to 
the  door  of  the  house,  shut  it  and  call:  'Quick  to  the  mountain,  or  whither 
you  wish,  and  they  blow  and  join  hands  and  shake  the  legs,  and  shut  the  mouth, 
and  turn  and  hold  hands.*  " 

Eegarding  the  debated  question  of  the  anthropomorphous  mutilated 
huacas,  there  are  among  others,  two  capital  points;  which  from  any  point 
of  view,  have  not  yet  been  fully  explained.  First,  why  the  amputation  of 
members  according  to  the  artists  who  sculptured  the  huacas,  are  limited  to 
the  tibia-tarsal  articulation,  while  the  corroding  disease,  for  which  the  amputa- 
tion must  have  been  done,  might  attack,  and  in  effect  does  as  well  the  legs,  the 
forearms  and  arms  and  even  the  hands  which  are  frequently  lost  by  Indians 
when  a  snake  stings  them  on  the  fingers;  as  their  companions  always  cut  off 
the  hand  as  well  as  the  foot  when  snake-wounded  (see  Gumilla).  And  second, 
why  do  those  clay  vessels,  so  well  illustrating  the  blind,  the  lame,  etc.,  never 
model  examples  of  amputations  of  superior  members? 

I  have  myself  expressed  the  opinion  in  some  of  my  writings,  that  an 
arm  was  not  represented  amputated  on  those  potteries  because  the  pot  really 
represented  the  soul  of  the  body  buried  with  it.  Believing  in  immortality  as 
these  people  did,  they  buried  food  and  di'ink  with  the  body  to  support  it, 
nourish  and  quench  its  thirst,  while  on  its  four  days'  journey  to  paradise. 
Therefore,  drink  of  some  kind  was  put  in  the  pot  and  buried  with  the  loved 
one.  Now,  I  said,  if  the  departed  lacked  arms  in  the  grave,  unless  artificial 
ones  on  the  image  of  the  pot  were  supplied,  he  could  not  reach  out  for  the 
drink  and  food  supplied  for  him.  Therefore,  if  the  buried  one's  arms  had 
been  cut  off  during  life  they  were  sure  to  put  arms  on  the  diseased  image  on 
the  pot. 


744      TESTIMONIES  ON  THE  MUM.MY  GROVE  POTTERIES  OF  OLD  PERU. 

To  this  Dr.  Palmer  reiDlied  (Perhaps  if  it  had  heeii  his  pleasure  to 
find  a  hiiaca  without  arms,  as  we  present,  it  would  take  some  value  away  from 
the  graceful  hypothesis  of  the  illustrious  American  physician)  :  "I  show  here," 
he  says,  "an  example  of  a  handless  one,  and  even  when  it  might  be  in  doubt 
that  it  is  by  amputation,  there  would  still  remain  the  fact  of  its  being  a  model 
without  superior  members,  which  are  necessary  to  wait  on  a  deceased  in  his 
tomb.  Even  if  the  huaca  did  not  exist,  there  is  still  another  fact  which  would 
invalidate  the  hypothesis  of  Dr.  Ashmead.  It  is  this:  The  Indians  never 
would  think  it  necessary  to  put  in  their  tombs  anthropomorphous  huacas  in 
the  manner  of  servants,  as  all  the  historians  concede  that,  when  they  give 
sepulture  to  a  person,  there  entered  jointly  with  them  servants,  so  that  they 
could  continue  to  serve  them  as  they  had  in  life." 

Cieza  de  Leon  says,  of  the  Collas :  "When  natives  die  in  the  Collao,  they 
cry  with  great  tears  many  days,  the  women  having  in  their  hands  pilgrim 
staffs,  and  girdles  on  their  bodies,  and  the  kinspeople  of  the  deceased  people 
carry,  each  one  what  he  can,  of  ewes,  lamlis  and  corn,  as  well  as  other  things, 
and  before  they  bury  the  dead  one,  they  kill  the  ewes,  and  put  the  Asaduras 
(not  in  dictionary)  in  the  places  that  they  have  in  the  apartments.  On  the 
days  that  they  cry  for  the  deceased  before  they  have  buried  him,  of  their  own 
corn  or  of  that  which  the  kinsmen  have  offered,  they  make  much  wine  and 
beverage  to  drink,  and  if  they  have  a  great  quantity  of  it  it  shows  for  the 
defunct  more  honor  than  if  they  had  little  wine.  They  make  then  the  beverage 
and  kill  the  ewes  and  lambs.  He  says  that  the  defunct  is  then  carried  to  the 
fields  where  they  have  the  sepulchre.  Thither  (if  he  was  a  lord)  most  people 
of  the  town  accompany  it,  and  when  near,  they  burn  ten  ewes  or  twenty, 
more  or  less,  according  to  who  the  defunct  was,  and  they  kill  the  women, 
children  and  servants,  who  had  come  with  him,  for  to  serve  him  seemingly  to 
conform  to  this  vanity.  And  these  such,  jointly  with  some  ewes,  and  otner 
things  of  his  house,  are  interred  together  with  the  body  in  the  same  tomb, 
putting  (according  to  the  custom  among  them)  some  living  persons,  and 
interring  the  deceased  in  this  way,  they  return,  all  of  those  who  had  gone, 
in  honor  to  the  house  where  they  went  from,  and  there  they  eat  food,  which 
they  had  brought  and  drink  the  wine  which  they  had  made,  going  out  from 
time  to  time  to  the  places  they  had  made  near  by,  to  the  house  of  the  lords, 
where  in  a  circle  and  as  was  the  custom,  dancing  and  crying;  and  this  during 
some  days,  when  they  command  to  join  them  the  poorer  Indians  and  squaws, 
giving  them  food  and  drink,  of  that  which  they  had  more  than  enough  for 
themselves.  And  if  the  deceased  was  a  great  lord,  they  said  that  not  at  once  on 
dying  did  they  inter  him,  because  before  what  they  had  made  they  held  him 
some  days,  making  use  of  other  vanities  not  spoken  of,  which,  being  done,  they 
say  that  they  went  out  into  the  town,  the  women  who  had  remained  with  other 
servants,  not  killed,  with  their  blanket  hoods,  and  some  of  them  carried  in 
their  hands  the  arms  of  the  lord,  others  the  ornament  which  they  put  on  the 
head,  and  others  his  clothes.  Finally,  they  carried  the  chair  in  which  he  had 
sat  and  other  things,  and  they  marched  to  the  sound  of  a  drum,  carried  before 
by  an  Indian  who  was  seen  crying,  and  all  said  dolorous  and  sad  words,  and 


TESTIMONIES  ON  THE  IMl'i\LMY  GROVE  POTTERIES  OF  OLD  PERU.     745 

they  were  seen  singing  funeral  songs  in  most  parts  of  the  town,  saying  in 
these  songs  what  the  lord  had  passed  through  during  life,  and  other  things  in 
that  relation." 

Garcihizo  records:  "That  when  the  Inca  or  some  priest  of  the  chiefs 
died,  they  killed  and  buried  alive  the  most  favored  of  the  servants,  the  women 
most  desirable.  These  offered  themselves  to  death,  or  they  were  seized  by 
the  hands  for  the  love  which  they  had  for  their  lord." 

As  is  seen,  no  religious  sacrifices,  no  superstitious  customs  of  certain 
warring  tribes,  or  the  habit  or  preoccupation  of  others,  that  for  greater  adorn- 
ment of  themselves,  had  made  in  the  face  the  most  varied  mutilations,  could 
explain  the  frequency  with  which  these  are  presented  in  a  single  subject, 
depriving  him  at  the  same  time  of  his  nose,  his  lips  and  the  inferior  members. 
Neither  can  we  believe  that  the  punishments  imposed  upon  criminals  gives  a 
satisfactory  explanation.  For  if  some  tribes  employed  as  punishment  a  certain 
,  mutilation,  this  was  very  restricted,  and  there  are  no  proofs  that  it  was  in  the 
i'orm  as  shown  on  their  huacas.  And,  moreover,  there  is  no  right  to  think 
that  individuals,  who  had  a  civilization  of  the  degree  which  these  same  clay 
figures  testify  to,  could  be  responsible  for  that  which  belonged  to  tribes  deprived 
of  civilization  and  without  there  being  contact  between  them. 

There  is  also  proof  present,  as  we  have  seen  in  the  representation,  of 
s}Tnbol  of  death  (the  skeleton  head  on  a  dancing  woman)  in  the  plates  on 
some  of  these  huacas,  that  the  huacas  had  relation  with  burial  of  the  sick 
and  dying.  Indeed  we  may  well  think  that  the  huacas  were  a  sort  of  idol, 
to  be  worshipped,  as  we  see  them  placed  upon  the  floor  in  their  dances,  while 
the  dancing  sick  and  dying,  or  those  doing  honor  at  funerals  perhaps,  are 
engaged  in  appealing  to  gods  for  relief  of  some  kind. 

There  are  anomalies  presented  by  the  huacas,  which  are  indicative  that 
the  mutilations  are  not  the  efliect  of  punishment.  For  instance,  in  one  we 
see  the  nose  and  mouth  mutilated,  and  at  the  same  time  the  head  and  body 
full  of  tumors;  thus  the  intention  of  the  artist  evidently  was  to  represent 
a  diseased  person,  and  not  a  punished  criminal.  A  clay  vessel  which  I  have 
studied  and  recorded  in  Berlin  with  my  own  writings,  shows  the  head  of  a 
diseased  one,  in  which  is  seen  clearly  atresia  of  the  buccal  opening. 

An  analogous  one  in  the  Museum  de  la  Plata,  figures  a  person  who  has 
lost  the  nose  and  has  the  upper  lip  swollen  in  such  a  form  that  only  to  a 
pathological  state  could  it  be  attributed. 

A  model  discussed  by  Prof.  Lehmann-Nitsche  in  the  Latin-American 
Congress,  presents  a  foot  amputated  and  the  bandage  covering  the  stump  is 
plainly  visible. 

I  have  published  in  Berlin  a  huaca  with  one  foot  amputated,  while  the 
other  stump  is  being  dressed  by  the  patient  represented,  who  has  it  thrown 
across  his  knee,  while  he  holds  a  cup  (of  medicine  presumably)  in  his  hand 
right  close  to  the  unhealed  stump. 

Another  huaca  with  the  three  mutilations  is  seen  lying  (presumably  sick) 
in  her  bed. 


746     TESTIMONIES  ON  THE  MU]\1MY  GROVE  POTTERIES  OF  OLD  PERU. 

Another  represents  a  blind  man  striking  a  drum,  and  having  a  triple 
mutilation.  In  another  huaca  has  been  traced  most  delicately  a  tear,  or  cut 
out  piece  regularly  circular  only  on  the  side  of  the  mouth. 

Now  if  they  had  been  punished  ones,  those  that  present  -amputation  of 
the  feet,  sometimes  at  least,  there  would  be  noted  a  loss  of  care,  postoperative, 
and  bones  issuing,  or  deformed  cicatrices  would  be  noted,  and  not  always  be 
observed  stumps  very  well  carved,  with  sutures  perfectly  correct,  as  could  have 
been  produced  only  by  careful  surgical  intervention. 

I  have  sustained  this  same  line  of  argument  before  in  the  Verhandlungen 
of  the  Berlin  Anthropological  Society  in  a  huaca  representing  a  foot  amputated 
with  the  bone  protruding,  shoM'ing  the  flap  removed  which  was  needed  to 
cover  the  tibia  and  fibula  after  amputation;  the  amputation  had  been  a 
circular  one. 

We  cannot  agree,  therefore,  as  to  what  Eivero  and  Tschudi  have  said, 
that  "operative  surgery"  was  completely  unknown  to  ancient  Peruvians,  for 
we  know  and  have  proved  it,  that  not  only  did  they  make  amputation,  but 
that  they  dared  to  intervene  in  trepanation  of  crania.  And  even  their  success 
was  due  to  superstitious  procedures,  that  does  not  change  the  argument  at  all. 
Dr.  Tello  and  Dr.  Palma  have  drawn  out  with  their  own  hands  from  graves 
near  Huarachiri  (very  ancient  burial  place)  trepanned  mummies  still  with 
the  bandages  put  on  them  at  the  time  of  the  surgical  intervention.  Various 
studies  have  put  beyond  any  doubt  the  existence  of  trepanation  among  ancient 
Peruvians,  and  in  the  valuable  collection  of  Peru  there  are  many  specimens 
most  convincing. 

Ancient  Peinivians  had  instrmnents  with  which  they  operated:  "Razors, 
kitchen  knives,  lancets,  and  many  other  kinds  of  tools,"  said  Coho,  "hut  the 
use  of  iron  is  only  known  to  Indians  of  Peru  through  New  Spain.  Their 
tools  are  made  of  certain  stone,  which  the  Mexicans  call  Iztlo,  and  those  of 
Peru,  Chillias,  which  is  transparent  as  glass,  and  it  is  found  of  three  colors, 
white,  black  and  blue.  There  are  many  quarries  of  it,  the  same  in  Peru  as  in 
New  Spain ;  cut  in  many  median  bits,  that  expose  angles,  and  are  cleaned  from 
other  stones  more  rough.  From  these  they  draw  it  out  with  great  industry, 
and  separate  layers,  with  ridge  in  the  middle,  and  with  two  edges,  they  make 
them  one-third  larger,  in  width  one  or  two  fingers,  a  little  bigger  than  our 
kitchen  knives,  and  they  are  edged  so  acute  as  to  cut  with  them  the  beard ;  they 
are  very  fragile  and  easily  blunted. 

In  the  graveyard  of  Huarachiri,  Dr.  Palma  says  he  found  some  instru- 
ments of  copper.   (Post-Columbian  surely  then  or  Spanish  intrusions.) 

That  the  Indians  were  expert  in  surgery  is  shown,  also,  by  a  relation  of 
Gumilla's  (El  Orinoco  Ilustrado,  Madrid,  1741),  where  he  speaks  of  the  neces- 
sity for  surgical  intervention  among  the  Indians,  who  hunt  armadilloes,  who 
do  not  carry  dogs.  With  those  who  take  along  dogs,  it  is  easy  because  the  dogs 
seize  them  before  they  had  entered  in  their  caves.  It  is  very  risky  to  put  one's 
hand  in  to  draw  them  out,  because  there  abound  snakes  which  being  heated 
take  refuge  in  the  caves.  "By  such  custom  succeed  many  misfortunes,  espe- 
cially in  the  nations  of  Indians,  Caujitos  and  Chiricoas,  who  are  wandering 


TESTIMONIES  ON  THE  MUMMY  GROVE  POTTERIES  OF  OLD  PERU.     747 

without  settled  situations,  to  whom  the  armadilloes  make  the  greater  part  of 
cost.  There  are  no  companies  of  these  Indians  who  have  not  forty  or  fifty 
handless  and  blind  ones.  They  are  so  barbarous,  that  if  on  drawing  out  the 
armadillo  the  snake  bites  them  on  the  hand,  their  companions  at  once  cut  it 
off,  or  if  they  are  alone,  they  themselves  do  it ;  the  same  if  the  foot  is  wounded 
there.'' 

Fray  Eodrigo  de  Loaiza  (Memorial  de  los  Cosas  del  Peru  tocantes  a  los 
indios,  1586)  says:  "The  best  medicine  that  they  have  is  to  cut  off  with 
some  sharp  stones  the  arms  and  legs,  etc." 

Conformably  to  all  that  has  been  exposed  after  careful  review  of  the 
ancient  literature  of  Peru  and  that  which  in  more  modern  times  has  been  pub- 
lished in  relation  to  this  point,  we  see  clearly  that  to  explain  the  mutilations 
on  the  anthropomorphous  huacas,  the  hypothesis  can  only  be  admitted,  that 
they  represent  something  of  pathological  origin.  This  fact  has  been  perfectly 
established  for  some  time.  But  what  disease  was  it  they  tried  to  represent? 
"If  we  admit,"  says  Dr.  Palma,  "the  existence  of  pre-Columbian  syphilis,  it 
is  undoubted  that  that  affection  could  explain  what  the  great  majority  of  the 
anthropomorphous  huacas  show  us,  since  the  disease  attacks  by  preference  the 
nose  and  upper  lip  as  well  as  the  lower  member,  sites  where  the  huacas  present 
their  mutilations."  Yes,  but  why  think  it  is  syphilis  when  the  disease  Uta, 
or  the  several  diseases  that  are  known  to  different  tribes  of  Indians  by  that 
name,  produces  a  thousand  deformations  of  nose  and  upper  lip  and  of  lower 
member  to  syphilis's  one.  If  syphilis  and  Uta  combined,  as  I  have  also 
claimed  is  the  case,  could  operate  together  their  destructive  tendencies  in  the 
same  patient,  then  let  us  count  in  Uta  on  that  debtor  page  of  this  grave 
account. 

Even  believing,  as  I  do,  in  pre-Columbian  syphilis,  which  was  known  to 
the  pre-Incans,  long  before  the  Incans  had  conquered  the  Aymaran  civilization, 
for  the  Incans  still  use  the  name,  as  I  have  said,  Huanthi  for  syphilis,  not 
having  any  word  to  express  it  in  their  own  vocabulary,  and  even  crediting 
these  graves  of  the  Yauyas  (pre-A3'marans)  in  Huarachiri  with  being  all  pre- 
Ajonaran,  from  which  Dr.  Tello  has  dug  up  those  undoubtedly  syphilitic  skulls 
which  he  recently  published  in  "La  Antiquedad  de  la  Sifilis  en  el  Peru,"  j^et  I 
can  not  attribute  to  syphilis,  as  he  does,  the  credit  of  having  been  the  only  dis- 
ease presented  by  the  artists  on  the  huacas  potteries.  And  if,  as  Dr.  Palma 
says,  he  has  found  copper  instruments  in  some  of  the  graves  excavated  by  Dr. 
Tello,  surely  those  graves  were  not  even  pre-Columbian,  for  no  such  instru- 
ments are  found  in  pre-Columbian  graves.  I  do  not  intend  to  deny  here  the 
plausibility  of  syphilis  (and  pre-Columbian  syphilis,  which  certainly  was  pre- 
Incan  in  date,  long  before  Columbus's  advent),  as  a  factor  in  the  awful 
phagedenism  attending  so  many  pre-Columbian  diseases.  I  admit  it,  and 
always  did;  but  I  cannot  agree  to  the  displacement  from  its  throne  of  glory 
of  Uta,  the  corroding  disease  with  many  different  names  of  pre-Columbian 
America,  which  undoubtedly  was  depicted  by  all  the  clay  artists  on  the  anthro- 
pomorphous huacas  idols."  Syphilis,  of  course,  may  have  influenced  the 
excessive  phagedenism  of  those  other  mixed  diseases,  which  we  know  as  a  con- 


748      TESTIMONIES  ON  THE  ]\IUMMY  GRO\E  POTTERIES  OF  OLD  PERU. 

dition  under  the  name  of  Uta,  and  it  was  that  awful  condition,  which  those 
artists  have  moulded  in  cla}-. 

We  must  all  believe  that  this  "disease,"  very  conmion,  which  first  and 
always  rooted  itself  in  the  face  and  feet,  indicated  to  the  surgeons  of  that  time, 
or  to  the  surgical  sense  of  every  individual,  for  they  must  have  all  known  how 
to  cut  their  own  members  off,  the  intervention  of  surgery  as  a  means  of  relief 
under  certain  circumstances  of  its  march,  and  such  a  disease  if  it  had  first 
rooted  itself  in  the  genital  organs  would  have  not  been  so  universally  rep- 
resented on  the  face  or  feet  (by  amputation),  but  we  should  have  had  other 
representations  to  the  genital  regions  in  some  of  the  clay  vessels,  besides  only 
the  snake  wrapped  around  tlie  individual's  neck,  while  the  snake's  mouth  ate 
off  the  virile  member  of  the  man.  This  showed  merely  that  this  disease  was 
pre-Columbian  and  that  the  organ  was  eaten  off  by  some  evil  being  to  which 
they  would  appeal  in  their  religious  medical  rites.  The  picture  is  symbolical 
of  syphilis,  nothing  else.  The  other  bad  effects  of  syphilis  must  liave  been 
included  in  the  disease  pictures  represented  on  the  huacas. 

A  disease  of  such  nature  exists  in  certain  regions,  hot  and  imhealthy, 
and  very  appropriate  for  the  culture  of  coca.  Mosquitoes  abound  there. 
Diego  de  ]\Iorales  says,  that  these  places  are  sickly  and  there  is  no  old  man  nor 
old  woman,  and  the  children,  except  very  few,  have  nearly  all  of  them  llagas 
"from  mosquitoes." 

Fernando  de  Santillan  says,  of  the  coca  fields,  that  the  climate  kills  infinite 
numbers  and  others  die  from  the  evil  they  call  "Mai  de  los  Andes,"  which  is 
like  cancer,  that  in  two  days  there  is  no  remedy,  and  others  of  hunger  and 
work,  and  he  speaks  of  it  as  a  sepulchre. 

Eodrigo  de  Loaizas  says,  "The  trouble  of  the  Indians  who  enter  into  the 
coca  benefits,  is  that  they  contract  a  disease  they  call  'Andeongo,'  like  that  of 
the  mountains,  which  affects  the  noses  and  produces  in  them  maggots,  by  tlie 
nasty  hot  and  very  humid  climate  which  disposes  to  corruption." 

Pedro  Pizarro,  in  1571,  speaking  of  wlien  Amagro  was  in  Cuzeo  prepar- 
ing his  way  in  Lima  against  Marquez  don  Francisco  Pizarro,  says:  "There 
are  towns  of  Indians  so  few  that  they  do  not  reach  to  200  Indians;  towns 
down  to  to-day  have  been  seen.  These  Indians  understand  to  cultivate  the 
herb,  coca,  for  the  lords.  It  is  so  profitable  that  they  traded  each  year  more 
than  600,000  pesos.  And,  please  to  God,  they  are  not  poor  in  their  spirits, 
because,  according  to  what  is  said,  those  who  enter  in  the  Andes  are  given  an 
evil  in  the  noses  of  kind  of  evil  oF  Saint  Anthony,  whicli  has  no  cure,  that  in 
these  tradings  they  die  although  there  are  some  remedies  to  allay  the  pain,  but 
in  the  end  it  kills  them.  AU  tlie  Indians  who  enter  are  given  the  disease,  and 
even  those  who  are  born  there  are  touched  by  this  evil  and  from  this  cause 
they  are  so  few.     In  this  land  of  the  Andes  are  bred  many  vipers." 

Dr.  Cosme  Bueno  says,  of  Cauta :  "The  places  are  very  diseased,  there 
being  noticed  two  kinds  of  evils,  as  are  observed  in  other  cold  provinces.  The 
first  is  verrugas,  which  is  not  breeding ;  m  time  only  perilous  and  troublesome. 
The  other  is  some  corrosive  llagas,  especial  to  the  face,  of  most  difficult  cura- 


TESTIMONIES  ON  THE  MUjMMY  GROVE  POTTERIES  OF  OLD  PERU.     749 

tion  as  appears  on  some.  Tliey  say  that  it  has  its  origin  in  the  bite  of  a  little 
insect  which  they  call  "Uta." 

Dr.  Lavoreria  says  (in  his  thesis  "The  Art  of  Curing  among  Ancient 
Peruvians")  :  In  these  works  we  have  found  mentioned  this  disease,  at  least 
by  the  indigenous  name,  but  in  our  opinion  it  is  Uta,  the  terrible  disease  which 
historians  call  "Mai  do  los  Andes,"  which  commonly  attacked  the  Indians  who 
cultivate  the  coca  for  the  Inca.  The  lands  where  they  cultivate  it  are  reputed 
to  be  unhealthy,  not  only  by  the  hot  and  humid  climate,  but  especially,  says 
Santillan,  by  its  reigning  in  them,  that  terrible  disease  Mai  de  los  Andes  which 
is  a  kind  of  cancer  (taking  the  word  cancer  in  the  sense  which  the  historians 
have  taken  it,  that  is  to  say,  as  synonymous  with  gangrene  or  corrosive  ulcer) 
and  in  precisely  the  broken  land  places  in  which  to-day  is  endemic  Uta,  and  by 
these  motives  we  must  believe  that  it  is  Mai  de  los  Andes. 

Dr.  Palma  says,  that  Uta  according  to  the  studies  which  he  has  made 
differs  immensely  from  the  features  the  chroniclers  consider  under  the  name 
Mai  de  los  Andes.  He  does  not  know,  however,  whether  that  disease  reigns  in 
the  places  where  it  dominates.  He  believes  according  to  the  description  of 
Eaimondi  and  Barailler,  that  the  Mai  is  identical  with  it,  so  far  as  its  ravages 
are  characteristic  in  the  assignment,  and  by  the  similarity  in  the  places  of  the 
mountains  where  they  cultivate  the  coca  and  which  the  chroniclers  call  Andes, 
and  the  regions  where  is  endemic  la  llaga,  which  the  cited  authors  speak  of 
under  this  name  of  "Llaga,"  and  with  that  of  "Uta"  are  designated  to-day 
diseases  of  the  skin  more  or  less  alike,  but  indiscribably  distinct  in  origin. 

"Nobody  can  affirm  with  scientific  vigorousness,"  says  Palma,  "the  nature 
of  the  divers  dermatological  affections  which  aboimd  among  the  nati^'es  of  the 
forests  of  our  country,  and  the  only  thing  that  we  can  clearly  deduce,  by  the 
references  and  by  what  we  see  in  patients  who  come  from  those  places,  is  that 
there  it  is  very  easy  for  ulcerations  of  different  nature  to  present  in  a  short 
while  of  their  evolution  an  aspect  very  distinct  from  what  was  found  originally, 
and  in  consequence  the  establishment  of  a  terrible  phagedenism,  which  makes 
the  lesion  most  destructive,  aggravating  considerably  the  prognostic."  Dr. 
Palma  thinks  Uta,  a  benign  affection,  which  yields  readily  to  treatment,  even 
by  the  Indians,  and  without  requiring  surgical  intervention.  "Founded  on 
this,  we  are,"  he  says,  "of  distinct  contraiy  opinion  to  Dr.  Ashmead  when  he 
thinks  that  the  mutilations  of  the  huacas  represent  the  effects  of  surgical  treat- 
ment for  Uta,i  since  the  curanderos  of  ancient  Peru  loiow  and  apply  not  only 
piedra  de  los  lipes,  the  Nunocta,  etc.,  and  that  really  our  natives  make  use  of 
these  for  treating  successfully  Uta.  Besides  which  they  surely  have  in  tJicir 
rich  therapeutics  a  thousand  other  recourses  to  conjure  the  evil  without  the 
necessity  of  assistance  by  cruel  surgical  treatments  which  the  affection  does 
not  require,  and  to  which  the  patients  would  not  have  submitted  easily,  know- 


1  I  never  claimed  tliat  all  the  Tnutilations  of  face  represented  surfjieal  inter- 
vention, only  those  of  the  face  with  clean  cut  edges,  circular  or  triangular,  like  Von 
den  Stienen  sent  me  a  photograph  of.  As  to  the  triple  mntilntion  huacas.  of  nose,  upper 
lip  and  feet,  T  claimed  surgical   treatment  only  of  the  foot  lesion. 


750     TESTIMONIES  ON  THE  MUMMY  GROVE   POTTERIES  OF  OLD  PERU. 

ing  that  they  could  get  well  by  medications  less  energetic  and  vigorous.  We 
cannot  say  any  more  of  those  extensive  and  profound  ulcerations  that  the 
patients  show  us  that  lately  have  come  from  the  mountains.  If  the  Andeongo 
or  Anti-onco,  ]\Ial  de  los  Andes,  was,  which  appears  very  probable,  an  affection 
characterized  by  the  presence  of  these  rebellious  ulcers,  with  truly  devastating 
tendencies,  it  is  perfectly  admissible  that  the  surgeons  of  ancient  Peru  inter- 
fered radically  to  extirpate  by  means  of  the  knife  the  parts  attacked  and  that 
the  mutilated  anthropomorphous  huacos,  which  the  potters  of  that  time  have 
left  us,  are  representations  of  surgical  treatment  for  that  disease." 

Dr.  Palma  thinks  that  the  mild  Uta,  is  transmitted  by  a  mosquito  which 
gets  the  pathogenic  germ  from  the  dead  body  of  certain  reptiles.  The  anthropo- 
morphous huacas,  represent,  he  says,  probably  the  effects  of  surgical  curation 
for  Anti-onco  (Mai  de  los  Andes,  that  is,  or  "Uta,"  as  it  is  called  of  the  coca 
regions).  "A  rose  by  any  other  name  would  smell  as  sweet,"  whether  it  is 
"Mai  de  los  Andes"  or  "Uta,"  what  signifies  that.  He  admits  the  surgical 
intervention !     .      .      . 

Dr.  Julio  C.  Tello  in  his  work  (La  Antiquedad  de  la  Sifilis  en  el  Peru) 
believes  that  the  disease  "Taqui-onco"  or  "Cara-onco"  (face-onco),  the  dis- 
ease of  the  dance,  was  really  syphilis.  He  quotes  Professor  Fournier  (Traite 
de  la  Syphilis,  1906)  who  says,  that  in  4,400  cases  of  tertiary  syphilis  he  had 
observed  229  times  lesions  of  the  nasal  skeleton.  Well,  and  what  would  that 
prove  in  the  case  of  the  surgical  cures  of  the  disease  represented  on  the  huacas 
potteries?  This  has  no  importance  to  the  question  involved  in  the  triple 
mutilation  represented  on  the  huacas  pots. 

Surely  tertiary  syphilis  forms  would  have  been  a  godsend  to  those 
admirable  master  potters  of  old  Peru  and  the  lesions  would  not  have  been 
limited  to  nose  and  upper  lip  and  feet,  there  would  have  been  more  than  the 
triple  mutilations  represented,  and  amputations  alone  would  not  have  cured 
syphilitic  phagedena. 

I  have  made  a  most  thorough  analysis  of  all  the  recent  Peruvian  works, 
which  have  been  so  kindly  sent  me  by  their  authors,  viz :  "La  Uta  del  Peru," 
by  Dr.  Ricardo  Palma;  "La  Uta  en  el  Peru,"  by  Dr.  Manuel  0.  Tomayo; 
"Algunas  Consideraciones  sobre  la  Monografia  La  Uta  en  el  Peru,"  por  el 
Dr.  Manuel  0.  Tomayo,  Delegado  de  la  Sociedad  Geografica  de  Lima,  y  de  la 
Universidad  de  Arequipa,  ante  el  IV  Congress  Cientifico  Latino-Americano 
de  Santiago  de  Chile,"  por  Ricardo  Palma  y  Julio  C.  Tello,  Alumnos  de  la 
Facultad  de  Medicina;  and  "La  Antiquidad  de  la  Sifilis  en  el  Peru,"  por 
Jules  C.  Tello,  Lima,  1909,  and  I  conclude  that  "Uta"  or  the  condition  of 
corrosive  ulceration  and  nothing  else  was  meant  to  be  represented  on  the  huacas 
by  the  ancient  potters  of  old  Peni,  and  that  in  the  mutilation  vocabulary 
under  the  definition  of  the  Aymaran  word  "Uta"  must  be  included  all  those 
diseases  which  have  as  main  characteristic  phagedenism,  this  would  include 
also  syphilis  in  complication  with  any  or  all  of  these  other  indigenous  diseases. 


FRACTURES  OF  PATELLA  AND  MODERJS  OPERATIVE  TREATMENT.  751 


FRACTURES  OF  THE  PATELLA  AND  THEIR  MODERN  OPERATIVE 

TREATMENT. 

By  AIME  PAUL  HEINECK,  M.D., 

Professor  of  Surgery,  Reliance  Medical  College;    Adjunct  Professor  of  Surgery,  Illinois 
University;     Surgeon   to  tin?  Cook  County  Hospital. 

CHICAGO,  ILL. 

The  patella  is  the  largest  sesamoid  bone  in  the  body.  It  is  developed 
and  embedded  in  the  substance  of  the  largest  and  most  powerful  muscle  group 
in  the  body,  the  quadriceps  extensor  femoris  muscle,  and  forms  a  part  of  the 
extensor  apparatus  of  the  knee.  The  patella  is  an  important  factor  in  the 
distribution  over  a  considerable  area,  of  any  force  applied  to  the  front  of 
the  knee.  It  provides  considerable  leverage  for  the  quadriceps  muscle,  and 
its  removal  is  followed  by  a  weakening  and  an  impairment  of  the  action  of 
the  quadriceps  extensor  tendon  upon  the  leg.  By  this  sesamoid  bone,  the 
tendon  of  the  quadriceps  is  kept  spread  out,  and  prevented  from  being  gathered 
up  in  a  round  cord.  Any  portion  of  the  patella,  base,  body,  apex,  and  borders, 
may  be  the  seat  of  fracture,  fractures  of  this  bone  are  almost  invariably  intra- 
articular, that  is,  the  line  of  fracture  almost  always  extends  into  the  knee- 
joint,  thereby  involving  the  largest  and  most  complex  synovial  cavity  of  the 
body.  This  fact  is  important  from  the  S}Tnptomatic,  therapeutic,  and  prog- 
nostic standpoints. 

Fractures  of  the  patella  possess  the  characteristics  common  to  all  frac- 
tures. They  may  be  subcutaneous;  they  may  be  open;  may  be  complete  or 
incomplete;  may  be  unilateral  or  bilateral.  The  right  and  left  patella  seem 
to  be  each  involved  with  about  equal  frequency.  If  the  fracture  be  bilateral, 
both  bones  may  be  fractured  simultaneously,  or  in  succession,  that  is,  an 
interval  of  time  of  greater  or  less  duration  intervening  between  the  two 
distinct  fractures. 

Fractures  of  the  patella  may  be  simple,  may  be  complicated  by  significant 
injuries  of  the  neighboring  structures  or  tissues.  In  forty-eight  out  of  fift}'- 
five  cases  reported  by  Boeckenheimer,!  an  injury  of  the  accessory  patellar 
ligaments,  or  reserve  extensor  apparatus,  was  present.  These  fractures  may 
be  recent,  may  be  old.  We  will  consider,  somewhat  arbitrarily,  we  acknowl- 
edge, as  old  fractures,  all  those  that  are  of  more  than  two  months'  standing. 

From  the  operative  and  from  the  prognostic  standpoints,  the  determina- 
tion of  these  different  types  of  fractures  is  of  great  importance.  For  instance, 
in  old  fractures,  the  fractured  surfaces  must  be  freshened  and  the  interfrag- 
mentary fibrous  band  resected.  Compound  fractures  call  for  immediate  opera- 
tion. Comminuted  fractures  may  call  for  removal  from  the  articular  cavity, 
of  detached  bony  fragments. 

Fractures  of  the  knee-cap  may  be  due  to  violence,  direct  or  indirect,  or 
to  muscular  action.  It  is  not  uncommon  for  two  or  all  of  these  factors  to  be 
associated  in  the  production  of  the  injury.     All  the  compound  fractures  that 


752     i'KACTURES  OF  PATELLA  AJSD  MOUERiN   OrEKATlVE  TREATMENT. 

have  come  under  our  observation,  or  that  we  have  found  reported  in  the 
literature,  were  due  to  direct  violence;  a  blow,  a  fall,  a  kick,  etc.,  upon  the 
knee-cap.  If  direct  violence  be  the  causative  factor,  the  greater  the  violence, 
the  greater  the  likelihood  of  stellation,  or  comminution  of  the  bone. 

Some  clinicians  classify  fractures  of  this  bone  into  (a)  blow  fractures, 
(b)  tear  fractures,  and  (c)  such  as  are  due  to  a  combination  of  both  factors, 
impact  or  traction.  From  an  etiological  standpoint,  this  classification  is  of 
value,  but  it  cannot  be  utilized  as  a  constant  guide  to  determine  whether 
operative  or  non-operative  treatment  is  indicated.  In  the  tear  fractures^ 
the  lateral  expansions  of  the  quadriceps  extensor  muscle  on  either  side  of  the 
patella  are  torn,  and,  almost  always,  there  is  considerable  separation  of  the 
fragments  of  the  fractured  bone.  Tear  fractures  have  been  reported  in  which 
separation  (detectable  by  inspection  and  palpation)  of  the  fragments  was  not 
present. 2  Such  cases  are  of  very  exceptional  occurrence.  Blow  fractures 
have  been  reported  in  which  marked  separation  of  the  fragments  was  found  to 
be  present. 

We  find  reported  such  statements  of  the  circumstances  surrounding  the 
accident  as  the  following:  While  making  an  effort  to  regain  his  balance,  ta 
restrain  himself  from  falling,  the  patient  fractured  his  patella.  In  a  case 
reported  by  Hamilton,^  it  is  stated  that  the  patient  slipped  in  a  room,  then 
fell  in  a  sitting  position;  a  fracture  resulted.  Mayer's'*'^  patient,  in  falling 
upon  her  back,  heard  a  cracking  sound  in  right  knee.  Eisendrath's  patient,'*'' 
an  intoxicated  individual,  fell  down  ten  or  twelve  steps  backward.  In  Bul- 
lett's  case,-"*  both  patellae  snapped,  as  patient  was  endeavoring  not  to  fall. 
Wright's^  patient  fell,  and  in  attempting  to  regain  his  balance,  felt  some- 
thing crack  in  his  knee.  Durand's'''  patient  ran  into  an  obstacle,  and,  in  falling 
baclcward,  fractured  his  patella.  Means'^  patient  refractured  his  patella  while 
lifting  a  heavy  load.  In  a  case  reported  by  Wright,*^  it  is  distinctly  stated 
that  the  patient  heard  a  crack  in  her  right  knee  before  hitting  the  steps  upon 
which  she  fell.  In  another  of  Wright's  cases  patient  lost  his  balance  and  fell 
backward  while  sparring. 

In  447  cases,  in  wliich  the  sex  of  the  patient  is  stated,  388  of  these  frac- 
tures occurred  in  males,  and  59  in  females. 

Fractures  of  the  patella  are  infrequent  in  childhood  and  in  adolescence. 

In  the  literature  of  fractured  patella  of  the  last  ten  years,  the  youngest 
patient  in  whom  this  accident  occurred,  was  a  male,  ten  years  old.  His 
fracture  was  compound.  He  recovered  only  limited  motion. ^o  One  of  Bogart's^i 
cases  was  a  girl,  14  years  old.  Her  fracture  was  also  compound.  Cox's 
case,i2  a  compound  fracture,  was  a  hoy  15  years  old.  The  oldest  patient 
reported  was  83  years  of  age.^"^  In  Vallas'  case,'*'*  the  patient  was  70  years 
old.  Trendelenburg!'*  reports  a  case  occurring  in  an  individual  71  years  of 
age.     One  of  Lotheisen's  patients*-''  was  73  years  old. 

The  line  of  fracture  may  be  longitudinal,  oblique,  transverse,  stellated. 
Comminution  is  not  infrequent.  Avulsion  of  tip  and  of  margin  of  base  is 
reported.*^  The  part  torn  ofT  may  be  the  lower  half-inch  of  the  apex 
paten.T.*"^    Meyer*^  reports  some  longitudinal  fractures,  the  diagnosis  of  which 


FRACTURES  OF  PATELLA  AiND  MODERN  OPERATIVE  TREATMENT.     753 

was  verified  by  the  Eoentgen  rays;  some  were  due  to  direct  violence,  others 
to  indirect  violence. 

The  fragments  may  be  equal  (rare)  or  unequal  in  volume. 
The  bone  may  be  broken  into  two,  three,  four  or  more  fragments.  In 
cases  reported  by  McWilliams,i9'=  by  Battlei^''  and  by  Doberauer,!^''  there  were 
five  fragments.  In  cases  reported  by  Erdman,-^'^  and  by  FellSj^oi^  gj^  fragments 
were  present.  Dumstrey,^!''  Cassedebat2i<=  and  Eanzi^i^  report  cases  each 
presenting  seven  fragments.  In  Modlin's  case,--  the  bone  had  been  fractured 
into  nine  fragments. 

Associated  with  all  fractures  of  the  patella,  haemorrhage,  both  intra- 
articular and  extra-articular,  is  present.  The  intra-articular  liEemorrhage  is 
of  symptomatic  and  of  prognostic  significance.  The  prepatellar  bursa  may 
be  the  seat  of  a  hannorrhagic  extravasate.  This  more  frequently  occurs  in  the 
fractures  due  to  direct  violence. 

Owing  to  the  fact  that  the  elasticity  of  the  soft  tissues  exceeds  the 
cohesion  of  the  bone,  in  tear  fractures  (those  that  are  due  to  the  overactioii 
of  the  quadriceps  extensor  muscle  or  to  the  exaggerated  traction  of  the  liga- 
mentum  patellae),  the  soft  tissues  do  not  yield  at  the  same  level  as  the  bone. 
The  bony  fragments  may  be  separated  as  much  as  two  centimeters  before 
rupture  of  the  overlying  soft  tissues  occurs.  (The  tear  in  the  prepatellar 
fibrous  tissues  may  be  above,  or  may  be  below  the  line  of  fracture.)  These 
soft  tissues  may  overlap,  partially,  or  completely,  one  or  both  fractured  sur- 
faces. This  fibroperiosteal  curtain  is  not  present  in  those  cases  (tliey  are  few 
in  number)  of  fractures  of  the  patella  in  which  there  has  not  occurred  a 
coincident  rupture  of  the  prepatellar  ligamentous  and  fibrous  tissue. 

Lucas  Championniere,--''  in  reporting  seventy  cases,  says  that  in  a  large 
proportion  of  tliem,  a  large  flap  of  fibrous  tissue  coming  from  the  anterior 
surface  of  the  patella,  was  interposed  between  the  fragments.  Baerlocher,24 
in  reporting  twenty-eight  cases,  says  that  in  every  one  of  his  cases,  it  was 
seen  at  the  time  of  operation  that  the  fractured  surfaces  were  covered  by 
interposing  soft  parts,  which,  had  subcutaneous  suture  or  non-operative  treat- 
ment been  employed,  would  have  prevented  osseous  union. 

In  complete  fractures  of  the  patella,  the  separation  existing  between  the 
fragments  may  be  slight,  may  be  marked.  It  is  always  increased  by  flexion 
of  the  leg  on  the  thigh.  The  capsular  tears,  the  lacerations  of  the  reserve 
extensor  apparatus,  play  an  important  role  in  this  fragmentary  diastasis. 
In  one  of  Fowler's  cases,^^  the  inter-fragmentary  space  was  two  and  one-half 
inches  in  width.     In  Ball's  case,2«  the  fragments  were  four  inches  apart. 

Another  S}Tnptom  frequently  noted  is  loss  of  the  power  of  extending 
the  leg  on  the  thigh.  We  find  in  the  reported  cases  such  expressions  as 
"Limb  useless;"  "Functional  disturbance  similar  to  that  of  paralysis  of  quad- 
riceps extensor  muscle;"  "Power  to  extend  the  knee  was  absent;"  "Absolute 
loss  of  function;"  "Absolute  impotency  of  liml) ;"  "Impossible  to  extend  lower 
limb;"  There  was  immediate  disability;"  "There  was  absolute  extensor 
paralysis,"  etc.,  etc. 

The  patella  is  not  uncommonly  the  seat  of  refracture.     This  accident  is 

6 


754      FRACTURES  OF  PATELLA  AI^D  MODERN  OPERATIVE  TREATMENT. 

more  frequent  in  the  first  few  months  following  the  original  accident.  It 
may  occur  later,  especially  when  flexion  has  remained  limited.  Among  the 
causes  of  ref racture  may  be  mentioned : — 

1.  Situation  of  the  patella  over  a  functionally  active  joint. 

2.  Atrophic  condition  of  the  bone. 

3.  Adhesion,  as  a  sequel  of  the  previous  fracture,  of  the  patella  to  the 
femur. 

4.  Forcible  flexion  of  the  knee,  as  by  a  fall,  beyond  the  range  of  motion 
that  has  been  acquired.  It  has  occasionally  been  caused  by  the  surgeon  in  an 
attempt  to  forcibly  increase  by  passive  motion,  the  flexibility  of  the  knee.-" 

Either  the  bone  itself,  or  the  fibrous  union,  may  be  severed,  that  is,  the 
fracture  may  be  above  the  bond  of  union,  may  be  below  the  bond  of  union, 
may  be  through  the  bond  of  union.  Eefractures  are  frequently  indirect 
fractures,  in  which  the  extensor  apparatus  yields  at  its  weakest  point  between 
the  fragments,  that  is,  at  the  ligamentous  bond  of  union. 

The  patella  may  be  twice  refractured.^o^ 

Pilcher^s  presented  to  the  Brooklyn  Surgical  Society,  cases  of  fractured 
patellae  that  had  been  treated  operatively  with  success.  At  the  same  time, 
he  showed  some  skiagrams.  One  of  the  latter  demonstrated  a  patella  with  two 
different  healed  fractures.  In  this  patella,  the  fractures  were  at  difl'erent 
sites.  In  Turner's  case,^^  at  the  time  of  operation,  it  was  seen  that  the 
refracture  was  at  the  same  place  as  the  previous  fracture. 

In  fractures  of  the  patella,  the  following  indications  have  to  be  met : — 

1.  The  fracture  must  be  reduced. 

2.  The  bony  fragments  must  be  maintained  in  intimate  apposition  until 
organic  union  between  them  has  been  effected. 

3.  The  continuity  of  the  divided  soft  tissues  must  be  re-established. 

4.  The  functional  integrity  of  the  knee-joint  must  be  restored. 

The  value  of  any  fonn  of  treatment  is  dependent  upon  its  ability  to 
meet  the  above  indications.  All  forms  of  treatment  can  be  classified  into  one 
or  the  other  of  two  main  classes:  The  non-operative  and  the  operative.  The 
latter  admits  of  further  subdivision  into  the  subcutaneous  and  open  methods. 

It  is  evident  that  in  each  individual  case,  the  adoption  or  rejection  of 
any  form  of  treatment  is  to  be  determined  largely  by  the  nature,  the  type 
of  fracture  at  hand.  Each  method  has  advantages  and  disadvantages;  indi- 
cations and  limitations. 

The  numerous  non-operative  methods  of  treatment  that  have  been 
emploj^ed;  the  large  number  of  percutaneous  and  subcutaneous  operations  for 
approximation  of  the  fragments,  that  have  been  proposed,  lauded,  tried,  and 
then  abandoned;  the  comparatively  great  number  of  patients,  who,  having 
been  subjected  to  non-operative  treatment,  of  themselves  seek  operative  treat- 
ment in  order  to  lessen  or  entirely  overcome  their  disability,  all  these  are 
proofs  that  all  the  non-operative,  and  the  subcutaneous  operative  methods 
as  well,  have  deficiencies  which  debar  them  from  ever  being  elective  methods 
of  treatment. 

Occasional  cases  are  to  be  found  in  the  literature  of  the  subject,  in  which 


FRACTURES  OF  PATELLA  AND  MODERN  OPERATIVE  TREATMENT.  755 

though  the  operator  succeeded  in  restoring  to  the  patella  its  normal  anatomical 
contour,  functional  integrity  of  the  knee-joint  was  not  secured.  Our  explana- 
tion for  these  cases  is  that  some  essential  step  in  the  operation  has  either 
been  completely  overlooked,  or  unskilfully  performed,  or  that  the  post- 
operative treatment  has  been  injudicious.  The  extravasated  blood  may  not 
have  been  removed  from  the  synovial  cavity;  the  lacerations  of  the  soft  tissue 
may  not  have  been  repaired,  etc. 

A  distinction  must  be  made  between  the  shortcomings  of  the  operator 
and  the  shortcomings  of  an  operative  procedure,  as  such. 

Why  do  we  advise  the  abandonment  of  the  various  subcutaneous  and  per- 
cutaneous operations?     Because: — 

1.  They  do  not  enable  the  surgeon  to  accurately  coapt  the  fractured  frag- 
ments. After  an  arthrotomy,  either  by  bone  suturing,  by  circumferential 
looping  or  ligaturing,  or  by  careful  sewing  of  the  torn  soft  tissues,  the  frag- 
ments can  be  closely  apposed  and  held  immovably  together.  This  intimate 
apposition  of  the  fractured  surfaces  lessens  the  liability  to  an  excess  either  in 
length  or  in  width,  of  callus  formation.  Any  change  in  the  contour  of  the 
patella  is  liable  to  interfere  with  the  normal  adaptation  of  its  articular  surface 
to  the  femoral  articular  surface. 

2.  They  do  not  enable  the  operator  to  freshen  the  fractured  surfaces.  In 
the  repair  of  old  fractures,  the  resection  of  the  inter-fragmentary  fibrous  bond 
of  union,  the  freshening  of  the  fractured  surfaces,  are  among  the  essential 
steps  of  the  operation. 

3.  They  do  not  insure  against  union  of  the  bony  fragments  in  a  faulty 
position.  Impaired  function  results  from  union  in  a  faulty  position.  The 
open  operation  enables  the  surgeon  to  overcome  any  tilting  of  the  fragments,  as 
well  as  any  tendency  to  union  in  faulty  position. 

4.  The  subcutaneous  methods  make  no  provision  for  the  toilet  of  the 
sjTiovial  cavity.  The  open  operation  allows  of  the  early  and  complete  removal 
of  all  articular  effusions,  of  all  extravasated  blood,  intra-  or  extra-articular, 
liquid  or  clotted,  of  all  completely  detached  bony  fragments. 

5.  The  tears  in  the  capsule,  the  lacerations  in  the  aponeurotic  expansions 
of  the  vasti,  demand  repair.  Only  by  means  of  an  open  operation  can  they 
be  repaired.  The  extensor  apparatus  of  the  leg  must  be  considered  as  one 
organ.  Structural  impairment  of  any  of  its  constituent  parts  entails  a  cor- 
responding impairment  of  function.  The  insertion  of  the  vastus  externus 
and  of  the  vastus  internus  into  the  capsule  of  the  knee-joint,  and  the  lateral 
prolongations  of  their  insertions  down  upon  the  head  of  the  tibia  and  fibula, 
are  of  assistance  in  the  extension  of  the  leg  on  the  thigh.  Solutions  of  con- 
tinuity in  these  tissues  must  bo  repaired. 

6.  None  of  the  subcutaneous  operations  allow  of  the  removal  of  the  fibro- 
periosteal  shreds  which  so  frequently  overlap  the  fractured  surfaces,  and 
which,  in  some  cases,  have  been  found  to  adhere  so  tightly  to  bony  projections, 
that  for  their  liberation  it  was  necessary  to  use  forceps  and  curette.  These 
fibroperiosteal  shreds  are  an  ol)stacle  to  osseous  union ;  they  can  be  removed 
only  by  an  open  operation. 


756  FRACTURES  OF  PATELLA  AA'D  MODERN  OPERATIVE  TREATMENT. 

7.  The  subcutaneous  and  percutaneous  operations  create  openings  which 
are  inadequate  for  the  escape  of  intra-articular  and  extra-articular  extravasates 
and  exudates,  but  which  are  ample  for  the  introduction  of  infection. 

The  probability  of  ankylosis,  joint  suppuration,  or  pyaemia,  following 
an  aseptic  arthrotomy,  can  almost  be  disregarded.  In  none  of  Moullin's-"-'^ 
cases  was  there  a  rise  of  temperature  worth  mentioning.  Stimson^^^  between 
the  years  1892-1906,  performed  the  open  operation  for  fractured  patellae  over 
two  hundred  times.  During  this  entire  period,  his  only  mishap  was  a  slight 
suppuration,  which  caused  no  subsequent  difficulty.  We  concede  that  the 
general  dangers  inherent  to  other  major  operative  procedures  are  also  present 
in  these  cases.  These  dangers,  anesthesia,  shock,  and  suppuration,  are  com- 
mon to  all  operations.  Shock  can  be  minimized  by  rapid  operating.  The 
time  consumed  in  the  performance  of  any  operation  should  l)e  the  shortest 
consistent  with  the  careful  and  complete  execution  of  the  different  steps  of 
the  operation.     We  will  not,  at  this  time,  discuss  the  other  two  dangers. 

We  believe  we  are  fully  justified  in  stating  that  the  dangers  of  the  open 
operation,  if  it  be  performed  with  due  precaution  by  careful  and  skilful 
hands,  are  practically  nil.  There  is  always  plenty  of  time  to  reach  hands 
well  able  to  perform  the  operation. 

What  are  some  of  the  advantages  of  the  open  operative  method? 

1.  Eefracture  of  tlie  patella  is  more  common  after  massage  and  other 
forms  of  non-operative  treatment  than  after  the  open  operative  treatment. 
Allessandri,32a  Gibbon.^^b  l^efracture  is  more  frequent  in  the  patella  than  in 
any  other  bone,  Lauper.ssd  By  more  closely  restoring  the  bone  to  anatomical 
perfection,  the  open  operative  treatment  lessens  to  a  considerable  degree  the 
tendency  to  refracture. 

2.  In  any  fracture,  the  union  between  the  fractured  fragments  which 
is  considered  the  most  desirable,  is  osseous  union.  Modern  surgeons  do  not 
expect  to  obtain  osseous  union  in  fractures  of  the  patella  which  are  treated 
non-operatively.  Its  occurrence  under  such  conditions,  though  possible,  is 
so  rare  that  it  is  considered  a  pathological  curiosity.  One  of  the  main  justifi- 
cations of  the  open  operative  treatment  is  the  frequency  with  which  osseous 
union  follows  its  employment. 

It  being  a  demonstrated  fact  that  osseous  union  can  be  obtained,  it  be- 
hooves us  to  employ  that  method  of  treatment  which  most  frequently  secures  it. 

It  cannot  be  contested  that  the  solidity  of  the  patella  contributes,  in  a 
great  measure,  to  the  stability  of  the  knee-joint.  Fibrous  union  of  the  frac- 
tured bone  imparts  to  the  articulation  a  weakness,  an  uncertainty,  an 
instability,  as  a  result  of  which  patients  with  fibrously  united  patella,  fre- 
quently fall.  This  lack  of  stability,  this  impairment  of  control,  predispose 
to  refracture  of  the  fibrously  united  patella.  It  is  exceptional  for  fibrous 
union  to  be  associated  with  absolute  functional  recovery.  Patients  with  fibrous 
union  are  handicapped  noticeably  in  going  up  or  down  stairs.  A  fibrous  bond 
of  union  has  a  tendency  to  elongate  under  use. 

3.  The  open  operations  enable  us  to  obtain  a  more  rapid,  a  more  complete 


FRACTURES  OF  PATELLA  AMD  .MODERN  Oi^ERATlVE  TREATMENT.     757 

recovery.     Koerte  considers  that  the  climbing  of  stairs  after  fracture  of  the 
patella  is  a  criterion  of  functional  recovery. 

4.  The  open  operation  enables  the  operator  to  mitigate  all,  and  to  remove 
most  of  the  conditions  that  tend  to  cause  imperfect  union  and  its  consequence, 
impaired  fimctional  integrity.  Let  us  enumerate  and  discuss  briefly  the  most 
important  of  these  unfavorable  conditions  to  osseous  union. 

1.  Separation  of  the  fragments. 

2.  Tilting  of  the  fragments.     Either  or  both  fragments,  often  are, 

or  may  be,  everted  or  inverted.  In  the  presence  of  tilting,  the 
fragments  can  never  be  maintained  with  the  fractured  surfaces 
exactly  towards  each  other,  either  by  bandages  or  by  retentive 
appliances,  or  by  any  subcutaneous  operative  method. 

3.  Eupture  of  the  tendinous  expansions  of  the  vasti  and  of  the  lateral 

portions  of  the  capsule  of  the  joint. 

4.  Prolapse  of  the  prepatellar  tissues  into  the  breach  caused  by  the 

separation  of  the  fractured  fragments. 

5.  Atrophy    of    the    quadriceps    femoris,    due    to    disuse,    arthritis, 

marked  contusions  of  the  muscle,  extravasated  blood  from  the 
joint,  through  the  rent  in  the  upper  part  of  the  capsule,  etc. 

6.  Arthritis  of  the  knee-joint. 

7.  Adhesions  of  the  patella.     Hamilton  and  Erdman  report  cases  in 

which  the  upper  fragment  was  found  adherent  to  the  femoral 
condyles. 

8.  Union  of  the  fragments  in  bad  position,  mechanically  interfering 

with  proper  function  of  joint. 
The  inter-fragmentary  interval,  in  recent  fractures,  can  be  increased  by 
flexion  of  the  leg  on  the  thigh,  and  lessened  by  extension  of  the  thigh  and 
leg  on  the  pelvis.  The  displacement  varies  with  the  type  of  fracture,  being 
practically  non-existent  in  incomplete  subaponeurotic  fractures,  being  most 
marked  in  such  cases  as  are  associated  with  extensive  laceration  of  the  pre- 
patellar and  parapatellar  fibrous  and  aponeurotic  tissues.  A  group  of  powerful 
muscles  is  attached  to  the  upper  fragment,  and  in  oblique  and  in  transverse 
fractures  displaces  this  fragment  upwards.  This  muscular  group,  the  quad- 
riceps extensor  femoris  muscle,  must  be  properly  controlled,  as  it  constantly 
tends  to  separate  the  fragments.  The  retraction  of  the  ligamentum  patellae 
displaces  the  lower  fragment  downwards,  and  also  has  a  tendency  to  evert  its 
fractured  surface.  The  upward  displacement  of  the  upper  fragment  by  the 
quadriceps  extensor  femoris  muscle,  of  itself,  would  not  make  the  open  opera- 
tion imperative,  as  the  contraction  of  this  muscle  and  the  associated  displace- 
ment of  the  upper  fragment  can  be  greatly  overcome  by  position ;  by  clamps ; 
by  forcible  and  prolonged  extension;  by  the  subcutaneous  and  percutaneous 
methods  of  vertical  or  circumferential  ligaturing  of  the  patella.  The  open 
method  enables  one  to  determine  the  extent  to  which  the  fraguients  are 
separated,  and  to  take  such  steps  as  may  be  needed  to  overcome  this  diastasis. 
The  surgeon  is  enabled  to  bring  the  fragments  into  more  exact  apposition, 
and  to  more  positively  maintain  them  there.     By  the  open  method,  increase  in 


758     FRACTURES  OF  PATELLA  AiND  MODERN  OPERATIVE  TREATMENT. 

length  of  the  patella  is  avoided.  Increase  in  the  dimensions  of  the  patella  is 
not  infrequently  noticed  after  the  subcutaneous  operations,  and  sometimes 
ap2)ears  to  limit  mechanically,  flexion  of  the  knee. 

One  or  both  fragments  may  be  everted  or  inverted,  or  one  may  be  everted 
and  the  other  inverted.  If  the  bone  be  fractured  into  more  than  two  frag- 
ments, one  or  more  of  the  fragments  may  be  everted  or  inverted.  Tilting  of  the 
fragments,  though  partly  due  to  the  traction  of  the  fibroaponeurotic  tissues 
attached  to  the  anterior  surface  of  the  patella,  is  mainly  dependent,  at  first, 
on  the  intra-articular  hgemorrhage,  and  later,  on  the  inflammatory  exudate 
consecutive  to  the  injury.  As  these  fractures  are  almost  always  intra-articular, 
an  associated  traumatic  synovitis  is  a  nearly  constant  accompaniment.  At 
times,  a  spicule  of  bone  between  the  fragments  is  a  contributory  factor.  The 
tilting  of  the  fragments  decreases,  often  disappears  completely,  with  the 
absorption,  or  with  the  removal  of  the  extravasated  blood,  and  of  the  inflam- 
matory exudate.  By  keeping  the  limb  in  an  appropriate  position,  by  controlling 
the  fragments  by  elastic  or  other  bandages,  so  applied  as  to  secure  apposition 
of  the  fractured  surfaces,  tilting  is  further  lessened.  The  open  operation 
enables  us  to  quickly  and  completely  remove  the  extravasated  intra-articular 
and  extra-articular  blood,  to  void  the  inflammatory  exudate,  to  make  the 
toilet  of  the  synovial  cavity. 

In  fractures  of  the  patella,  as  in  other  fractures,  in  addition  to  the  lesion 
of  the  bone,  we  have  co-existing  injuries  of  the  contiguous  soft  tissues. 

When  one  recalls  the  intimate  relations  with  the  patella,  of  the  fascia, 
muscles  and  ligaments  which  surround  it,  no  stretch  of  the  imagination  can 
possibly  conceive  a  fracture  of  this  bone  without  some  associated  damage  to 
the  surrounding  structures.  The  more  extensive  that  damage  the  greater  the 
separation  of  the  bone  fragments,  the  less  the  liability  to  spontaneous  func- 
tional recovery.  Vallas,  Mikulicz,  Baerlocher,  Lejars,  and  Stimson  emphasize 
the  importance  of  restoring  the  continuity  of  the  torn  reserve  extensor 
apparatus. 

Upon  the  proper  repair,  upon  the  proper  reunion  of  these  soft  tissues,  is 
dependent,  in  an  important  measure,  the  functional  integrity  of  the  knee- 
joint.  E.  W.  Andrews  says  that  the  patella  union  is  only  an  incident  in  the 
ligamentous  and  tendinous  repair  by  suture.  So  important  is  the  approxi- 
mation of  these  torn  tissues,  so  essential  is  the  restoration  of  the  continuity 
of  the  aponeurotic  fibers  of  the  vasti,  of  the  rectus  femoris,  and  of  the  deep 
fascia  of  leg  and  thigh,  that  many  operators,  in  the  treatment  of  fractured 
patellae,  limit  all  their  suturing  to  the  torn  soft  tissues.  It  has  recently  been 
shown  that,  in  operating  upon  these  fractures,  it  is  even  more  important  to 
suture  the  lateral  ligaments  than  to  suture  the  patella  itself.  The  tears  in 
the  joint  capsule  and  in  the  aponeurotic  fibers,  allow  the  quadriceps  extensor 
femoris  muscle  to  still  further  separate  the  fragments,  and  to  increase  the 
forward  eversion  of  the  superior  fragment.  The  open  method  enables  the 
medical  attendant  to  carefully  repair  the  tears,  anterior  and  lateral,  in  the 
joint  capsule  (the  patella  forms  a  part  of  the  articular  capsule),  and  to 
approximate  the  margins  of  all  lacerations  in  the  tendinous  expansions  of  the 


FRACTURES  OF  PATELLA  A^D  MODERN  OPERATIVE  TREATMENT.     759 

vasti.     The  active  extension  of  the  leg  depends  in  a  large  measure  upon  the 
state  of  the  reserve  extensor  apparatus. 

The  prolapse  of  the  prepatellar  fibrous  tissues  between  the  fragments  of 
the  fractured  bone  is  one  of  the  important  obstacles  to  non-union.  The  pre- 
vention by  these  intervening  soft  tissues  of  the  exact  apposition  of  the  frag- 
ments is  one  of  the  most  valid  reasons  for  resorting  to  the  open  operation. 
When  present,  these  interposed  soft  tissues  constitute  an  obstacle  to  osseous 
union,  removable  only  by  the  open  operation. 

These  interposed  soft  tissues  constitute  a  fibroperiosteal  curtain  which  may 
overlap  the  fractured  surface  of  either  fragment.  In  some  cases,  both  frac- 
tured surfaces  are  either  partly  or  completely  covered  by  this  prolapsing  pre- 
patellar tissue.  These  prolapsed  tissues  may  be  easily  removable,  may  be 
hooked  to  the  underlying  bone.  When  hooked  to  the  fractured  surfaces  their 
removal  is,  at  times,  attended  with  some  difficulty.  In  many  fractures  of  the 
patella,  be  they  tear  or  blow  fractures,  or  due  to  both  factors,  the  prepatellar 
bursa  is  contused.  Blood  and  portions  of  the  prepatellar  bursa  can  enter  into 
the  formation  of  the  prolapsed  prepatellar  curtain,  being  superimposed  upon 
the  aponeurotic  tissues. 

By  the  aid  of  the  open  operation,  all  inter-fragmentary  soft  tissues  are 
easily  removable.  Bony  union  presupposes  an  exact  apposition  of  two  osseous 
surfaces.  Blood  interposed  between  the  fragments,  we  do  not  consider  as  a 
foreign  body,  it  being  known  that  the  presence  of  blood  is  constant  between 
fractured  surfaces.  Intervening  tissues  of  other  description  act  as  foreign 
bodies  and  are  productive  either  of  fibrous  union  or. of  non-union.  We  concede 
that  massage  relieves  pain,  promotes  the  circulation,  and  aids  in  the  removal  of 
exudates,  but  can  it  accomplish  anythmg  towards  the  removal  of  the  soft  tissues 
that  have  prolapsed  in  the  breach  between  the  fragments?  The  attempt  to 
remove  the  inter-fragmentary  soft  tissues  by  rubbing  the  fractured  surfaces  one 
upon  the  other  is  illusory.  Interposed  soft  tissues  can  be  removed  with  cer- 
tainty only  by  means  of  the  open  operation. 

The  atrophy  of  the  quadriceps  femoris  muscle  found  in  these  cases  is  due, 
partly  to  disuse,  partly  to  extravasation  of  blood  in  the  substance  of  the  muscle, 
partly  to  associated  injury  to  the  muscle  and  to  its  contained  nerve  filaments. 
By  the  aid  of  the  open  operation,  all  blood  extravasates  can  be  removed,  fascial 
tears  sutured. 

The  patients  regain  the  use  of  their  limbs  in  a  comparatively  short  period 
of  time,  the  period  of  immobilization  is  markedly  shortened.  Active  use  pre- 
vents and  overcomes  atrophy,  attendant  upon  disuse.  Atrophy  of  the  quad- 
riceps extensor  femoris  was  recorded  in  the  cases  reported  by  Uosenberger,"^-^* 
by  Straeter,'^'^''  etc.  The  early  removal  of  all  extravasated  blood,  liquid  or 
clotted,  from  the  articular  cavity  and  from  the  periarticular  tissues,  limits  the 
liability  to  the  formation  of  adhesions,  intra-   and  extra-articular  in  nature. 

By  the  emplo3'ment  of  the  open  operative  treatment,  all  the  above-men- 
tioned obstacles  to  restoration  of  functional  integrity  can  be  more  rapidly, 
more  effectually  overcome  than  l)y  resorting  to  non-operative  methods  of  treat- 
ment, separate  or  combined.     The  open  method  makes  possible  the  removal 


760  FRACTURES  OF  PATELLA  AND  MODERN  OPERATIVE  TREATMENT. 

from  the  joint  cavity  of  detached  bony  fragments;  it  enables  the  operator  to 
absolutely  prevent  the  imion  of  the  fragments  in  a  faulty  position,  that  is,  in  a 
position  mechanically  interfering  with  the  proper  function  of  the  joint;  the 
tendency  to  adhesion  of  the  upper  patellar  fragment  to  the  femoral  condyles 
is  lessened.  Increase  in  the  dimensions  of  the  patella  following  the  open 
operative  treatment  is  a  rarity.  Any  increase  in  the  dimensions  of  the  patella 
is  very  liable  to  interfere  with  the  adaptability  of  the  patellar  and  femoral 
articular  surfaces. 

Refeeences. 

L      BocKEXHElMER:     Voii  Bergmami's  Klinik,  Arcli.  f.  Klin.  Chir.,  1903,  Vol.  LXXVIIL 
p.  187. 

2.  Wegner:     Deutsche  Zeitschr.  f.  Chir.,  1900,  Vol.  LVII,  p.  157. 

3.  Hamilton,  G.  G.:     Edinburg  Med.  Jour.,  1906,  Vol.  LXI,  p.  206. 

4a.  Mayer:      Brussels,  Verh.  d.  Dsutsch.   Cliir.  Gesellsch.,  1905,  Vol.  XXXIV,  p.   186. 

4b.  EiSENDRATii,   D.  N.:      Ills.  Med.   Jour.,   Springfield,   190.3,  Vol.  IV,  p.   736. 

5.  BuLLETT:     Amer.  Med.,  1903,  Vol.  V,  p.  211. 

6.  Wright,  J.  S.:  Intern.  Clinics,  1905,  Vol.  Ill,  p.  155. 

7.  Durand:     Lyon  Med.,  1906,  Vol.  CVI,  p.  1126. 

8.  Means,  W.   J.:      Columbus  Med.   Jour.,   1899.  Vol.  XXIII.   p.   1. 

9.  Wright,  J.  S.:     Internat.  Clinics,  1905,  Vol.  Ill,  p.  155. 

10.  ScANNELL,  D.  D.:     Boston  Med.  and  Surg.  Jour.,  1900,  Vol.  CLV,  p.  568. 

11.  BoGART,  A.  H. :  Brooklyn  Med.  Jour.,  1905,  Vol.  XIX,  p.  127. 

12.  Cox,  E.  M.:  Med.  Rec.',  1901,  Vol.  LIX,  p.  53. 

13.  Phelps,  Chas.:     N.  Y.  Med.  Jour.,  1898,  Vol.  LXVIII.  p.  871. 

14.  Trendelenburg:     Ther.  d.  Gegenwart,  1905,  Vol.  XLVI,  p.  17. 

15.  Lotheisen:     Beitr.  f.  Klin.  Chir.,  1899,  Vol.  XXIV,  p.  673. 

16.  MoscHOWiTZ:     Med.  Rec,  N.  Y.,  1904,  Vol.  LXVI,  p.  1036. 

17.  Wright,  J.  S.:     Internat.  Clinics,  1905.  Vol.  Ill,  p.  155. 

18.  Meyer,  Alfr.:     Deutsche  Zeitschr.  f.  Chir.,  Vol.  LXXXV,  p.  657. 
19a.  Doberauer:     Beitr.  z.  Klin.  Chir.,  1905,  Vol.  XLVI,  p. —. 

19b.  Battle,  W.  H.:     The  Lancet,  1898,  Vol.  II,  p.  690. 

19c.  McWiLLiAMS,  C.  S.:      Med.  Rec.  N.  Y.,  1907,  Vol.  LXXI,  p.   748. 

20a.  Erdman,  J.  E.:     Annals  of  Surg.,  1900,  Vol.  XXXII,  p.  709. 

20b.  Fells  and  Bentall:     Brit.  Med.  Jour.,  1905,  Vol.  1,  p.  75. 

21a.  Ranzi:     Arch.  f.  Klin.  Cliir.,  1906,  Vol.  LXXX,  p.  569. 

21b.  Dumstrey:     La  Presse  Med.,  1904,  Vol.  XII,  p.  197. 

21c.  Cassedebat.  p.  A.:     Arch.  Gen.  de  Med.,  Paris,  1901,  N.  S.  V.,  p.  46. 

22.  Modlin,  J.  G.:     Brit.  Med.  Jour.,  1901,  Vol.  I,  p.  826. 

23.  Championniere,  Lucas:     Arch.  Internat.  de  Chir.,  Gand.,  1903,  Vol.  I,  p.  27. 

24.  Baerlocher,  H.  :     Correspond,  f.  Schweizer  Aertze,  1903,  Vol.  XXXII,  p.  105. 

25.  Fowler:     Med.  News,  1903,  Vol.  LXXXII,  p.  592. 

26.  Ball,  Chas.   B.:   The  Practitioner,  1898,  Vol.  LX,  p.  483. 

27.  Lauper:      Correspond,  f.   Schweizer  Aertze,  1904,  Vol.  XXXIV,  p.  321. 

28.  Pilciier,  L.  S.:      Long  Island  Med.  Jour.,   1907,  Vol.   I,  p.  516. 

29.  Turner:     The  Lancet  1907,  Vol.  II  p.  1540. 

30.  MOULLIN,  C.  I\I.:     The  Lancet,  1905,  Vol.  II,  p.  879. 

31.  Stimson,  L.   a.:      "A  Practical  Treatise  on   Fractures  and  Dislocations,"  PliiJa., 

1907,  Lea  Bros.  &  Co. 
32a.    Allessandri:      Centr.  f.   Chir.,  1902,  Vol.   XXIX,  p.  473. 
32b.    Gibbon,  J.  H.:     N.  Y.  Med.  Jour.,  1906,  Vol.  LXXXIII,  p.  1070. 
32c.    Meyers,  Willy:     Ann.  of  Surg.,  1901,  Vol.  XXXIII,  p.  194. 
32d.    Lauper:      Corres.   f.  Schweizer  Aertze,   1904.  Vol.  XXXIV,  p.  321. 
33a.    Rosenberger:     Wuerzburg,  Rev.  de  Chir.,  Paris,  1899,  Vol.  XIX,  p.   120. 
33b.    Straeteb:      Zentr.   f.    Chir,,    1903,   Vol.   XXX,   p.    149. 

(Continued  in  Jununry  issue.) 


MICROSCOPY  AND   ITS  VALUE   TO  THE   MODERN   PHYSICIAN.  761 


Editorial 


MICROSCOPY  AND  ITS  VALUE  TO  THE  MODERN  PHYSICIAN. 

Magnifying  lenses  were  not  in  ii?e  nntil  alxnit  the  end  of  the  sixteenth 
century.  It  was  known  before  tlien  that  letters  were  enlarged  when  seen 
through  a  globe  filled  with  water,  but  it  was  thought  that  the  magnification 
depended  upon  the  nature  of  the  water,  or  of  the  transparent  bodies,  and  not 
upon  the  lenticular  form  of  the  glass. 

The  histor}'  of  the  microscope,  like  that  of  nations  and  sciences,  has  had 
its  brilliant  periods,  in  which  it  shone  with  uncommon  splendor.  Thus,  soon 
after  the  invention  of  the  microscope,  the  field  it  presented  for  observation 
•was  cultivated  by  men  of  the  first  rank  of  science,  who  enriched  almost  every 
branch  of  natural  history  by  the  discoveries  they  made  by  means  of  this 
instrument. 

'WTien  the  microscope  was  first  invented  it  was  regarded  as  a  mere  acces- 
sory, a  plaything,  an  unnecessary  addition  and  an  imposition  upon  the  medical 
profession,  and  upon  the  public  in  general.  However,  now,  it  is  regarded  as 
an  extreme  nece:-sity,  especially  in  minute  examinations  and  investigations, 
also  in  the  advancement  of  every  branch  of  science  and  art. 

When  the  microscope  first  made  its  appearance,  the  public  considered 
minute  organisms  too  despicable  to  demand  notice,  but,  however,  these  same 
individuals  were  highly  perplexed  at  the  stupendous  destruction  which  visited 
their  crops  and  destroyed  them.  However,  the  microscope  beheld  the  cause 
of  the  destruction  in  a  tiny  fungus,  whose  rapid  propagation  and  multiplica- 
tion wrought  havoc. 

The  microscope  has  now  been  perfected  to  such  a  degree  that  it  is  possible 
to  see  the  minutest  bacilli,  and  has  thus  led  to  important  results  in  the  treat- 
ment of  disease.  A  physician  without  a  microscope  is  like  a  man  without  eyes. 
He  is  uncertain  and  unprotected,  and  must  be  considered  incompetent  simply 
because  he  is  unable,  without  the  aid  of  the  microscope,  to  arrive  at  a  correct 
diagnosis.  If  a  man  persists  in  the  ways  of  former  days,  using  the  implements, 
practicing  the  technic,  persisting  in  the  halnts  that  characterized  generations 
of  the  past,  he  is  considered  a  back  number. 

It  is  a  striking  truth,  that  few  of  the  great  phenomena  of  nature  are  pro- 
duced by  great  and  visible  causes,  and  so  it  is  in  medicine.  We  believe  that 
the  microscopic  life  which  teems  in  the  ocean,  the  land,  and  the  air,  plays  the 
highest  and  most  important  part  in  the  economy  of  creation. 

Its  value  in  tlie  physician's  office  cannot  be  overestimated  in  the  examina- 
tion of  sputa  of  our  patients,  and  thus  being  able  to  say  positively  whether 
the  man  is  suffering  from  tul)ercu]osis,  pneumonia,  streptococcic  or  stapliylo- 
coccic  infection.  How  important  it  is  to  l)e  able  to  state  with  certainty,  and 
at  an  early  date,  whether  or  not  the  patient  is  suffering  from  cancer  of  tlie 
stomach,  by  examining  the  vomitus  microscopically.     The  diagnosis  and  imme- 


762       OSTEOTOMY  OF  THE  CUJS'EIFORM.  PURULEIs'T  PERITONITIS. 

diate  recognition  of  diphtheria  is  made  possible  from  a  smear  preparation 
of  the  exudate,  and  thus  distinguish  the  Klebs-Loffler  bacilli,  through  the  aid 
of  the  microscope.  Upon  the  microscope  often  depends  the  diagnosis  of  t3'phoid 
fever,  by  means  of  the  Widal  reaction.  In  many  cases  the  absolute  diagnosis 
of  gonorrhoea  depends  upon  a  microscopic  examination  of  the  discharges,  which 
is  very  important  from  a  medico-legal  point  of  view. 

It  is  often  impossible  for  the  surgeon  to  make  a  positive  diagnosis,  in  cases 
in  which  malignancy  is  suspected,  of  the  growth  removed  by  the  operation, 
without  the  aid  of  the  microscope.  The  microscope  has  led  to  the  development 
of  the  germ  theory,  the  discovery  of  antitoxin,  and  the  greatest  boon  to  man- 
kind— the  realization  of  aseptic  surgery,  and  reveals  with  ease  the  method 
of  spreading  disease.  It  follows  up  the  ravages  of  disease,  and  the  many 
abstruse  and  morbid  phenomena  of  life  and  death. 

Much  has  already  been  written  of  late  years  concerning  the  microscopic 
application  in  a  medico-legal  sense.  Everything  that  concerns  medical  examina- 
tions in  a  legal  sense,  can  be  facilitated,  and  occasionally  determined,  by  the 
use  of  the  microscope.  It  can  be  applied  particularly  in  malpractice  suits, 
suits  of  damages,  and  especially  those  cases  which  depend  upon  the  detection 
of  any  adulteration  of  food  or  drink.  In  the  author's  experience,  there  is  an 
instance  on  record  where  a  man  was  found  dead  and  covered  with  blood. 
Nothing  was  found  about  the  dead  man  except  an  axe  covered  with  blood,  and 
some  hairs.  It  was  now  thought  that  a  clue  was  obtained  leading  to.  the  dis- 
covery of  the  murderer,  and  the  hatchet  was  submitted  to  microscopic  examina- 
tion. The  report  proved  that  the  hair  found  was  that  of  an  animal,  and  not 
of  a  man.  This  was  also  confirmed  by  the  events  of  the  trial,  and  the  evidence 
fell  to  the  ground.  To  the  microscope  this  person  was  not  only  indebted  for 
the  declaration  of  his  innocence,  but  also  the  preservation  of  his  life. 


/Vlatcria  /Vlcdica  and  Therapeutics 


OSTEOTOMY  OF  THE  CUNEIFORM  FOR  dressment  of  the  big  toe  follows,  and 

HALLUS  VALGUS.  after  suture  of  the  wound,  a  plaster  of 

Dr.  E.  Eeidl,  Linz,  describes  a  new  pro-  Paris    dressing   is    applied,    the    author 

cedure  in  the  treatment  of  hallus  valgus,  advises  the  wearing  of  a  cast  until  bony 

He  states  that  a  longitudinal  incision  is  union    has    occurred.      The    skiagrams 

made  over  the  inner  border  of  the  foot,  taken    several    months    after    operation 

so  as  to  expose  the  internal  border  of  the  show  an  ideal  result.     (Archiv.  fiir  klin- 

cuneiform  and  corresponding  tarso-meta-  ische  Chirurgie,  1909,  Vol.  88,  No.  2.) 

tarsal  articulation.     A  wedge  with  base  

outward  is  cut  out  of  the  cuneiform  and  PURULENT    peritonitis,    TREATMENT 

the  base  of  the  metatarsal  is  sufficiently  OF. 

liberated  to  make  it  mobile.     The  bone  Dr.  N.  Gulcke  summarizes  the  prin- 

is  then  forced  from  its  position  of  adduc-  ciples  in  the  treatment  of  this  disease, 

tion  into  normal,  parallel  relations.     Ee-  Small  incisions,  especially  in  peritonitis 


RUBBER  BANDS  FOR  DRAINAGE. 


SCAPULOPEXY  IN  MYOPATHY. 


763 


following  appendicitis,  general  anaes- 
thesia; search  for  the  cause  of  the  sup- 
purative process  and  its  removal  if  pos- 
sible (extirpation  of  the  appendix,  suture 
of  the  perforation,  etc)  ;  avoidance  of 
eventration  of  the  intestines  whenever 
possible  or  their  rapid  replacement; 
suture  of  the  wound;  no  irrigation  with 
saline  solutions,  but  during  the  first  two 
days  abundant  subcutaneous  infusion, 
two  to  four  quarts  daily,  also  rectal  injec- 
tions of  hot  saline  solution;  removal  of 
the  drains  on  the  third  day;  in  perito- 
nitis resulting  from  appendicitis  intro- 
duction of  the  drain  into  the  Douglas 
pouch  and  a  counter-incision,  usually  on 
the  left  side,  with  insertion  of  another 
drain  into  the  pouch.  Among  the  thirty- 
three  cases,  comprising  various  forms  of 
peritonitis,  recovery  took  place  in  twenty, 
60.6  per  cent.  The  greatest  mortality 
was  in  perforation  peritonitis,  all  the  pa- 
tients dying;  the  least  in  peritonitis  due 
to  appendicitis,  75  per  cent  of  cures. 
From  the  statistics  Guleke  concludes  that 
over  one-half  of  such  eases  can  be  saved 
by  prompt  intervention.  (Beitrage  z. 
klin.  Chir.,  Bd.  60.) 


RUBBER  ELASTIC  BANDS  FOR  DRAINAGE. 

Dr.  E.  Stanley  Eyerson  has  found  the 
ordinary  elastic  band  a  convenient  means 
of  carrying  out  the  principles  of  wound 
drainage.  The  discharge  was  found  to 
run  up  between  the  approximated  surface 
of  the  two  layers  of  rubber,  as  well  as 
between  the  outer  surface  of  the  band 
and  the  surrounding  wall  of  the  sinus. 
The  bands  can  be  easily  introduced  and 
removed  without  causing  pain.  The 
flexibility  of  the  bands  allows  the  cavity 
to  collapse  and  thus  haptens  the  healing 
process.  The  size  to  be  used  will  depend 
upon  the  depth  and  capacity  of  tl'e 
cavity,  the  length  of  the  wound  into  the 


cavity,  and  the  amount  of  discharge  from 
it.  They  can  be  sterilized  by  boiling  and 
kept  ready  for  use  in  bichloride  solution. 
To  prevent  them  from  slipping  into  the 
wound  the  outside  is  left  long,  or  a  small 
strip  of  dressing  is  passed  through  the 
outer  loop,  or  a  safety  pin.  (Can.  Lan- 
cet, July,  1909.) 


SCAPULOPEXY  IN  MYOPATHY. 
Dr.  Panchet  recommends  operative 
treatment  for  this  disease  as  it  serves 
to  re-establish  a  relative  functional 
capacity  and  ability  to  work.  Scapu- 
lopexy  was  successfully  performed  in  a 
case  of  juvenile  muscular  dystrophy 
(Erbs  type),  in  which  the  shoulder  mus- 
cles of  both  sides  were  involved  in  the 
atrophy,  both  shoulders  presenting  dis- 
tinct flail-joints.  Surgical  interference 
was  resorted  to  on  the  basis  of  the  reflec- 
tion that  under  manual  fixation  of  the 
scapula — which  projected  under  the 
fashion  of  a  wing — the  arm  could  be 
raised  to  the  horizontal  plane,  and  the 
hand  be  placed  upon  the  head.  The  in- 
sertion of  the  first  to  ninth  rib  was 
exposed  by  a  longitudinal  incision  two 
fingers'  width  away  from  the  spinous 
process  and  parallel  with  these;  the 
inner  margin  of  the  scapula  was  fresh- 
ened, and  so  were  the  corresponding 
points  of  the  ribs.  A  number  of  holes 
were  bored  through  the  scapula,  and 
wires  were  pulled  through,  twisted 
around  the  rib,  and  fastened  in  place. 
The  outcome,  after  bony  union  had 
occurred,  was  excellent,  as  had  been 
'anticipated,  the  scapula  occupied  its 
nonnal  anatomic  level,  and  the  arm 
could  be  raised  to  the  horizontal  plane. 
The  results  obtained  by  the  interference 
were  especially  well  illustrated  by  com- 
parison with  the  side  which  had  not 
been  operated  upon.  (Bull,  et  mem.  de 
la  Soc.  de  Chir.  de  Paris,  I,  XXXIV.) 


764        SODIU-M  CHLORIDE  IN  HAEMORRHAGE. 


TREATMENT  OF  QUINSY. 


SODIUM   CHLORIDE  IN  INTERNAL 
HEMORRHAGE. 

Dr.  R.  von  den  Velden  shows  that 
chlorides  and  also  the  bromides  have  a 
pronounced  hffimostyptic  effect,  this 
action  being  probably  due  to  the  with- 
drawal of  water  from  the  tissues,  with 
mobilization  of  a  component  of  the 
coagulative  process    (thrombokinasis.) 

The  dose  given  by  mouth  in  the 
author's  prescriptions  never  exceeds  5 
Gm.,  which  suffices  to  induce,  within  a 
few  minutes,  an  increase  of  the  coagu- 
lative power  of  the  blood,  lasting  from 
one  hour  to  an  hour  and  a  half.  In  a 
case  of  delicate  stomach,  or  when  an 
especially  rapid  and  strong  effect  is 
desired  3-5  centimeter  of  a  sterile 
common  salt  solution  (10  per  cent.)  may 
be  injected  into  a  vein  of  the  arm. 
(Deutsche  mod.  Wochensehrift,  XXXV, 
1909.) 


SUPPURATION  OF  THE  ACCESSORY 
SINUSES,  TREATMENT  OF. 

Dr.  Martens  states  that  the  aspiration 
method,  a  procedure  which  has  not  yet 
received  sufficient  consideration,  is  a  very 
valuable  diagnostic  aid  in  suppuration  of 
the  accessory  nasal  sinuses.  The  pus  can 
be  brought  out  by  means  of  aspiration, 
especially  in  the  case  of  the  ethmoid  cells. 
A  single  aspiration  will  not  suffice,  how- 
ever, and  when  the  pus  is  stringy  or 
scanty  a  duration  of  from  three  to  five 
minutes,  and  an  aspiratory  force  of  from 
15  to  25  centimeters,  mercury  column, 
are  required.  The  author  constructed  a 
pump  with  a  vacuum  meter  for  this  pur- 
pose, which  may  be  utilized  for  thera- 
peutic procedures.  In  the  presence  of 
extensive  changes  in  the  mucosa  and  the 
bone,  the  aspiration  method  alone  is 
insufficient;  but  there  are  many  cases 
in  which  it  will  accomplish  the  desired 


object,  without  necessitating  the  use  of 
the  knife.  Among  the  numerous  acute 
empyemata  which  recover  spontaneously, 
and  the  various  chronic  suppurations 
which  fail  to  heal  without  operation, 
there  are  many  cases  of  suppuration  of 
the  ethmoid  cells,  the  frontal  sinus,  and 
the  sphenoid  sinus,  which  may  be  suc- 
cessfully treated  by  conservative  meas- 
ures in  shape  of  aspiration.  (Deutsche 
Wochensehrift,  Xo.  4,  1909.) 


TAMPONING    IN    THE    TREATMENT    OF 
PROLAPSE  OF  RECTUM. 

Dr.  P.  Sick  expatiates  on  the  advan- 
tages of  tamjjoning  in  treatment  of  pro- 
lapse of  the  rectum.  An  incision  is 
made  between  the  tip  of  the  coccyx  and 
the  circular  sphincter  fibers,  through  the 
superficial  fascia  into  the  loose  connective 
tissue  behind  the  rectum.  There  are  no 
vessels,  muscles  or  nerves  to  be  injured  at 
this  point.  The  rectum  is  then  detached 
up  to  the  promontory,  as  for  resection, 
tamponed  with  a  little  gauze,  and  a  strip 
of  medicated  gauze,  folded  four  or  six 
times  is  introduced.  The  incision  3  or  -1 
centimeters  long  is  closed  with  plaster 
or  collodion.  The  tampon  is  removed  as 
after  a  nephropexy  in  one  or  two  weeks, 
but  not  until  after  the  second  or  third 
week  should  the  patient  be  allowed  to 
defalcate  seated.  This  technic  is  espe- 
cially applicable  for  children,  and  he 
thinks  it  is  much  superior  to  the  Ekehorn 
technic,  which  he  declares  is  neither 
simple,  harmless,  nor  promising  of  per- 
manent results.  (Zentrall)latt  fiir  Clii- 
rurgie,  Leipsic.) 


TREATMENT  OF  QUINSY. 
Dr.  D.  J.  Guthrie  reports  successful 
results  of  his  treatment  of  this  affection. 
In  a  case  which  he  reports  the  supra- 
lonsillar  swelling  was  opened  in  the 
usual  way  with  bistoury  and  sinus  for- 


TUBERCULIM   Ibi  TUBERCULOSIS. 


VACCINE  IN  ASTHMA. 


765 


ceps,  and  a  quantity  oi'  blood-stained  pus 
evacuated.  A  tent  was  erected  over  the 
bed,  and  inhalation  of  steam  with  com- 
pound tincture  of  benzoin  was  given  con- 
stantly— a  measure  which  afforded  the 
patient  much  relief — and  a  calomel  purge 
was  administered.  Toward  evening  the 
swelling  had  slightly  diminished,  but 
swallowing  was  still  impossible  and 
speech  thick.  Ice  was  ordered  to  be 
sucked  at  intervals,  and  instructions 
given  that  2  drams  of  brandy  be  admin- 
istered every  three  hours  as  soon  as  the 
patient  was  able  to  swallow.  On  the  fol- 
lowing morning  the  patient  was  able  to 
swallow  with  little  difl&culty  and  oedema 
had  diminished.  Temperature  was  99  de- 
grees ;  pulse  85.  The  tonsil  of  the  opposite 
side  was  found  to  be  covered  with  yellow- 
ish spots  (follicular  condition).  A  throat 
spray  of  peroxide  of  hydrogen  was  recom- 
mended and  the  steaming  discontinued. 
A  mixture  containing  5  minims  of  liquor 
strychninas  and  15  minims  liquor  ferri 
perchloridi  to  each  (B.  P.)  dose  was  pre- 
scribed. Following  this  the  condition 
rapidly  improved,  oedema  and  swelling 
diminished  and  the  patient  made  an  un- 
eventful recovery.  (Glasgow  Medical 
Journal,  September,  1909.) 


TUBERCULIN  TREATMENT  OF  PULMO- 
NARY TUBERCULOSIS. 
Dr.  P.  K.  Pel  states  that  tuberculin 
is  still  in  the  period  of  trial.  He  has 
been  unable  to  acquire  much  enthusiasm 
for  it.  There  are  so  many  unaccountable 
by-effects,  such  as  headache,  fever,  in- 
somnia, rheumatoid  pains,  loss  of  appe- 
tite and  weight,  acceleration  of  the  pulse 
and  general  depression,  while  acute  ex- 
acerbations or  con)plications  of  the  tuber- 
culous process  may  be  encountered,  as 
also  an  individual  hypersusceptibility  to 
tuberculin.  The  course  of  treatment  is 
so  long,  so  complicated,  the  indications 


are  so  restricted  and  there  are  so  many 
contra-indications,  that  he  declares  the 
failure  to  institute  tuberculin  treatment 
is  not  a  sin  of  omission,  for  the  present. 
The  clinics,  hospitals  and  sanatoriums 
should  make  a  point  of  comparative  and 
critical  study  of  tuberculin  treatment  to 
place  it  on  a  solid  basis.  (Berliner 
Klinische  Wochenschrift,  Sept.  20,  '09.) 


VACCINE  IN  BRONCHIAL  ASTHMA. 

Dr.  D.  W.  Carmalt-Joncs  suggests  that 
one  cause  of  spasmodic  dyspnoea  in 
chronic  bronchitis  is  a  specific  bacterial 
toxin,  the  result  of  a  definite  infection 
and  amenable  to  treatment  by  the  cor- 
responding vaccine.  In  1907,  while  mak- 
ing some  investigations  into  the  bacteri- 
ology of  chronic  bronchitis,  he  isolated  a 
certain  organism  in  nearly  pure  culture 
from  the  sputum  of  a  female  patient. 
He  took  her  opsonic  index  to  this,  and 
finding  it  low,  suggested  inoculation,  to 
which  she  agreed.  She  was  given  a  dose 
of  25  millions  hypodermicalh',  and  was 
instructed  to  come  back  in  two  days.  She 
suffered  severely  from  bronchial  asthma. 
On  her  return  she  said  that  though  her 
cough  was  no  better,  her  breathing  had 
been  much  relieved.  Carmalt-Jones  used 
the  same  vaccine  extensively  among  pa- 
tients suffering  from  bronchial  asthma, 
in  about  70  cases  in  all,  and  of  these  he 
liad  collected  52,  who  gave  the  experi- 
ment a  fair  trial,  that  is,  who  attended 
for  inoculation  at  least  twice.  Taking 
results  as  a  whole,  31  patients  have  found 
some  degree  of  improvement  in  the  fre- 
quency, and  39  in  the  severity  of  their 
attacks;  26  have  improved  in  their 
powers  of  taking  exercise,  and  29  have 
slept  better.  In  some  cases  improve- 
ment has  been  sliglit  and  in  others  tem- 
porary. In  4  patients  no  improvement 
at  all  has  resulted.  (Britisli  "Medical 
.Tournal,  October  9th.) 


766 


X-RAYS  FOR  PROSTATIC  CONCRETIONS. 


BOOK  REVIEWS. 


X-RAYS  FOR  PROSTATIC  CONCRETIONS. 

Dr.  Gosta  Forrsell,  in  Munch.  Med. 
Woch.,  discusses  the  use  of  the  X-ray  in 
the  diagnosis  of  concretion  of  the  prostate 
gland.  He  made  X-ray  photographs  of 
eleven  cadavers,  and  then  dissected  out 
the  glands.  Among  these  there  were 
two  with  prostatic  stones.  He  also  ex- 
amined one  hundred  living  patients.  The 
author  gives  details  of  the  exact  position 
in  which  the  patient  should  be  placed  in 
order  that  the  symphysis  may  not  hide 
the  concretions.  He  intensified  his  plates. 
In  thirteen  of  the  one  hundred  clinical 
cases  prostatic  stones  were  found.  These 
were  of  two  types.  The  first  type  were 
found  in  ten  cases  and  the  second  in 
three.  In  the  first  type  the  shadows  of 
the  stones  appeared  as  small  discrete 
round  dots,  varying  in  size  from  pinliead 
to  that  of  a  hempsced,  arranged  sym- 
metrically on  both  sides  of  the  midline 
just  above  the  symphysis.  The  histories 
showed  no  etiological  factor,  the  concre- 
tions seeming  to  be  nonnal  results  of  old 


age.  Between  the  ages  of  twenty  and 
fifty  they  occurred  in  only  five  per  cent, 
of  the  cases,  while  between  fifty  and 
ninety-three  they  were  found  in  twenty 
per  cent.  In  the  second  t}^e  the  shadows 
occurred  as  good-sized  patches  made  up 
of  conglomerations  of  the  small  ones. 
These  appeared  higher  up  in  the  pelvis, 
from  1.5  to  3.0  centimeters,  above  the 
symphysis.  This  type  does  not  seem  to 
be  so  definitely  a  senile  condition,  as  it 
occurs  in  middle  life.  It  appears  to  be 
caused  by  pathological  changes.  Forr- 
sell  concludes  that  his  researches  have 
demonstrated  that  the  position,  arrange- 
ment, form  and  density  of  prostatic  con- 
cretions are  very  characteristic,  and  that, 
as  a  rule,  the  differentiation  from  otber 
concretions  within  the  pelvis  is  possible. 
Also,  that  prostatic  stones,  both  nonnal 
and  pathological,  are  much  more  com- 
mon than  previously  thought,  and  that 
they  can  be  discovered  by  a  careful  X-ray 
examination.  (Medical  Standard,  Sept., 
1909.) 


5ook  Reviews 


American  Illustrated  INIedical  Dictionaby.  A  New  and  Complete  Dictionary  of  Terms 
Used  in  Medicine,  Surgery,  Dentistry,  Pharmacy,  Chemistry,  Nursing,  and  Kindred 
Branches;  with  New  and  Elaborate  Tables  and  many  Handsome  Illustrations,  "llie 
New  (Fifth)  Revised  Edition.  By  W.  A.  Newman  Dorland,  M.D.  Large  Octavo  of 
876  Pages,  Avith  2.000  New  Terms.  Philadelphia  and  London:  W.  B.  Saunders  Com- 
pany, 1909,     Flexible  leather,  $4.50,  net;    indexed,  $5.00,  net. 

It  would  be  difficult  to  mention  a  more  useful  book  than  the  "American  Illustrated 
Medical  Dictionary."  The  aim  of  tliis  boolv  is  to  furnish  full  definitions  of  the  terms  used 
in  medicine  and  its  allied  sciences,  and  such  collateral  definitions  of  the  terms  of  medicine 
and  kindred  branches. 

The  important  features  of  this  work  are  the  attractive  appearance,  convenient  size, 
colored  plates,  and,  above  all,  the  anatomical  and  clinical  tables,  as  well  as  elaborate  tables 
on  arteries,  muscles,  nerves,  veins,  etc.;  of  bacilli,  bacteria,  diplococci,  micrococci,  etc., 
weights  and  measures,  eponj'mic  table  of  diseases,  operations,  signs  and  symptoms,  stains,  tests, 
methods  of  treatment,  etc. 

Everything  is  concise  and  complete,  and  is  arranged  in  a  shape  complete  for  quick 
reference.  The  pronunciations  are  simple,  and  easily  understood,  and  the  definitions  are 
trustworthy. 

The  print  is  excellent,  and  it  will  indeed  prove  an  indispensable  work  of  reference. 


BOOK  REVIEWS.  767 

SuEGiCAL  Diagnosis.  By  Daniel  N.  Eisendiath,  M.D  ,  Professor  of  Surgery  in  the  Medical 
Department  of  the  University  of  Illinois  (College  of  Physicians  and  Surgeons).  Second 
Revised  Edition.  Octavo  of  885  Pages,  with  574  Original  Illustrations,  25  in  Colors. 
Philadelphia  and  London:  W.  B.  Saunders  Company,  1909.  Cloth,  $0.50,  net;  Half- 
morocco,  $8.00  net. 

The  study  of  surgical  diagnosis  is  perhaps  the  most  significant  characteristic  of 
medical  science  to-day.  Tl'ie  necessity  of  making  a  correct  diagnosis  before  instituting  treat- 
ment, is  the  great  aim  of  the  author  throughout  this  volume.  Every  afi"ection  is  described, 
step  by  step,  and  renders  the  diagnosis  easy  by  grouping  the  various  injuries  and  diseases 
in  the  manner  in  which  the  surgeon  or  general  practitioner  must  consider  them  when  he 
examines  a  patient  for  the  purpose  of  making  a  correct  diagnosis. 

The  exposition  is  clear  and  lucid,  and  the  writer  has  taken  pains  to  give  tabulated 
differential  diagnostic  tables  to  differentiate  those  affections  which  simulate  each  other. 

The  volume  is  divided  into  eight  chapters:  Chapter  I,  Surgical  Aflections  of  the  Head; 
II,  Surgical  Affections  of  the  2seck;  III,  Thorax;  IV,  Abdomen;  V,  The  Extremities; 
VI,  Diseases  and  Injuries  of  the  Spine;  VII,  Postoperative  Complications;  VIII,  Methods 
of  Examination. 

In  the  text,  the  descriptions  of  the  various  conditions  are  described  according  to  the  par- 
ticular case;  general  statements  being  avoided.  Every  description  is  complete  in  itself. 
Especially  noteworthy  are  the  chapters  on  "Cerebral  Localization,"  "Cystoscopy  and  Ureteral 
Catheterization,"  "Abdominal  Tumors,"  Acute  Abdominal  Affections,"  "Hernia,"  etc. 

The  author  proves  himself  to  be  an  .able  diagnostician.  This  work  is  profusely  illustrated, 
containing  574  original  illustrations,  25  of  them  in  colors,  and  every  one  of  them  show 
every  detail  that  the  author  endeavors  to  bring  out. 

A  Text-book  of  Obstetrics:  Including  Related  Gynecologic  Operations.  By  Barton  Cooke 
Hirst,  M.D.,  Professor  of  Obstetrics  in  the  University  of  Pennsylvania.  Xew  (Sixth) 
Revised  Edition.  Octavo  of  992  Pages,  with  847  Illustrations,  4.3  of  them  in  Colors. 
Philadelphia  and  London:  W.  B.  Saunders  Company,  1909.  Cloth,  $5.00  net;  Half- 
morocco,  $6.50,  net. 

In  this  splendid  volume  there  is  afforded  a  striking  demonstration  of  the  fact  that  all 
the  diseases  of  women  must  be  considered  in  relation  with  the  chief  act  in  woman's  history, 
child-bearing.     The  vast  majority  of  them  are  consequences  of  that  process. 

The  systematic  way  in  which  the  author  has  covered  the  subject  is  admirable.  It  has 
been  the  constant  aim  of  the  author  to  condense  the  text,  as  far  as  consistent  with  a  com- 
prehensive treatment  of  the  subject.  The  work  is  one  of  surpassing  excellence,  and  an  ex- 
tensive amount  of  original  drawings  and  photographs  have  been  employed,  which  show  con- 
siderable care  and  forethought. 

The  book  is  divided  into  seven  parts:  Part  I,  Pregnancy;  Part  TI,  Tlie  Physiology  and 
Management  of  Labor  and  of  the  Puerperiuni;  Part  III,  The  Mechanism  of  Labor;  Part  IV, 
The  Pathology  of  Labor;  Part  V,  Pathology  of  the  Puerperium;  Part  VI,  Obstetric  Opera- 
tions;   Part  VII,  The  Newborn  Infant. 

All  the  chapters  are  good,  and  nothing  of  importance  seems  to  have  been  left  unsaid. 
A  complete  and  comprehensive  text-book,  and  as  such  can  be  highly  recommended  to  students, 
general  practitioners,  and  specialists. 

A  Practical  Treatise  ox  OpnTHALMOLOGY.  By  L.  Webster  Fox,  M.D.,  LL.D.,  Professor  of 
Ophthalmology  in  the  Medico-Chirurgical  College;  Ophthalmic  Surgeon  in  the  Medico- 
Chirurgical  Hospital,  Philadelphia,  Pa.;  Member  of  the  Army  Reserve  Medical  Corps, 
Etc.  Cloth,  807  Pages,  with  Six  Colored  Plates  and  300  Hlustrations  in  the  Text. 
New  York  and  London:     D.  Appleton  &  Co.,  1910.     Price,  $G.00. 

The  ceaseless  production  of  text-books  on  ophthalmolog^'  has  so  sorely  tried  reviewers 
and  literary  critics,  that  it  is  refreshing  to  have  the  work  under  consideration  before  us.  No 
end  of  innovations  have  been  attempted,  to  elevate  sucli  books  from  the  general  class,  so  as 
to  serve  the  needs  of  both  specialist  and  genera!  practitioner  alike;  yet,  there  still  remained 
a  gap  to  be  spanned.  This  book  cannot  be  justly  reviewed  as  a  whole,  as  its  individual 
merits  are  too  striking  to  be  simply  mentioned  in  a  general  criticism.  The  chapters  on 
"Embryology"  and  "Anatomy"  are  concise  and  authoritative  desiderata  often  lacking  in  what 
are  at  best  rather  diflicult  subjects  to  manage  in  a  practical  treatise.     Plate  II,  showing 


768  .  BOOK  REVIEWS. 

the  origin  and  distribution  of  the  optic  nerve  fibers,  is  conspicuous  for  its  lucidity  and 
artistic  execution.  The  chapter  on  "Diseases  of  the  Eyelids"  is  unusuallj'  complete.  Espe- 
cially noteworthy  of  mention  are  tlie  parts  devoted  to  "Herpes  Zoster  Ophthalmicus," 
"Xanthelasma,"  "Ptosis,"  "Ectropion"  and  "Entropion."  In  the  chapter  on  the  "Lacrymal 
Apparatus"  we  find  a  beautiful  delineation  of  the  operation  for  extirpation  of  the  lacrymal 
sac.  The  diseases  of  the  conjunctiva  are  considered  abreast  of  the  progress  in  bacteriologj', 
this  chapter  being  alone  a  valuable  monograph  on  the  subject.  It  is  gratifying  to  note  the 
consideration  given  the  newly  discovered  trachoma  bodies,  although  it  is  to  be  regretted  that 
their  morphology  is  still  somewhat  obscure;  but  on  the  whole,  the  subject  has  been  treated 
with  due  regard  to  contemporaneous  literature. 

Wliile  the  rarer  forms  of  corneal  disease  are  not  discussed  in  extenso,  a  commendable 
characteristic  in  every  practical  treatise,  their  classification  is  nevertheless  unusually  clear. 
Ophthalmic  surgeons  will  find  in  the  chapter  several  original  and  undoubtedly  useful  thera- 
peutic procedures.  The  chapter  on  the  "Iris  and  Ciliary  Body"  appeals,  first  of  all,  to  the 
student,  for  here  he  will  find  a  comprehensive  table  sliowing  the  diflerential  diagnosis  be- 
tween conjunctivitis,  iritis,  and  glaucoma,  subjects  which  so  often  try  both  student  and 
teacher.  The  chapters  devoted  to  the  "Diseases  of  the  Choroid,  Retina,  and  Optic  Nerve" 
are  manifestly  the  result  of  a  ripe  experience  in  ophthalmoscopy,  and  present  the  full  pano- 
rama of  knowledge  which  the  ophthalmoscope  has  revealed.  Color-perception  and  color- 
blindness are  not  only  discussed  from  the  ophthalmological  standpoint,  but  are  prefaced 
by  an  outline  of  the  physics,  and  appended  by  a  description  of  the  various  practical  tests, 
long-felt  wants  by  railroad  surgeons.  The  chapter  on  "Glaucoma"  merits  the  closest  observa- 
tion and  study,  as  it  is  modern  and  authoritative  throughout.  The  chapters  devoted  to 
"General  Diseases,"  "Nervous  Diseases,"  and  the  "Pupil  in  Health  and  Disease,"  again 
prove  the  necessity  for  every  specialist  being  a  general  clinician,  and  disprove  the  ab- 
surd demarcation  of  specialism  from  general  medicine.  Refraction  and  the  extra-ocular 
muscles  are  thoroughly  discussed  in  a  manner  which  should  equip  every  general 
practitioner  studying  these  chapters  with  a  practical  working  knowledge  of  the  subjects. 
A  chapter  on  "Operative  Technique"  and  one  on  "Laboratory  Technique"  are  the  final  chapters, 
a  complete  and  accurate  index  finishing  the  work.  The  illustrations  throughout  the  book 
must  be  seen  to  be  appreciated,  and  they  reflect  great  credit  both  ujion  the  author  and  the 
publishers.  In  attempting  to  present  correct  illustrations  of  such  conditions  as  blastomycosis 
of  the  eyelid,  herpes  zoster,  ophthalmicus,  extirpation  of  the  lacrymal  sac,  peridectomy, 
Hutchinson  teeth,  the  proper  way  of  holding  instruments,  Mules'  operation,  and  many  other 
conditions,  the  author  and  publishers  have  set  themselves  a  ditllcult  task,  which,  nevertheless, 
has  been  most  satisfactorily  overcome.  The  illustrations  showing  the  proper  way  of  holding 
various  ophthalmic  instruments  inaugurates  a  new  departure  in  a  text-book  on  ophthalmologj'. 
These  illustrations  forcibly  present  the  fact  that  the  manner  of  holding  ophthalmic  instru- 
ments is  not  immaterial,  something  which  urgently  needs  implantation  in  this  country,  where 
the  "Handhabung  der  Instrumente"  of  the  German  master  operators  is  too  often  a  closed 
book.  The  author  makes  no  extravagant  statements  in  his  preface,  at  no  time  is  he  ultra- 
scientific,  he  has  been  most  considerate  of  contemporaneous  literature,  and  generous  in  the 
quotations  of  his  colleagues.  Here  and  there,  a  punctuation,  a  letter  slightly  misplaced,  or  a 
slight  ambiguity  in  diction  may  be  encountered,  and  these  have  to  be  found  with  a  searchlight. 
There  is  only  one  mistake  that  we  feel  that  the  author  has  made,  namely,  by  not  giving 
us  more  books  from  his  pen,  which  is,  however,  amply  compensated  for  by  the  quality  of 
his  latest  production,  which  must  remain  a  classical  authority  on  the  subject. 


INDEX 

MONTHLY  CYCLOPEDIA  SECTION 


BALDWIN,  EDWARD  R.,  393. 
BARNES,  HARRY  LEE,  580. 
BENEDICT,  A.  L.,  641. 
BLAKE,   CLARENCE  JOHN, 

475. 
BRAV,  HERMAN  A.,  268. 
BROWNING,  C.  C,  207. 
BUTLER,  MARGARET  F.,  7. 
DEAVER,  JOHN  B.,  257. 
DOWNING,  BERTHA  C,  528. 
FLICK,  LAWRENCE  F.,  456. 
GOLDTHWAIT,  JOEL  E.,  270. 
GORDON,  ALFRED,  199. 
GREEN,  THOS.  G.,  136. 
HANSELL,  HOWARD  F.,  75, 

594. 
HEMMETER,  JOHN  C,  449. 


List  of  Contributors 

HINSDALE,    GUY,    193. 
HUBER,    JOHN    B.,    10. 
JACOBI,   A.,   385. 
KING,   ALFRED,   467. 
KOLIPINSKI,    LOUIS,    65,    129, 

328. 
LAPLACE,    ERNEST,   717. 
MCCARTHY,    D.    J.,   709. 
McKEE,  JAMES  H.,  513. 
MATAS.   RUDOLPH,   705. 
MUSCHLITZ,    C.   H.,   13. 
OLIVER,  CHARLES  A.,  651,  721. 
PHILLIPS,   W.    F.    R.,   522. 
POTTENGER,   F.    M.,   1. 
RICHARDSON,    CHARLES    W., 

577. 
RIEWEL,   H.   v.,   587. 


ROBBINS,    H.   A.,    519. 
SAJOUS,    C.    E.    DE    M.,    16,    83, 

211,   278,   341,  533,  596,  662. 
SCHUMANN,    E.    A.,  80. 
SIDIS,    BORIS,    473. 
SMALL,  H.   BEAUMONT,  599. 
STEWART,  F.   E.,  335,   397. 
STILLMAN,   WILLIAM   O.,  658. 
TAYLOR,     J.     MADISON,     150, 

403,   712. 
UNDERHILL,   F.   P.,   460. 
UPSON,    HENRY   S.,   648. 
WEAVER,   H.    B.,   272. 
WILCOX,     REYNOLD    WEBB., 

i333. 
WILEY,    H.    W.,    321. 
WILLIAMS,  TOM  A.,  146,  468. 


Names  of  Authors  Quoted  During  the  Year  1909 


Adami,   J.    G.,    729. 

Amberg,   Eniil,  347. 

Andalo,    F.,    670. 

Andre,  Ch.,  23. 

Antenore,    N.,    544. 

Arloing,   F.,  26. 

Arloing  F.,  and  P.  Courmont,  30 

Armstrong,   J.    M.,    349. 

Auld,  A.  G.,  89. 

Baboock,   R.  H.,  411. 
Baird,  A.  W.,  603. 
Baldwin,    E.    R.,    157,    393. 
Barker,  Llewellys  F.,  and  F.  M. 

Hanes,    667. 
Barlach,  20. 

Barnes,   Harry  Lee,   580. 
Basch,   K.,   222. 
Bashford,    E.    F.,   599. 
Benedict,    A.    L.,    641. 
Bettmann,   H.   W.,   21. 
Blake,   Clarence  John,  475. 
Blake.   E.   M.,  348. 
Blumfeld,    J.,    543. 
Boas,    I.,    541. 
Braun,    W.    and    H.    Boruttau, 

602. 
Brav,    Herman    A.,    268. 
Brennemann,  Joseph,  218. 
Brocq,   537. 
Brown,    L.,    25,    219. 
Browning,    C.    C,    207. 
Burkitt,    R.    W.,   600. 
Butler,    Margaret   F.,   7. 

Cade,    A.,    22. 
Casselberry,   W.   E.,  540. 
Chute,    A.     L.,    733. 
Clarke.    T.    W.,    478. 
Claude  and  .Sehmiergeld,  346. 
Colbeek.    E.    H.,    89. 
Coleman,    Warren,    734. 
Coombs,   C,   93. 
Cornet.    P.,   282. 


Courmont,  Jules  and  A.  Lesieur, 

31. 
Courmont,    P.,   30. 

Davis,  J.  S.,  284. 

Deaver,   John   B.,   257. 

Deeks,  W.   E.  and  W.  F.   Shaw, 

730. 
Dixon   A.,   282. 
Don,  Alexander,  350. 
Dow,  W.,  284. 
Downing,  Bertha  C,  528. 

Earp,    S.    E.,    349. 
Ehrenfried,  Albert,  730. 

Fenner,    R.,    91. 
Flick,    Lawrence  F.,   456. 
Forchheimer,   F.,   217. 
Foxworthy,    F.    W.,    478. 
Frank,    R.    T.,   218. 
Franz,   536. 
Freeman,  R.  G.,  536. 
Freer,  218. 
French,   H.,   407. 

Gohrung,    J.    A.,    24. 
Glaserfeld,    B.,    535. 
Goldthwait,    Joel    E.,    270. 
Goodhart,   J.    F.,    6G9. 
Gordon,    Alfred,    199,    283. 
Gossage,   A.   M.,   605. 
Gottheil,  W.  S.,  541. 
Gowera,    W.    R.,    412. 
Green,    Thomas,    G.,    136. 
Gunzel,    Otto,    665. 
Guthrie,    D.    J.,    668. 

Haggard,   W.    D.,   28. 
Hall,  A.  J.,  600. 
Hamilton,    A.    McL.,   26. 
Hancs,    Frederick   M.,    667. 
Hansen,    Howard   F.,   75,   594. 
Ilartog,    535. 


Heineke,    H.,    604. 
Heitzman,    C.    W.,    92. 
Hemmeter,   John   C,   449. 
Herman,    G.,   734. 
Herrman,   C,  414. 
Hessert,  William,  669. 
Hinsdale,  Guy,  193. 
Howland,    J.,    22. 
Huber,    John    B.,    10. 
Huchard,   543. 

Jacob!,  A.,  385. 
Johnston,    C.   A.,   414. 

Kanavel,   A.   B.,   285. 

Katzenstein,    J.,    603. 

Kelly,    H.   A.,   733. 

Kerr,  W.  W.,  407. 

King,  Alfred,   407. 

King,    W.,    217. 

Knowles,    F.    C,   217. 

Koeppe,    H.,    537. 

Kolipinski,   Louis,  65,  129,  328. 

Koplik,    H.,   220. 

Lacassagne    and    Martin,    28. 

Laplace,   Ernest,   717. 

LaRoque,  G.   Paul,   732. 

Lees,    D.    B.,   221. 

L6opold-Levy,      H.      Rothschild 

and   Huchard,   543. 
Lesem,   Wm.,   346. 
Lesieur,    A.,   31. 
Lewln,    408. 
Litzenberg,    J.    C.     and    S.     .M. 

White,  25. 
Lloyd,    W.,    155. 

McAllster.    C.    J.,    and    H.     C. 

Ross,    155. 
McCabe.   W.   M.,   408. 
McCarthy,  D.  J.,  709. 
McCllntock,  C.  T.  and  W.  King, 

217. 
McCrea,    Thos.,    540. 


(769) 


770 


INDEX. 


McKee,   James  H.,   513. 
McPhedran,   A.,  31. 

Marinesco,   G.,  21. 
Martin,   28. 
Matas,    Rudolph,    705. 
Maury,  J.  W.   D.,  410. 
Murray,   G.   R.,  602. 
Muschlitz,  C.   H.,   13. 

Nassauer,   M.,   411. 

Oliver,    Charle.?   A.,   651, 
Osier,    Wm.,    282. 

Payr,    731. 
Pearce,    19. 
Pedersen,  V.  C.  349. 
Pels-Leusden,    90. 
Phillips,    John,    216. 
Phillips,   W.    F.    R.,   522. 
Pinard,   A.,   477. 
Plehn,   603. 
Poncet,    A.,    28. 
Ponthiere,    L.    de,   156. 
Pottenger,   P.    M.,   1. 
Power,     D'Arcy,    735. 
Prest,    E.    E.,    ;!48. 
Price,  G.  E.,  406. 

Reiche,    A.,    410. 
Richardson.  Charles  Vv'., 
Riewel,   H.   V.,   587. 
Ringer,  A.   S.,   412. 
Robbins,    H.    A.,    519. 
Robinson,    B.,    346,    hZS. 
Rogers,  L.,  544. 


Roily,    F.,   409. 
Rosenberger,  R.  C.,  607. 
Rossiter,   P.    S.,  538. 
Rothschild,   601. 
Rothschild,   H.    de,   543. 
Rubens,   29. 
Rudisch,    J.,   476,    666. 
Ruhrah,    John,   542. 
Rzentkowski,    C.    v.,    406. 

Sajous,  C.  E.  de  M.,  16,  83,  211, 

278,   341,^533,  596,   662. 
Sajous,    L.    T.    de   M.,   411. 
Salzer,  H.,  350. 
Savill,    T.    D.,    606. 
Schabad,  J.  A.,   413. 
Schmiergeld,    346. 
Schumann.   Edward  A..  SO. 
Schwarz,   E.,  667. 
Senftleben,  222. 
Sergent,   E.,  606. 
Shaw,    W.    F.,    730. 
Shepherd,    F.   J.,   535. 
Sidis,    Boris,    473. 
Sill,    E.    M.,    730. 
Small,    H.   Beaumont,  599. 
Sprenger,   157. 
Spriggs,   N.   I.,   220. 
Squire,   J.    E.,  539. 
Stewart,   F.   E.,  335,  397. 
Stillman,  William   O.,   658. 
Stockton,   C.  J.,   536. 
Stone,    A.    K.,    605. 
Stone,   C.   H.,   413. 
Stowe,  H.   M.,  409. 
Strieker,  L.,   604. 
Stuart-Low,  W.,   729. 
Suker,    G.    F.,   539. 


Sweeny,  G.  B.,  414. 
Swett,    P.    P.,    476. 

Taylor,  J.  Madison,  150,  403,  712. 

Teissier,  J.,  19. 

Terray,   408. 

Thumim,    L.,    347. 

Tirard,    N.,    23,    665. 

Tivy,  C.   B.   F.,   665. 

Tovey,   D.   W.,  729. 

Underbill,  Frank  P.,  460. 
Upson,   Henry  S.,  648. 

Veit,  90. 

V'on  den  Velden,  R.,  283. 
Von  Kutschera,  A.,  477. 
Von  Noorden,  Carl,  668. 

Wakefield,  A.  W.,  20. 

Wallace,     G.     B.      and      A.      S. 

Ringer,   412. 
Ward,    S.    B.,   732. 
Watson,  L.  F.,  732. 
Waugh,  W.  F.,  221. 
Weaver.   H.   B.,  272. 
Weill,    E.    and    G.    Mouriquaud. 

219. 
White,   C,   731. 
White.    S.    M.,    25. 
Widmer,   C.   S..  731. 
Wilcox,    Reynolds    Webb,    333. 
Wiley,    H.    W.,    321. 
Williams,    J.    W.,    91. 
Williams,  Leonard,  345. 
Williams,    Tom  A.,    146,    468. 
Wilson,    L.    B.,    24. 


Original  Articles 


Achylia  gastriea.     A.  L.   Benedict 641 

Adrenal   extract   in  Addison's  disease.     Charles 

E.   de  M.   Sajous 211 

The  adrenal  principle  as  the  main  active  agent 
in  pituitary,  testicular,  ovarian,  and 
other  animal  extracts.  Charles  E.  de  M. 
Sajous   278,  341 

Adrenals   in   sudden   death.     Charles   E.    de   M. 

Sajous  596,  662 

Case    of    neuroma    of    the    orbit.      Howard    F. 

Hansen    594 

A  case  of  tuberculosis  of  the  uterus,  cervix 
and  vagina,  with  pyometra.  Edward  A. 
Schumann    80 

Cataract.      Charles   A.    Oliver 651,721 

Cholelithiasis:       gall-stone    disease.       John     C. 

Hemmeter   449 

The    clarification    of    our    concepts    concerning 

hysteria.      Tom   A.    Williams 146 

Congenital    unilateral    hypertrophy — Report    of 

case.     C.  H.   Muschlitz 13 

Constitutional  conditions  affecting  nasal  ca- 
tarrh.    Charles  W.    Richardson 577 

Curative   powers   in   human   milk.     J.    Madison 

Taylor    712 

Dementia  precox   caused   by   dental   impaction. 

Henry    S.    Upson    648 

Diabetes  mellitus  as  an  infectious  disease.  Al- 
fred   King    467 

Diet  as  a  prophylactic  and  therapeutic.    H.  W. 

Wiley    321 

Extra-uterine  pregnancy.     John  B.   Deaver 257 

The  fsecal  origin  of  some  forms  of  postoperative 
tetanus,  and  its  prophylaxis  by  dietetic 
or  culinary  measures.     Rudolph    Matas..  705 

A  few  practical  applications  of  the  newest  prin- 
ciples introduced  by  Dr.  Sajous.  J. 
Madison    Taylor    150 

Graduated  outdoor  labor  in  pulmonary  tubercu- 
losis.    Guy   Hinsdale    193 

The     hypnoidal     state     in     psychotherapeutics. 

Boris   Sidis   473 


The  importance  of  careful  postoperative  treat- 
ment in  rectal  operations.  Herman  A. 
Brav    268 

The  importance  of  the  joints  of  the  pelvic  gir- 
dle.    Joel  E.   Goldthwait  270 

Is  the  human  body  supplied  with  an  auto- 
protective  mechanism?  A  new  theory  of 
immunity  based  on  the  ductless  glands. 
Charles   E.    de  M.    Sajous 16 

Medical      treatment      of      acute      appendicitis. 

Thomas   G.    Green    136 

The  milk   question   from  the  standpoint  of  the 

pediatrician.     James  H.   McKee 513 

Ocular    traumatism.    A   cause   of   the   neuroses. 

Howard   F.    Hansell    75 

Organic  nervous  diseases  from  a  pension  exam- 
iner's  standpoint.     D.    J.    McCarthy 709 

Pneumonia:  Its  danger  point  and  how  to  avoid 
it,  according  to  Dr.  Sajous.  J.  Madison 
Taylor    403 

Practical  suggestions  in  the  administration  of 
tuberculin,  together  with  a  discussion  of 
theory  upon  which  its  action  is  baaed. 
F.   M.   Pottenger   1 

The  present  knowledge  of  the  action  of  cathar- 
tic  drugs.     Frank  P.   Underbill   460 

Preventive   medicine    in    a    neglected    direction. 

Bertha    C.    Downing 528 

The  problem  of  efficient  nursing  for  persons  of 

moderate   means.     William  O.   Stillman.  658 

The    prognosis    of    febrile    cases    of    pulmonary 

tuberculosis.     Harry    Lee   Barnes 580 

Progress  and  changes  in  the  treatment  of  tu- 
berculosis during  the  past  twenty  years. 
Edward    R.    Baldwin    393 

Relations    of    rectal    disease    to   general   health. 

Ernest   Laplace    717 

Report  of  case  of  tuberculosis  of  the  ovary 
treated  with  tuberculin.  C.  C.  Brown- 
ing      207 


INDEX. 


771 


Requisites  for  the  treatment  of  the  psycho- 
neuroses:  Psychopathological  ignorance, 
and  the  misuse  of  psychoneurotherapy  by 
the  novice.     Tom  A".   Williams 4GS 

Seasonal     influence     on     suicide.       W.     F.     R. 

Phillips     522 

Some  reflex  neuroses  cured  by  treatment  of  co- 
existent nasal  affections.  Margaret  F. 
Butler    7 

The  standardization  of  materia  medica  pro- 
ducts.    F.  E.  Stewart  335,  397 

Superficial   dermatitis   of  the  external   auditory 

canal.     Clarence  John   Blake 475 

Syphilis  in  its  relation  to   nervous  and  mental 

diseases.      Alfred    Gordon    199 

The  therapeutic  action  of  iodine  and  mercury 
in  diseases  other  than  syphilis.  H.  A. 
Robbins    519 


Therapeutics  of  pain.     Lawrence  F.   Flick 456 

The  therapeutics  of  solution  of  calcium  creo- 
sote.    Louis   Kolipinski   328 

The   three-day   treatment   of   drug   and   alcohol 

habitues  with   hyocine.     11.   V.   Riewel..  587 

The  thyroid  preparations  in  practice.     Charles 

E.  de  M.  Sajous 83 

The  treatment  of  the  Stokes-Adams  syndrome. 

Reynold    Webb    Wilcox 333 

The  treatment  of  typhoid  fever  with  solution  of 

calcium   creosote.     Louis   Kolipinski.  .65,  129 

Tuberculin  therapy.     H.  B.  Weaver   272 

Use    of    tobacco    by    the    immature.      John    B. 

Hubcr    10 

Variations  in  the  medicinal  therapy  of  pneu- 
monia in  the  last  half  century.  A. 
Jacobi     385 


Editorials 


The  early  treatment  of  insanity.     H.  Beaumont 

Small    599 


The   Philadelphia   water   supply.     C.    E.    de  M. 

Sajous    533 


The  transactions  of  the  National  Association  of 

U.  S.  Pension  Examining  Surgeons 729 


General  Index 


Abdominal  operations,  early  rising  after.     Har- 

tog   535 

Eruptions  after.     F.  J.  Shepherd  535 

Phenomena    with     incipient    pneumonia.       B. 

Glaserfeld    535 

Abortion,   treatment  of.     Franz   536 

Abscess  in  the  ear,  yeast  in  the  treatment  of. 

N.  Antenore  544 

Of    the    liver,     tropical,     prevention    of.      L. 

Rogers    544 

Acetone  treatment  of  inoperable  carcinoma.     D. 

W.    Tovey    729 

Achylia  gastrica.     C.   J.  Stockton 536 

A.  L.  Benedict 641 

Acromegalv,    cardiovascular   changes   in.     John 

Phillips    216 

Addison's  disease,  adrenal  extract  in.    C.  E.  de 

M.    Sajous   211 

Adenoids  in  infancy.     R.   G.  Freeman  536 

Nocturnal      incontinence,      and     the     thyroid 

gland.     Leonard  Williams   345 

Adiposis   dolorosa.     G.   E.    Price    406 

Adolescent,  haemorrhages  into  the  vitreous  body 

in  the.     J.   A.   Gehrung   24 

Adrenal  extract  in   Addison's  disease.     Charles 

E.    de   M.    Sajous   211 

Gland,   lesions   of.     Pearce   19 

Principle  as  the  main  active  agent  in  pitu- 
itary,    testicular,     ovarian,     and     othor 

animal     extracts.       Charles    E.     de    M. 

Sajous    278,  341 

Adrenalin-saline    infusion    in    peritonitis.       H. 

Heineke    604 

Adrenals,    haemorrhage   of   the,    in    Infants.     J. 

C.   Litzenberg  and  S.    M.  White 25 

In      sudden      death.        Charles      E.      de      M. 

Sajous    596,  662 

Relation  of,   to  pancreatic  glycosuria.     C.   H. 

Stone    413 

Albuminuria.     Nestor  Tirard   665 

Intermittent,  of  childhood  considered  In  its 
relation  to  hereditary  tuberculosis.  J. 
Teissier  19 


Alcohol  habitugs,  three-day  treatment  of,  with 

hyoscine.     H.  V.  Riewel  587 

American  Journal  of  Clinical  Medicine 158 

American  Journal  of  Surgery 158 

American    Medical    Editors'    Association    Meet- 
ing     286 

Amoebic  dvsentery,  treatment  of.     W.  E.  Deeks 

and  W.  F.  Shaw 730 

Amyl    nitrite,    action    of,    on    the   arteries.      C. 

V.    Rzentkowski    406 

Anaemia,    infantile,    prevention   of.     J.    Katzen- 

stein    603 

Pernicious.      H.    French    407 

Anassthesia.  prevention  of  nausea  following.    L. 

F.    Watson    732 

Angina  pectoris,  painless  and  painful.     W.   W. 

Kerr    407 

Anthrax,  treatment  of.     Barlach   20 

Antitoxin,    oral   administration    of.     C.    T.    Mc- 

Clintock  and  W.  King 217 

Appendicitis,     acute,     medical     treatment     of. 

Thomas   G.    Green    136 

Treatment  of.     B.    Robinson    346 

Arteries,    action    of    amyl    nitrite    on.      C.    v. 

Rzentkowski    406 

Arteriosclerosis,  nature  of.     J.  G.   Adami 729 

Pathogenesis  of.     E.  H.  Colbeck  89 

Ascites  In  typhoid  fever.     A.   McPhedran 31 

Asphyxia,  pleural  adhesions  in.    Lacassagne  and 

Martin   28 

Asthma.     A.  G.  Auld 89 

Bronchial,     atropine     in     the     treatment     of. 

Terray   408 

Treatment  of.     Otto  Gunzel    665 

Calomel  in.     C.  B.   F.  Tivy 665 

Its  cause  and  treatment.     W.  Lloyd 155 

Atropine  as  a  hemostatic  286 

In  diabetes  mellitus.     J.  Rudisch   476 

In      the     treatment     of      bronchial      asthma. 

Terray    408 

Autointoxication,    Intestinal.      A.    Dixon 282 

Recurring    corvza    a    manifestation    of.      P. 

Cornet    282 


772 


INDEX. 


Auto-protective  mechanism,  is  the  human  body 

supplied  with  an?     C.   B.  de  M.  Sajous.     16 

Bier's    method    of    passive    congestion.      A.    W. 

Wakefield    20 

Bismuth    poisoning.      Lewin    408 

Blood-pressure,   lowering  of  by  nitrites.     G.    B. 

Wallace  and  A.  S.  Ringer 412 

Book   Reviews:— 

An  Alabama   Student   and  other  Biographical 

Essays.    William  Osier  158 

Art  of  Natural  Sleep.     Lyman  P.  Powell 95 

Atlas  and  Text-book  of  the  Human  Anatomy, 

Vol.    III.      Johannes    Sobotta 32 

Bacterial  Food  Poisoning.    A.  Dieudonne 224 

Blood  Examination  in  Surgical  Diagnosis.     Ira 

S.  Wile   159 

Book     on     the     Phvsician     Himself.      D.     W. 

Cathell  and  William  T.  Cathell  415 

Borderland  Studies.     George  M.   Gould 94 

Climate.     Robert  DeCourcey  Ward   90 

Dante — Physician.      A.    G.    Drury    480 

Diseases  of  the  Nervous  System.  Alfred  Gor- 
don       158 

Diseases  of  the  Nose  and  Throat.     D.  Braden 

Kyle    94 

Diseases  of  the  Nose,  Throat,  and  Ear,  and 
their  Accessory  Cavities.  Seth  Scott 
Bishop    479 

Diseases     of     the     Skin     and     the     Eruptive 

Fevers.     Jay  F.  Schamberg  415 

Diseases  of  the  Spinal  Cord.  R.  T.  William- 
son     224 

Disorders  of  the  Bladder.     Fallon  Cabot 224 

Emergency  Surgery.    John  W.   Sluss   d(, 

Epoch-making  Contributions  to  Medicine,  Sur- 
gery and  the  Allied  Sciences.     C.  M.   B. 

Camac    736 

Essentials  of  Laboratory  Diagnosis.     Francis 

Ashley    Faught    COS 

Everyday    Diseases    of    Children    and    Their 

Rational  Treatment.    George  H.  Candler.  672 
Expansion  of  Races.     Charles  Edward  Wood- 
ruff      672 

Experimental  Pharmacology.     Charles  Wilson 

Greene  735 

Experimental  Researches  on  Specific  Thera- 
peutics.     Paul    Ehrlich    671 

Experimental  Study  of  Sleep.     Boris  Sidis 670 

Functional    Nervous    Disorders   in    Childhood. 

Leonard    Guthrie    96 

Further    Advances    in    Physiology.      Leonard 

Hill    736 

General   Surgery.     Ehrich  Lexer 160 

Glandular  Enlargement  and  other  Diseases  of 
the  Lymphatic  System.  Arthur  Ed- 
munds         96 

Glimpses  of  Medical  Europe.  Ralph  Thomp- 
son      351 

Hygiene  for  Nurses.     Isabel  Mclsaac   288 

Insomnia  and  Nerve  Strain.     Henry  S.  Upson  480 

International  Clinics,  Vol.  III.     Edited  by  W. 

T.    Longcope    93 

Manual  of  Diseases  of  the  Nose  and  Throat. 

Cornelius   G.    Coakley   95 

Manual    of   the    Practice   of  Medicine.     A.    A. 

Stevens    32 

Medical    Lectures    and    Aphorisms.       Samuel 

Gee  160 

Medical  Sociology.     James  Peter  Warbasse 730 

Nervous     and     Mental     Diseases.       Archibald 

Church   and   Frederick   Peterson   671 

On  Infantilism  from  Chronic  Intestinal  Infec- 
tion.     C.    A.    Herter 671 

On   Means  for  the   Prolongation   of  Life.     Sir 

Hermann  Weber  95 


Book  Reviews  (Continued): — 
Operations    of    General    Practice.      Edred    M 

Corner   288 

Orthopedic  Surgery  for  Practitioners.     Henry 

Ling  Taylor  671 

Parsimony  in  Nutrition.     Sir  James  Crichton- 

Brown    287 

Pastoral   Medicine.     Alexander  E.   Sanford 223 

Practice    of     Medicine     for    Nurses.       George 

Howard   Hoxie    288 

Psychic     Treatment     of     Nervous     Disorders. 

Paul    Dubois    735 

Psychological    Principles    in    Treatment.      W. 

Langdon    Brown    287 

Psychology  of  Dementia  Precox.     C.  G.  Jung.  672 

Pulmonary  Tuberculosis  and  All  Its  Com- 
plications.    Sherman   G.    Bonney 351 

Reference  Hand-book  for  Nurses.    Amanda  K. 

Beck  224 

Refraction  and  How  to  Refract.    James  Thor- 

ington  416 

Report   of    Committee    on    Building   of   Model 

Houses.     Gen.  George  M.   Sternberg 223 

Seven  Hundred  Surgical  Suggestions.    Walter 

M.    Brickner    16O 

Surgery:     Its    Principles   and   Practice.      Vol. 

IV.     W.  W.  Keen 608 

Surgery  of  the  Ear.     Samuel  J.  Kopetzky 32 

Surgical  Memoirs  and  Other  Essays.    James  G. 

Mumford    2S6 

Text-book     of    Botany    and     Pharmacognosy. 

Henry  Kraemer  416 

Text-book     of     Operative     Surgery.      Warren 

Stone    Bickham    352 

Text-book    of    Otology.      Fr.    Bezold    and    Fr. 

Siebenmann:    Translated  by  J.  Hollinger.  286 

Text-book     of    Surgical     Anatomy.       William 

Francis    Campbell    288 

The  Body  at  Work.     Alexander  Hill 287 

The   Efficient   Life.     Luther   H.    Gulick   94 

The  Matter  With  Nervousness.    H.  C.  Sawyer.  480 

The    Problem    of    Age,     Growth    and    Death. 

Charles  S.    Minot   159 

The  Semi-insane,  the  Semi-responsible.  Jo- 
seph  Grasset   223 

Tuberculosis  of  the  Nose  and  Throat.  Lor- 
enzo B.  Lockard  479 

Bromide  eruption.     F.  C.  Knowles  217 

Bromides,  epilepsy  and  the.     Wm.  Lesem  346 

Bronchial  asthma,  atropine  in  the  treatment  of. 

Terray    408 

Treatment  of.     Otto  Gunzel   665 

Bronchitis,    chronic,    treatment    of.      F.    Forch- 

heimer  217 

Burns,    treatment   of,    general.     Pels-Leusden. .    90 
Buttermilk  in  Infant  feeding.     H.   Koeppe 537 

Calcium    creosote,    therapeutics   of   solution    of. 

Louis  Kolipinski   328 

Treatment    of    typhoid    fever    with    solution 

of.     Louis    Kolipinski    65,129 

Calomel  in  asthma.     C.   B.  F.   Tivy   665 

Cancer  in  man  and  animals.     E.  F.  Bashford..  599 

Of  the  Tongue.     Alexander  Dow 350 

Thyroidectomy    and.     W.    Stuart-Low 729 

Carbon   dioxid  in  lupus  erythematosus.     W.   S. 

Gottheil   541 

Carcinoma,  excitation  of  the  leucocytes  in  cases 

of.     C.  J.  McAlister  and  H.  C.  Ross 155 

Inoperable,     acetone    treatment    of.       W.     D. 

Tovey   729 

Cardiovascular    changes    in    acromegaly.      John 

Phillips   216 

Case    of    neuroma    of    the    orbit.      Howard    F. 

Hansen    594 

Of  tuberculosis  of  the  uterus,  cervix,  and 
vagina,  with  pyometra.  Edward  A. 
Schumann    80 


INDEX. 


773 


Cataract.     Charles  A.  Oliver  651,  721 

Cathartic  drugs,  present  knowledge  of  the  ac- 
tion of.     Frank  P.   Underbill 460 

Cerebrospinal     meningitis,     epidemic.      W.     M. 

McCabe    408 

Cholecystitis.     H.- W.  Bettmann  21 

Chronic,    as    a    cause    of    myocardial    incom- 
petence.    R.   G.   Babcock 411 

Cholelithiasis:      Gall-stone    disease.      John     C. 

Hemmeter   449 

Cholera,  treatment  of.    R.  W.  Burkitt 600 

Chorea,  nasopharyngeal  origin  of.     L.   de  Pon- 

thiere   156 

Treatment    of,    by    intraspinal    injections    of 

magnesium  sulphate.     G.   Marinesco   ....    21 

Clarification  of  our  concepts  concerning  hys- 
teria.    Tom  A.  Williams  146 

Club  foot,  cure  of,  in  infancy,  without  opera- 
tion.    Albert  Ehrenfried   730 

Colles's  fracture.     P.  P.   Swett  476 

Congenital    unilateral    hypertrophy.     Report   of 

case.     C.   H.    Muschlitz    33 

Conjunctival  tuberculin  test.     E.  R.  Baldwin...  157 

Constitutional  conditions  affecting  nasal  ca- 
tarrh.    Charles  W.  Richardson 577 

Coryza,  recurring,  a  manifestation  of  autoin- 
toxication.    P.   Cornet  282 

Cretinism,      thyroid     treatment     of.       A.      von 

Kutschera   477 

Curative   powers  in   human   milk.     J.    Madison 

Taylor    712 

Cytologic  examination  of  tuberculous  effusions 
in  the  various  cavities,  diagnostic  value 
of.      A.    Cade    22 

Dementia  praecox  caused  by  dental  impaction. 

Henry    S.    Upson    648 

Dental  impaction,   dementia  prsecox  caused  by 

Henry   S.   Upson   648 

Dermatitis,  superficial,  of  the  external  auditory 

canal.     Clarence  John   Blake   475 

Diabetes     and     exophthalmic     goiter.       G.     R. 

Murray    602 

Treatment  of.     J.   Rudisch    666 

Mellitus    as    an     infectious    disease.       Alfred 

King    467 

Atropin  in.    J.  Rudisch  476 

Effect  of  certain   drugs  on.     A.   J.   Hall 600 

Diet  as  a  prophylactic  and  therapeutic.     H.  W. 

Wiley    321 

Diphtheria,  heart  in.     J.  Howland  22 

Dissemination  of  Koch's  bacillus,  flies  as  agents 

in  the.    Ch.  Andre 23 

Ductless     glands     in     epilepsy.       Claude     and 

Schmiergeld   346 

New  theory  of  immunity  based  on  the.     C. 

E.    de   M.    Sajous    16 

Dysentery,  amoebic  treatment  of.     W.  E.  Deeks 

and  W.   F.   Shaw   730 

Dysmenorrhcea.     Veit   90 

Early  rising  after  abdominal  operations.     Har- 

tog   535 

Treatment  of  insanity.  H.  Beaumont  Small.  599 

Ectopic  gestation.    R.  T.  Frank  218 

Eczema,  chronic,   in  infants.     Freer 218 

Treatment  of.     Brocq   537 

Efficient     nursing     for     persons     of     moderate 

means.     William  O.  Stillman 658 

Effusions,     tuberculous,     diagnostic     and     prog- 
nostic significance  of.     P.  Courmont 30 

Elephantiasis,   treatment   of.     P.    S.    Rossiter..  538 
Empyema    and     delayed    resolution     in     lobar- 

pneumonia.    Thos.  McCrea 540 

Endocarditis,  infectious.     Wra.   Osier   282 

Infective   or   ulcerative.     N.    Tirard 23 


Enlargement     of     the     prostate,     etiology     of. 

Rothschild     .• 601 

Epilepsy   and  the   bromides.     Wm.   Lesem 346 

Ductless   glands   in.      Claude   and    Schmier- 
geld      346 

Senile.     T.  D.  Savill  606 

Epistaxis,   treatment  of.     Beverly   Robinson 538 

Eruptions    after    abdominal    operations.      F.    J. 

Shepherd    535 

Ethyl  chlorid  as  a  general  anaesthetic.     E.   M. 

Sill  730 

Excitation  of  the  leucocytes  in  cases  of  car- 
cinoma.   C.  J.  McAlister  and  H.  C.  Ross.  155 

Exophthalmic  goiter.     G.   F.  Suker   539 

And  diabetes.     G.    R.   Murray 602 

And  pregnancy.     H.   M.   Stowe  409 

And  the  reproductive  function.     A.  Pinard..  477 
Exophthalmos   and   other  eye   signs   in   chronic 
nephritis.      Llewellys     F.     Barker     and 

Frederick   M.    Hanes   667 

Extra-uterine  pregnancy.    John  B.  Deaver 257 

Eyelids,    oedema   of   the,   and    influenza.      N.    I. 

Spriggs    220 

Faecal  origin  of  some  forms  of  postoperative 
tetanus,    and    its   prophylaxis.     Rudolph 

Matas    705 

Fever  in  infection,  action  of.     F.  Roily 409 

Few  practical  applications  of  the  newest  prin- 
ciples   introduced     by    ^r.     Sajous.      J. 

Madison    Taylor    150 

Flatulency.     E.  Schwarz  667 

Flies  as  agents  in  the  dissemination  of  Koch's 

bacillus.    Ch.  Andre 23 

Food  intoxication   in   infancy.     Joseph   Brenne- 

mann    218 

Fracture,  Colles's.    P.  P.  Swett 476 

Furunculosis  and  pemphigus  in  children,  sweat- 
ing and  mercurial  baths  for.    A.  Reiche.  410 

Gall-stone  disease.    John  C.  Hemmeter 449 

Gastric  digestion  of  infants.    T.  W.  Clarke 478 

Ulcer,   milk-free  diet  in.     F.  W.  Foxworthy. .  478 

Glycosuria    in    pregnancy,    clinical    significance 

of.    J.  W.  Williams  91 

Pancreatic,    relation    of   the    thyroid   and    ad- 
renals to.     C.  H.  Stone  413 

Gout,     treatment    of,     by     thyminic    acid.      R. 

Fenner   91 

Graduated  outdoor  labor  in  pulmonary  tubercu- 
losis.    Guy  Hinsdale   193 

Rest  in  pulmonary  tuberculosis.     E.  E.  Prest.  348 

Graves's  disease,  pathological  changes  in  the 
thyroid  as  related  to  the  varying  symp- 
toms in.     L.  B.   Wilson  24 

Haemoptysis,   treatment  of.     J.   E.   Squire 539 

Haemorrhage,  internal,  salt  in  treatment  of.    R. 

Von    Den    Velden 283 

Into  the  vitreous  body  in  the  adolescent.     J. 

A.    Gehrung   24 

Of  the  adrenals  in  infants.     J.   C.   Litzenberg 

and  S.  M.   White  25 

HtEmorrhoids,     new     operations     for.       C.     W. 

Heitzman   92 

Heart  in  diphtheria.     J.  Howland  22 

In  pulmonary  tuberculosis.     L.   Brown 25,  219 

Massage  in  surgery.     C.   S.  White  731 

Rheumatism  of  the.     A.  M.  Gossage 605 

Hernia,    etiology   of.     C.   Widmer 731 

Homogeneous  cultures  of  the  tubercle  bacillus. 

S.  Arloing  and  P.  Courmont 30 

Human   milk,   curative  powers  in.     J.    Madison 

Taylor   712 

Hyoscine,  three-day  treatment  of  drug  and  al- 
cohol   habitufs   with.     H.    V.    RIewel 587 


^74 


INDEX. 


Hypertrophy,      congenital     unilateral.       C.     H. 

Muschlitz  13 

Hypnoidal  state  in  psychotherapeutics.     Boris 

Sidis    473 

Hypophysis  and  ovaries,   relations  between.    L. 

Thumim    317 

Hysteria,  clarification  of  our  concepts  concern- 
ing.    Tom  A.  Williams  146 

Ichthyosis    and    the    thyroid    gland.      E.    Weill 

and  G.   Mouriquand   219 

Ileus,  treatment  of.    W.  Braun  and  H.  Boruttau.  G02 

Immunity,  new  theory  of,  based  on  the  duct- 
less glands.     C.   E.  de  M.   Sajous 16 

Tuberculous      and      negative      reinoculations. 

Jules  Courmont  and  A.  Lesieur  31 

Importance   of   careful   postoperative  treatment 

in  rectal   operations.     Herman  A.   Brav 268 

Joints    of    the    pelvic    girdle.      Joel    E.    Gold- 

thwait    270 

Incipient  tuberculosis.     C.  A.   Johnston 414 

Infancy,   food   intoxication  in.     Joseph   Brenne- 

mann  218 

Infant  feeding,  buttermilk  in.     H.   Koeppe  537 

Infantile    ansemia,    prevention    of.      J.    Katzen- 

stein    603 

Scorbutus,  early  diagnosis  of.    H.  Koplik 220 

Infection,  action  of  fever  in.     F.  Roily 409 

Infectious  endocarditis.     Wm.   Osier   2S2 

N.  Tirard  23 

Inflammatory   tuberculosis.     A.    Poncet 28 

Influenza    and    oedema    of    the    eyelids.     N.    I. 

Spriggs    220 

Insanitv,     early    treatment    of.      H.    Beaumont 

Small    599 

Insomnia.     A.    Gordon    283 

Intestinal  autointoxication.     A.   Dixon 2S2 

Obstruction.     J.  W.  D.  Maury  410 

Intramuscular    injections    in    the    treatment    of 

syphilis.     V.   C.    Pedersen    349 

Iodine  and  mercury  in  diseases  other  than 
syphilis,  therapeutic  action  of.  H.  A. 
Robbins   519 

Is  the  human  body  supplied  with  an  auto- 
protective  mechanism.  A  new  theory  of 
immunity  based  on  the  ductless  glands. 
Charles  E.  de  M.  Sajous 16 

Ivy  poisoning.    A.  W.  Baird 603 

Koch's  bacillus,  flies  as  agents  in  the  dissemi- 
nation of.     Ch.  Andre 23 

Laryngeal  tuberculosis.     W.  E.   Casselberry 540 

Latent  malaria,  diagnosis  of.     Plehn 603 

Leucocytes  in  meningitis.     W.   Dow   284 

LeucorrhcEa,   treatment  of.     M.   Nassauer 411 

Lime  starvation  and  rachitis.     J.  A.  Schabad...  413 

Liver,  tropical  abscess  of.     L.  Rogers 544 

Lobar  pneumonia,  empyema  and  delayed  reso- 
lution in.     Thos.   McCrea  540 

Locomotor  ataxia,  treatment  of.  A.  McL.  Ham- 
ilton        26 

Lupus    erythematosus,    solid    carbon    dioxid    in. 

W.    S.    Gottheil    541 

Vulgaris,    new    principles    for    treatment    of. 

Payr   731 

Magnesium    sulphate,    treatment    of    chorea   by 

intraspinal  injections  of.     G.   Marinesco.    21 

Malaria,   latent,  diagnosis  of.     Plehn  603 

Mastoiditis.     Emil  Amberg   347 

Materia    medica    products,    standardization    of. 

F.   E.    Stewart   335,  397 

Maternal  milk  as  an   immunizing  agent  to  the 

nursling.     L.  T.  de  M.  Sajous  411 

Medical      treatment      of      acute      appendicitis. 

Thomas    G.    Green    13S 


Meningitis,     epidemic     cerebrospinal.       W.     M. 

McCabe   408 

Leucocytes   in.     W.    Dow   284 

Mercury  and  iodine  in  diseases  other  than 
syphilis,  therapeutic  action  of.  H.  A. 
Robbins    : 519 

Milk-free  diet  in  gastric  ulcer.  F.  W.  Fox- 
worthy     478 

Milk,   human,   curative  powers  in.     J.   Madison 

Taylor  712 

Maternal,    as    an    immunizing    agent    to    the 

nursling.     L.   T.  de  M.   Sajous  411 

Question   from  the  standpoint   of   the   pediat- 
rician.     James   H.    McKee 513 

Myocardial  imcompetence,   chronic  cholecystitis 

as  a  cause  of.     R.   H.   Babcock 411 

Myocarditis,    chronic,    nitroglycerin    in.      S.    B. 

Ward    732 

Rheumatic.     C.    Coombs    93 

Myopathy  and  syringomyelia.     W.   R.  Gowers..  412 

Nasal     affections,     rubber    ball     treatment    of. 

Sprenger    157 

Catarrh,    constitutional    conditions    affecting. 

Charles   W.    Richardson    577 

Nasopharyngeal   origin   of  chorea.     L.    de  Pon- 

thiere    156 

Nausea.    I.  Boas  541 

Following  anaesthesia,    prevention   of.     L.    F. 

Watson    732 

Nephritis,  chronic;  exaphthalmos  and  other 
eye  signs  in.  Llewellys  F.  Barker  and 
Frederick  M.  Hanes , 667 

Nervous  and  mental  diseases,  syphilis  in  its  re- 
lation  to.     Alfred   Gordon    199 

Diseases,  organic,   from  a  pension  examiner's 

standpoint.     D.   J.   McCarthy 709 

System,    relations   between    thymus    and.      K. 

Basch   222 

Neuroma  of  the  orbit.     H.   F.   Hansel! 594 

Neuroses,    ocular    traumatism   a    cause    of   the. 

Howard   F.   Hansell   75 

New  theory  of  immunity  based  on  the  duct- 
less glands.     C.  E.  de  M.   Sajous 16 

Nitrites,   lowering  of  blood-pressure  by.     G.  B. 

Wallace  and  A.   S.   Ringer 412 

Nitroglycerin    in    chronic    myocarditis.      S.    B. 

Ward    732 

Nocturnal   incontinence  and  the  thyroid   gland. 

Leonard  Williams    345 

Obesity.     Carl  von  Noorden 668 

Obstruction,  intestinal.     J.  W.   D.   Maury 410 

Ocular    traumatism,    a    cause   of    the    neuroses. 

Howard  F.  Hansell   75 

(Edema   of   the    eyelids,    influenza    and.      N.    I. 

Spriggs    220 

Ophthalmia  neonatorum.     L.    Strieker    604 

Ophthalmo-reaction  in  tuberculin.     F.   Arloing.    26 

Opium  habit.     W.  F.  Waugh 221 

Orbit,  neuroma  of  the.    Howard  F.  Hansell 594 

Organic    nervous   diseases    from    a   pension   ex- 
aminer's standpoint.     D.  J.  McCarthy...  709 
Ovarian   extract,   adrenal  principle  as  the  main 

active  agent  in.    C.  E.  de  M.  Sajous. 278,  341 
Tuberculosis   treated   with   tuberculin.     C.    C. 

Browning   207 

Ovaries  and  hypophysis,  relations  between.     L. 

Thumim    347 

Overfeeding  of  children.     John  Ruhrah 542 

Pain,    therapeutics   of.     Lawrence  F.    Flick 456 

Pancreatic   glycosuria,    relation    of   the   thyroid 

and  adrenals  to.     C.   H.   Stone   413 

Pancreatitis,  etiology  and  pathogenesis  of.     W. 

D.   Haggard   28 

Passive   congestion.    Bier's   method   of.     A.    W. 

Wakefield    20 

Pelvic   girdle,    importance  of  the  joints  of  the. 

Joel  E.   Goldthwait   270 


INDEX. 


776 


Pemphigos  in  children,  sweating  and  mercurial 

baths  for.    A.  Reiche  410 

Peritonitis,     adrenalin-saline    infusion    in.      H. 

Heineke    604 

Pernicious  ancemia.     H.   French   407 

Philadelphia  water  supply.     C.  E.  de  M.  Sajous.  533 
Pituitary  extract,  adrenal  principle  as  the  main 

active  agent  in.    C.  E.  de  M.  Sajous.  .278,  341 
Pleural   adhesions    in    sudden    death,    asphyxia, 
and    severe    injuries.      Lacassagne    and 

Martin    28 

Pleurisy  and  pneumonia  in  inflammation  of 
intra-abdominal    organs.      G.    Paul    La- 

Roque  732 

Pneumonia,     incipient,     abdominal     phenomena 

with.     B.    Glasserfeld    535 

In    Inflammation    of   intra-abdominal    organs. 

G.   Paul  LaRoque   732 

Its  danger  point  and  how  to  avoid  it,  accord- 
ing to  Dr.  Sajous.    J.  Madison  Taylor...  403 

Lobar.     Thos.  McCrea  540 

Strophanthin    in   collapse   in.     A.    K.    Stone. .  605 
Variations  in  the  medicinal  therapy  of,  in  the 

last  half  century.     A.  Jacob!   385 

Postanoesthetic     vomiting,      treatment     of.       J. 

Blumfeld    543 

Postoperative  psychoses.     H.  A.  Kelly   733 

Tetanus,  faecal  origin  of  some  forms  of.  Ru- 
dolph   Matas    705 

Practical  applications  of  the  newest  principles 
introduced   by   Dr.    Sajous.     J.    Madison 

Taylor    150 

Suggestions  in  the  administration  of  tubercu- 
lin, together  with  a  discussion  of  theory 
upon  which  its  action   is  based.     F.   M. 

Pottenger  1 

Pregnancy    and    exophthalmic    goiter.      H.     M. 

Stowe   409 

Extra-uterine.     John  B.   Deaver   257 

Glycosuria  in,   clinical  significance  of.     J.  W. 

Williams    91 

Tubal.     G.   Herman    734 

Present   knowledge   of   the   action    of   cathartic 

drugs.    Frank  P.  Underbill  460 

Status  of  obstetrical  teaching  in  Europe  and 

America    670 

Preventive    medicine    in    a   neglected    direction. 

Bertha   C.   Downing   528 

Problem  of  efficient  nursing  for  persons  of 
moderate  means.  William  O.  Still- 
man   533,  658 

Prognosis  of  febrile  cases  of  pulmonary  tuber- 
culosis.    Harry  Lee   Barnes    580 

Progress  and  changes  in  the  treatment  of  tu- 
berculosis during  the  past  twenty  years. 

Edward  R.   Baldwin   393 

Prostate,  etiologv  of  enlargement  of.  Roths- 
child      601 

Psychoneuroses.  requisites  for  the  treatment  of 

the.    Tom  A.  Williams  468 

Psychoses,  postoperative.     H.   A.   Kelly 733 

Psychotherapeutics,    hvpnoidal   state   in.     Boris 

Sidis    473 

Pulmonary  tuberculosis,  graduated  outdoor  la- 
bor in.     Guy  Hinsdale  193 

Graduated  rest  in.     E.   E.   Prcst 34S 

Heart  in.     L.  Brown    25,  219 

Prognosis   of  febrile   cases   of.     Harry   Lee 
Barnes  580 

Rachitis  from  lime  starvation.     J.  A.   Schabad.  413 
Rectal   disease,   relations  of,   to  general  health. 

Ernest    Laplace    717 

Operations,  importance  of  careful  postopera- 
tive treatment  in.     Herman  A.   Brav 268 

Rectum,   ulceration  of  the.     D'Arcy  Power 735 

Reflex  neuroses  cured  by  treatment  of  co-exist- 
ent nasal  affections.    Margaret  F.  Butler.      7 


Relations   of   rectal   disease   to   general   health. 

Ernest   Laplace    717 

Renal  tuberculosis,  diagnosis  of.     A.  L.  Chute.  733 

Report  of  case  of  tubrrculosis  of  the  ovary 
treated  with  tuberculin.  C.  C.  Brown- 
ing     207 

Reproductive  function  and  exophthalmic  goiter. 

A.  Pinard    477 

Requisites    for    the    treatment    of    the    psycho- 
neuroses:    Psychopathological  ignorance        , 
and  the  misuse  of  psychotherapy  by  the 
novice.     Tom  A.  Williams   468 

Retinal  hasmorrhages.     E.  M.  Blake 348 

Rheumatic   myocarditis.      C.    Coombs 93 

Rheumatism,    acute:     Treatment.     S.    E.   Earp.  349 
And    subacute,    effective    treatment   of.      D. 

B.  Lees   221 

Of  the  heart.     A.   M.  Gossage  605 

Tuberculous    and    inflammatory    tuberculosis. 

A.    Poncet    28 

Rubber     ball     treatment     of     nasal     affections. 

Sprenger  157 

Quinin  in  whooping-cough.     F.  Andalo  670 

Quinsy,  treatment  of.     D.  J.  Guthrie  668 

Salt  in  treatment  of  internal  haemorrhage.     R. 

von    dem   Velden    283 

Scarlet  fever  carriers.    C.  Herman 414 

Treatment  of.     Rubens   29 

Scorbutus,     infantile,    early    diagnosis    of.      H. 

Koplik   220 

Seasonal  influence  on  suicide.  W.  F.  R.  Phil- 
lips    522 

Senile  epilepsy.     T.  D.  Savill 606 

Severe  injuries,  pleural  adhesions  in.  Lacas- 
sagne and  Martin 28 

Skin-grafts,  method  of  splinting.     J.   S.   Davis.  284 

Small-pox,  diagnosis  of.    J.  M.  Armstrong 349 

Solid    carbon    dioxid    in    lupus    erythematosus. 

W.   S.   Gottheil   541 

Some  reflex  neuroses  cured  by  treatment  of 
co-existent  nasal  affections.  Margaret  F. 
Butler  7 

Standardization    of    materia    medica    products. 

F.    E.    Stewart    335,397 

Stokes-Adams  syndrome,  treatment  of.  Rey- 
nold  Webb   Wilcox    333 

Strophanthin  in  collapse  in  pneumonia.     A.   K. 

Stone    605 

Sudden     death,     adrenals    in.      C.     E.     de     M. 

Sajous  596,  662 

Pleural  adhesions  in.    Lacassagne  and  Mar- 
tin        28 

Suicide,     seasonal     influence     of.       W.     F.     R. 

Phillips    522 

Superficial   dermatitis  of  the  external   auditory 

canal.     Clarence  John  Blake   475 

Suprarenal  insufficiency.     E.   Sergent  606 

Sweating  and  mercurial  baths  for  furunculo- 
sis  and  pemphigus  in  children.  A. 
Reiche    410 

Syphilis  in   its  relation  to  nervous  and  mental 

diseases.     Alfred  Gordon   199 

Intramuscular  injections  in  the  treatment  of. 

V.  C.  Pedersen   349 

Syringomyelia,  myopathy  and.     W.   R.   Gowers.  412 

Tenosynovitis  of  the  hand.     A.  B.  Kanavel 285 

Testicular    extract,    adrenal    principle    as    the 

main    active    agent    in.      C.     E.    de    M. 

Sajous  278.  341 

Tetanus,    postoperative,    fjpcal    origin    of    some 

forms  of.     Rudolph  Matas   705 

Treatment  of.     William  Hessert  669 

Therapeutic    action    of   Iodine   and    mercury    in 

diseases    other    than     syphilis.       H.     A. 

Robblns    519 


776 


INDEX. 


Therapeutics  of  pain.     Lawrence  F.  Flick 456 

Of     solution     of     calcium     creosote.       Louis 

Kolipinski    328 

Three-day     treatment     of     drug     and     alcohol 

habitues  with  hyoscine.  H.  V.  Riewel.  587 
Thyminic  acid  in  treatment  of  gout.  R.  Fenner.  91 
Thymus    and     the    nervous    system,     relations 

between.    K.  Basch  222 

Thyroid,   ichthyosis  and  the.     E.   Weill  and   G. 

Mouriquand  219 

In     adenoids     and     nocturnal      incontinence. 

Leonard  Williams    345 

Instability.     Leopold-Levy,   H.   de  Rothschild, 

and  Huchard  543 

Pathological    changes    in,    as    related    to    the 
varying    symptoms   in    Graves's   disease. 

L.    B.    Wilson    24 

Preparations    in   practice.     Charles   E.    de   M. 

Sajous  83 

Relation   of,   to  pancreatic  glycosuria.     C.    H. 

Stone  413 

Transplantation  of.     H.  Salzer  350 

Treatment  of  cretinism.  A.  von  Kutschers..  477 
Thyroidectomy  and  cancer.  W.  Stuart-Low...  729 
Tobacco,    use    of    by    the   immature.      John    B. 

Huber    10 

Tongue,  cancer  of  the.     Alexander  Don 350 

Transplantation  of  the  thyroid.     H.   Salzer 350 

Treatment     of     the     Stokes-Adams     syndrome. 

Reynold   Webb  Wilcox 333 

Of    typhoid    fever    with    solution    of    calcium 

creosote.      Louis    Kolipinski    65,129 

Tropical    abscess    of    liver,    prevention    of.      L. 

Rogers   544 

Tubal  pregnancy.    G.  Herman  734 

Tubercle   bacillus  in  the  circulating  blood.     R. 

C.    Rosenberger   607 

Homogeneous    cultures   of   the.      S.    Arloing 
and  P.   Courmont  30 

Human  and  bovine.     G.   B.    Sweeny 414 

Tuberculin,    case   of   tuberculosis   of    the   ovary 

treated  with.     C.   C.  Browning 207 

Ophthalmo-reaction  in.     F.  Arloing 26 

Practical    suggestions    in    the    administration 

of.     F.   M.   Pottenger   1 

Test,  conjunctival.     E.  R.  Baldwin   157 

Therapy.     H.   B.   Weaver   272 

Tuberculosis,  hereditary,  intermittent  albumin- 
uria of  childhood  considered  in  its  rela- 
tions to.     J.   Teissier   19 

Incipient.     C.   A.   Johnston    414 


Inflammatory    and    tuberculous    rheumatism. 

A.    Poncet    28 

Laryngeal.    W.  E.  Casselberry  540 

Of  the  ovary  treated  with  tuberculin.       C.   C. 

Browning   207 

Of  the  uterus,  cervix,   and  vagina,   with  pyro- 

metra.     Edward  A.  Schumann 80 

Progress    and    changes    In    the    treatment   of. 

during  the  past  twenty  years.     Edward 

R.   Baldwin  393 

Pulmonary,  graduated  outdoor  labor  in.     Guy 

Hinsdale  193 

Graduated  rest  in.     E.  E.  Prest  348 

Heart  in.     L.    Brown 25,219 

Prognosis   of    febrile   cases   of.      Harry    Lee 

Barnes  580 

Renal,  diagnosis  of.     A.   L.   Chute  733 

Tuberculous  effusions  and  their  diagnostic  and 

prognostic  significance.    P.  Courmont 30 

Diagnostic    value    of    cytologic    examination 

of.     A.  Cade  22 

Immunity  and  negative  reinoculations.    Jules 

Courmont  and  A.  Lesieur  31 

Rheumatism.     A.  Poncet  28 

Typhoid  fever,  ascites  in.    A.  McPhedran  31 

Of  short  duration.     Warren  Coleman  734 

Treatment  of,  with  solution  of  calcium  creo- 
sote.     Louis    Kolipinski    65,  129 

Ulceration     of    the    rectum,     chronic.       D'Arcy 

Power  735 

Ulcerative  endocarditis.    N.  Tirard  23 

Unilateral     hypertrophy,     congenital.       C.      H. 

Muschlitz   13 

Uric  acid,  treatment  of.    J.  F.  Goodhart 669 

Use    of    tobacco    by    the    immature.      John    B. 

Huber  10 

Uterus,    cervix,     and    vagina,    tuberculosis    of. 

Edward  A.    Schumann    80 

Variations  in  the  medicinal  therapy  of  pneu- 
monia in  the  last  half  century.  A. 
Jacob!   385 

Vitreous    body,    haemorrhages    into   the,    in    the 

adolescent.     J.  A.  Gehrung  24 

Vomiting,     postanesthetic,     treatment     of.       J. 

Blumfeld    543 

Whooping-cough,   quinin  in.     F.   Andalo   670 

Treatment  of.     Senftleben   222 

Yeast  in   the  treatment  of  abscess  in   the   ear. 

N.  Antenore  544 


INDEX 

MEDICAL  BULLETIN  SECTION 


ADLER,    LEWIS   H.    JR. 
ALLPORT,    W.   H. 
ANDERS,   JAMES  M. 
ASHMEAD,  ALBERT  S. 
BOEHM,    JOSEPH    L. 
BURGHOLDER,   A.   J. 
BUXTON,    L.   HAINES. 
CHRISTIAN,   H.   M. 
CUTTER,    EPHRAIM. 
DAVIS,    LUCIEN    C. 
HALE,  B.  L. 
HARDIN,  CHARLES  B. 


List  of  Contributors 

HEINECK,    AIME    PAUL. 

HILL,   EDWARD  C. 

HOLLOPETER,  WM.  C. 

HORNE.  BROSE. 

LAPLACE,    ERNEST. 

M'GLINN,   JOHN   A. 

M'KEE,   E.    S. 

NOVACK,  HARRY  J. 

OTT,  ISAAC. 

RANKIN,    GUTHRIE. 

RAUDENBUSH,  JAMES 
STRICKER. 

RAVITCH,   M.  L. 


ROBINSON,    BYRON. 
RODMAN,    WILLIAM    L. 
ROSS,    THOMAS    W. 
ROTCH,    THOMAS   MORGAN. 
SCOTT,   JOHN   C. 
SHOEMAKER,  JOHN  V. 
STEPHENS,   T.   G. 
THOMAS,    R.    C. 
WALLIS,   J.    FRANK. 
WAHRER,    C.    F. 
WOODBURY,    CAPTAIN 
FRANK    T. 


General 

ADDRESSES. 

Address  at  the  Commencement  Exercises  of  the 
Medico-Chirurgical  College  and  Hospital, 
Philadelphia,  Pa.,  on  June  5,  1909. 
Hon.   Chauncey  M.   Depew    417 

BOOK  REVIEWS. 

A  Hand-book  of  Suggestive  Therapeutics,  Ap- 
plied Hypnotism,  Psychic  Science. 
Henry   S.    Munro    63 

American   Illustrated    Medical    Dictionary.     W. 

A.    Newman    Dorland    7C6 

Annual  Report  of  the  Pennsylvania  State  Col- 
lege for   the  Year  1907-1908 511 

Arteriosclerosis,  Etiology,  Pathology,  Diag- 
nosis, Prognosis,  Prophylaxis,  and 
Treatment.      Louis    M.    Warfleld 61 

A    Practical    Treatise    on    Ophthalmology.      L. 

Webster  Fox   767 

A    Reference    Hand-book    of    Gynecology    for 

Nurses.     Catharine   McFarlane 128 

A  Text-book  of  Medical  Chemistry  and  Toxi- 
cology.    James   W.    Holland    255 

A    Text-book     of     Obstetrics.       Barton     Cooke 

Hirst    767 

Bulletin  of  the  Lloyd  Library  of  Botany, 
Pharmacy,  and  Materia  Medica.  J.  W. 
and  C.   G.   Lloyd   640 

Constipation  and  Intestinal  Obstruction.  Sam- 
uel   G.    Grant    256 


Index 

Department    of    Commerce    and    Labor    Bureau 

of  the  Censua.     S.  N.   D.  North 384 

Diet  in    Health    and    Disease.     Julius   Frieden- 

wald   and   John   Ruhrah 576 

Diseases    of    the    Genito-urinary     Organs    and 

Kidney.      Robert   Holmes    Greene 127 

Gonorrhoea  in  Women.     Palmer  Findlcy 63 

Hand-book  of  Diseases  of  the  Rectum.     Louis 

J.    Hirschman    512 

Lincoln's   Love    Story.     Elanor   Atkinson 192 

Modern   Materia  Medica  and   Therapeutics.     A. 

A.    Stevens    704 

New  and  Non-official   Remedies  for  1909 3S4,  511 

Obstetric    Nursing    and    Gynecology.      Edward 

P.    Davis    192 

Parsimony   in   Nutrition.      Sir  James  Crichton- 

Browne     254 

Physiological  and  Medical  Observations  Among 
the  Indians  of  Southw(stern  United 
States  and  Southern  Mexico.  Ales 
Hrdlicka     511 

Practical   Dietetics   with    Reference   to    Diet   In 

Disease.      Alide    Frances    Pattee 192 

Primary    Studies    for     Nurses.      Charlotte    A. 

Aikens     255 

Principles  and  Practice  of  Physical   Diagnosis. 

John  C.    DaCosta   128 

(777) 


778 


INDEX. 


Proceedings  of  the  Academy  of  Natural  Sci- 
ences  of    Philadelphia    384 

Saunders   Books    04 

Saunders"  Pocket  Medical  Formulary.     William 

M.    Powell    255 

Surgical   Diagnosis.     Daniel  N.   Eisendrath 767 

Taber's  Pocket  Encyclopaedic  Medical  Diction- 
ary. Clarence  W.  Taber  and  Nicholas 
Senn    63 

The  Principles  of  Pharmacy.     Henry  V.  Arny. .  575 

The  American   Pocket   Medical   Dictionary.     W. 

A.  Newman  Dorland    576 

The   Emmanuel    Movement   in   a  New    England 

Town.     Lyman   P.    Powell    510 

Third  Report  of  the  Wellcome  Research  Labora- 
tories at  the  Gordon  Memorial  College, 
Khartoum.     Andrew   Balfour  610 

Thirty-flfth  Annual  Report  of  the  Secretary  of 
the  State  Board  of  Health  of  the  State 
of  Michigan,  for  the  fiscal  year  ending 
June   30,    1907    64 

The   Climber.     E.    F.   Benson    255 

The   Death  of  Lincoln.     Clara  E.    Laughlin 256 

Transactions  of  the  Sixth  Annual  Conference 
of  State  and  Territorial  Health  Officers 
with  the  United  States  Public  Health 
and  Marine  Hospital  Service   63 

Transaction  of  the  American  Climatological  As- 
sociation  for   the   Year   1908 256 

Transactions  of  the  Medical  Society  of  Loudon. 
Frederick    J.    Poynton    and    Thomas    H. 

Kellock 254 

Transactions   of  the   Tenth   Annual   Meeting   of 

the    American    Proctologic    Society 254 

Treatment  of  the  Diseases  of  Children.    Charles 

Gilmore  Kerley   576 

Tuberculosis  a  Curable  and  Preventable  Dis- 
ease.    S.   Adolphus  Knopf   512 

Vaccine    and    Scrum    Therapy.      Edwin    Henry 

Schorer    511 

CLINICAL    LECTURES. 

Acne    indurata.      John    V.     Shoemaker,     M.D., 

LL.D     289 

Arthritic  muscular  atrophy.  John  V.  Shoe- 
maker,   M.D.,    LL.D 481 

Catarrhal  jaundice.     John  V.  Shoemaker,  M.D., 

LL.D 97 

Diabetes  mellitus.     John   V.    Shoemaker,    M.D., 

LL.D 97 

Epithelioma.    John  V.  Shoemaker,  M.D.,  LL.D.  609 

Gastric  ulcer.    John  V.  Shoemaker,  M.D.,  LL.D.  545 

Influenza.     .John  V.  Shoemaker,   M.D.,   LL.D...  673 
Infantile  gonorrhoeal   vulvo-vaginitis,   aphthous 
stomatitis.      Wm.    C.    Hollopeter,    M.A., 
M.D 673 

Lupus    vulgaris.      John    V.    Shoemaker,    M.D., 

LL.D 161 


Psoriasis.     John  V.  Shoemaker,  M.D.,  LL.D 353 

Sciatica.     John  V.  Shoemaker,  M.D.,  LL.D 423 

The    Spirochsete    pallida.      Warren    C.    Batroff, 

M.D 103 

Thyrotomy    for   tumor   of   the    left   vocal    cord, 

and    excessive    mobility    of    the    tongue. 

Richard  H.    Johnston,   M.D 228 

Tinea   versicolor.      John    V.    Shoemaker,    M.D., 

LL.D 225 

Typhoid     fever.      John    V.     Shoemaker,     M.D., 

LL.D 33 

Uraemia.     John   V.   Shoemaker,   M.D.,  LL.D 737 

EDITORIALS. 

Advantages  and  disadvantages  of  dancing 115 

Co-education    241 

Cremation,   the  best  method  of  disposal   of  the 

dead    503 

Education  for  deficient  children    375 

Four  thousand   consumptives  starve  yearly 569 

International   tuberculosis  exhibition   177 

Microscopy     and     its     value     to     the     modern 

physician    751 

Modern  and  Grecian  athletics   48 

Music  as  a  remedial  agent  568 

Pellagra    633 

Specific    remedy   in    the   diagnosis   and   therapy 

of    urogenital   tuberculosis 698 

Strophanthus  437 

The  milk  supply  of  cities 373 

The  Pinellas  Peninsula,   Florida  50 

Vivisection  and  its  results   307 

MATERIA  MEDICA   AND  THERAPEUTICS. 

Acute    mental    cases,    temporary   treatment    of. 

Damayne    and    Mezie    243 

Adhesive   plaster   in  the   treatment  of  swelling 

feet.      Stabsarzt    Blecher 242 

Adrenalin    in    infective    diseases.      Hoddick 180 

Its   action   on   the  skin.     G.   Sardou 376 

In   the   treatment   of   cancer.      Floersheim 180 

In    intestinal    hEemorrhage.      C.    J.    Wiggers..  376 

Intravenously  in   collapse.     B.   Kothe .570 

In  tabetic  crises.     Roehber  635 

Alcohol  in  the  treatment  of  neuralgia.  Alex- 
ander      117 

Alloplastic   substitution   of  the  dura.     Ilanel...  309 
Alopecia   of    dental    origin.      Rousseau    Decelle.  439 

Amoeboic  dysentery.     Granville  S.   Hanes 439 

Ammonium     carbonate     in     the     treatment     of 

coryza.     Beverly   Robinson    117 

An  early  symptom  of  phthisis— enlargement  of 
the  heart  and  liver.  S.  von  Unter- 
burger     243 

Antiferment  serum  in  the  treatment  of  suppu- 
ration.    A.    Fuchs    .505 


INDEX. 


■79 


Antiformin  in  the  detection  of  tubercle  bacilli. 

O.    Seemann    571 

Appendicitis,   treatment  of.     Beverly  Robinson.  506 
Treatment  of,  by  a  new  method.     Jaeger 243 

Arterial   sclerosis,   treatment  of.     Gouget 117 

Arteriosclerosis,  treatment  of  gastric  symp- 
toms.    H.   L.   Aikin    506 

Arthritis,   severe,   treatment  of.     A.    Schawlow.  635 

Artificial  pneumothorax  in  the  treatment  of 
chronic  tuberculous  empyema.  Wencke- 
bach      377 

Atropin  in  asthma.     P.  V.  Terray 244 

Treatment     of     ulcus     ventriculi.       D.     von 

Tabora    244 

Aural   diagnosis.     G.   E.    Shambaugh 310 

Bier's   hyperasmia  method   in  the   treatment  of 

inflammation  of  the  glands  of  Bartholin. 

Plass    .^ 118 

Bromide    and   deprivation    of   salt    in    epilepsy. 

Jules   Courmont   and   Cremien    53 

Eruption    in    childhood.      F.    C.    Knowles 571 

Bromural     in     the     treatment    of    seasickness. 

Prof.    Ziehen    53 

Bronchial    affections,    raising    the    foot    of    the 

bed  in  the  treatment  of.  P.  Schiifer. ..  377 
Burns,  treatment  of.     Renner  118 

Caesarean   section,    adrenalin    in.     Bogdanovics.  571 

Calcium  salts  in  skin  diseases.     Bettmann 572 

In    treatment   of    convulsions.      Silvestri. .. .    54 

In  epilepsy.     A.   P.   Ohlmacher 635 

Camphor    in    digestive    intoxicants    in    infants. 

Wurtz    700 

-Naphthol  in  tuberculosis.     W'erden 181 

Cantharides  in  acute  nephritis.  E.  Lancereaux.  636 
Carbon  dioxide  snow,  uses  of.     M.  L.  Heidings- 

feld    378 

Carbuncle,   treatment   of.     Max   Grassmann 244 

Cerebellar   tumor,    removal   of.     T.    Diller   and 

Otto  C.    Gaub    572 

Tumors,    treatment   of.     Siemerling   243 

Cerium    oxalate    for    relief    of    vomiting.      G. 

Baehr  and   H.   Wessler   245 

Chloroform  in  haemoptysis.  Joseph  B.  Fish..  440 
Cholera  infantum,  carrot  soup  in  treatment  of. 

C.     Beck     572 

Choline    in    animal    tissues    and    fluids.      Mott 

and   Halliburton    636 

Congealed   carbon  dioxide   in   the  treatment  of 

angioma.     Sauerbruch    246 

Copper  subacetate  inhalation  In  the  treatment 

of  tuberculosis.     Billard   440 

Corsets  for  ptoses.    A.  E.  Gallant 54 

Coryfin,   its  use  in  colds.     Baumgarten 119 

Craniectomy     for     albuminuric     retinitis     and 

uraemia.     Cushing  and   Bradley 181 

Creosote    in    pulmonary    tuberculosis.      Beverly 

Robinson     637 


Decapsulation   of   kidnoy   for  chronic   nephritis. 

Gatti    65 

Digipuratum    on     the    circulatory    system.      J. 

Szinnyei    337 

Dionin  in  keratitis  and  Iritis.  Chas.  J.  Scott.  700 
Dislocation    of    the    shoulder,    reducing    a.      G. 

Schichhold     507 

Dry  heat  in  gynecology.    Gellhorn  G38 

Effect  of  oxygen   upon   wounds   and   infections. 

Burkhardt   246 

Electric  treatment  of  asthma.     Gunzel    55 

Electricity  in  ileus.     F.  Sejars  700 

Empyema,  treatment  of  by  flushing  and  suction 

W.    Pust    378 

Of  the  nasal  sinuses,  treatment  of.  Mortens.  378 
Enemata  of  collargol  in  the  treatment  of  septic 

diseases.      Curt   Seidel    132 

Epileptic  psychosis,  treatment  of.  Siemerling.  379 
Erysipelas,   vaccine  treatment  of.     G.  W.   Ross 

and  W.   J.   Johnson    247 

Ethyl     chloride     as     an     anajsthetic.       A.     H. 

Miller    '  573 

Euquinine  in  the  treatment  of  whooping-cough 

and  typhoid  fever.    C.  Binz  55 

Eucalyptus  in  hemorrhage.    A.Todd-White....    55 

Facial  paralysis,  treatment  of.     F.   Marsh 574 

Faradic  current  in  otosclerosis   574 

Ferratin.     Schmiedeberg   441 

Fibrolysin  in  pleural  adhesions.  Schniilgen. ..  248 
Formol     in     the    treatment    of    sweating    feet. 

Viela   55 

Fracture   of   the   patella,    treatment  of  old.     J. 

Roller     119 

Gastric   ulcer,    treatment  of.     Mayerele 574 

Gelatin  as  an  anaesthetic  and  as  a  haemostatic. 

L.    J.   Facio    119 

And  salt  solution  infusions  in  typhoid  hsemor- 

raghe.      Witthauer    56 

In  therapeutics.     O.   Wandel   638 

Gelsemium.    Wm.   Henry  Morse   182 

General  anesthesia  by  the  rectum.  Dumont..  183 
Genital     tuberculosis,     treatment     of.       F.     J. 

McCann     248 

Glycerin  extract  on  liver  in  alcoholic  cirrhosis. 

Jacques    Carles     56 

Guaiacol    as   an   anaesthetic    and   antiphlogistic. 

Hecht  , 701 

Gunshot    wounds    of    the    head,    treatment    of. 

Paul   F.   Eve   701 

High    frequency     currents     in     tabes     dorsalis. 

Nagelschmidt    120 

In    the    treatment    of    enlarged    prostate. 

Hunter    57 

Hot  air  in  the  treatment  of  acute  inflammations. 

Jsclin    57 

lodin  lavage  of  the  infected  puerperal  uterus. 

Ortali    120 


780 


INDEX. 


Irrigations     in     the     treatment     of     venereal 

Ulcers.      Zinsser    57 

Solutions   of   boric   and   salicylic   acid   in    the 

treatment  of  carbuncles.     Grassman —    58 

Hydrocephalus,     chronic     idiopathic     internal, 

cured  by  draining  the  ventricle.    Halben.  379 

Hydrocyanate  of  iron    442 

Hydrogen  peroxide  in  medicine.  E.  Fried- 
lander    249 

Hyperemia    in     the     treatment    of    chilblains. 

C.    Ritter     58 

Treatment  in  gynecology.     A.   Stein   120 

Hypertrophied   prostate,   treatment  of.     Hilder- 

brandt    121 

Hypodermics    of    iron    in    antemia.      Leroy    F. 

Peters    58 

Hypophysis     extract    upon     the     blood-vessels. 

Pal    638 

Hysteria,    treatment   of    701 

Indoxyluria  in  mental   diseases.     G.   Pardo 183 

Infantile     meningitis,     treatment     of.       Roque 

Macouzet    249 

Ingrown  toe-nails,  treatment  of.  W.  Stoeckel.  380 
Injections  of  salt  solution  in  sciatica.     D'Orsay 

Hecht     121 

Injection    treatment    for    haemorrhoids.      Edwin 

A.    Hamilton    701 

Insomnia  in  heart  disease,  treatment  of.     F.  J. 

Wethered   249 

Intoxication     with     chloroform,     treatment     of. 

K.  Wirth   311 

Intraoral    cancer,    operative    treatment    of.      C. 

P.    Childe    280 

lodin  in  surgical  tuberculosis.  W.  A.  Tatchell.  311 
An   antidote   in  phenol  poisoning.     Maberly..  183 

lodipin,    uses   of.      E.    Lustwerk    639 

lodifin    in    eye    affection   of    luetic    origin.      W. 

Zimmerman    311 

Iodoform  and  ichthyol  in  pulmonary  tubercu- 
losis.    Samuel   Floersherm   702 

Isporal   in  cardiac   affections.     Peters 122 

Keloids,    injections   of   fibrolysin    in    the   treat- 
ment of.     R.    E.   Brennan    122 

Laparotomy    in    the    treatment    of    gangrenous 

hernia.      F.    Hesse    184 

Lipoid  substances  in  the  treatment  of  tetanus. 

Bockenheimer    184 

Liquor   hydrargyri   perchloridi   in   treatment  of 

diarrhoea.      Faichnie    123 

Lumbar  puncture   in   injuries  of  the  head.     P. 

Savy    702 

Magnesium   sulphate   in   tetanus.     Miller    123 

Mastitis,    treatment  of.      Feinen    311 

Maxillary   readjustment.      G.    V.    I.    Brown 381 

Meningococcal    serum    in    epidemic    meningitis. 

Lange     381 

Meningeal,  sinus  and  labyrinthine  complica- 
tions, treatment  of.     S.  MacCuen  Smith.  507 


Meningitis,    treatment    of,    by   urotropin.      S.    J. 

Crowe    508 

Mercurial  treatment  in  syphilis.     E.   C.   Hay...  703 
Moles   and   more  or   less   extensive  nevi,   Tesla 
current  in  the  treatment  of.     Aspinwall 
Judd    382 

Movable  kidney,  treatment  of.  A.  B.  Bevan...  250 
Mustard  packs  in  bronchitis.  A.  A.  Herzfeld.  .442 
Mercury  in   infectious  and  contagious  diseases. 

H.    E.    Jones    185 

Mercury  in  tuberculosis.     B.  L.  Wright 58 

Methylene-blue   for   fissured   nipples.      Dresh...     59 

Neuroprin    in    nervous    diseases.      Roasenda 382 

New  noses  in  twenty  minutes,  new  process  for. 

H.   R.    Allen    443 

Obesity,  principles  for  treatment  of.  Kisch.  443 
Oil    in    the    treatment    of    stomach    affections. 

Riitimeyer     ^..    59 

Operative     treatment     of     ascites     to     hepatic 

cirrhosis.     Bogojawlensky    312 

Of     puerperal      peritonitis      and      thrombo- 
phlebitis.     Leopold    185 

Orthostatic   albuminuria.     Jehle   250 

Osmic  acid  in  trifacial  neuralgia.  H.  H.  Ger- 
main      313 

Osteotomy  of  the  cuneiform   for  hallus  valgus. 

R.    Reidl    762 

Oxygen    insufflation    for    revival    of    newborn. 

Cavazza    124 

Oxygen    in   puerperal   infection.     Reynier 59 

Oxygen   in   tuberculous  peritonitis.     S.   A.    Mc- 

Glinn     186 

Pancreas  diabetes,   treatment  of.     Bruck 124 

Paraffin   for  incontinence  of  urine.     Fabre  and 

Trillat    60 

Paralysis  of  the  shoulder,  mechanical  treat- 
ment.    David   Silver    251 

Pernicious      anaemia,      treatment     of.        Byron 

Bramwell    251 

Phlegmons    of    the    hand,    with    hot-air    baths, 

treatment   of.     H.    Iselin    508 

Physostigmin     in     postoperative     ileus.       Goth.  124 

Picrotoxin.     "William   F.   Waugh   187 

Phosphorus  as  a  brain  food.    W.  Koch 444 

Pilocarpine    in     the     laryngeal    obstruction    of 

measles.     A.    Montefusco    60 

Pineapple   as    a    medicine    187 

Placenta   prjEvia,    treatment  of.      W.    Hannes. .  313 

B.    Kronig    509 

Pokeberry  poisoning.     Lester   444 

Potato  diet  in  obesity.     G.   Rosenfeld 639 

Postoperative  treatment.     O.    D.    Hamlin 313 

Prophylaxis  in  epidemic  cerebrospinal  menin- 
gitis.     Seibert    314 

Protargol  in  the  treatment  of  ophthalmia  neo- 
natorum.     Motais    444 

Purulent  peritonitis,  treatment  of.  N.  Gulcke.  762 
Pyrenol     in     the     treatment     of     asthma     and 

emphysema.      Boelike    314 


INDEX. 


781 


Quinine   in    cholera.     Ussher    60 

Radium,    its    therapeutic    applications.      Wick- 
ham    and   Degrais    445 

Treatment   of    Angiomata    60 

Radical  operation  for  umbilical  hernia.     Martin.  1S7 

Rheumatism,   treatment  of.     N.   S.   Davis 251 

Rubber  elastic  bands  for  drainage.     E.  Stanley 

Ryerson    7G3 

Ruptured   kidney,    treatment  of.     Morestin 315 

Sabromin,     a    new     bromide    preparation.      V. 

Mering    252 

Saline  injections   in    the   treatment  of   sciatica. 

J.    Flesch    252 

Salt  in  the  treatment  of  internal  hfemorrhage. 

Von   Den  Velden    315 

Scapulopexy  in  myopathy.     Panchet  763 

Scarlet  fever,   treatment  of.     Gordon 316 

Scissors-magnet    extraction    of    foreign    bodies 

from  the  eyeball.     E.   Jackson  446 

Scopolamin-morphin      anassthesia.  C.      M. 

Nicholson    383 

Serotherapy  in  the  treatment  of  post-diphtheritic 

paralysis.     G.    E.    Schneider   and   L.    A. 

Vandeuvre     188 

Severe    haemorrhage,    suture   of    the    lung    for. 

Lotsch    446 

Silver   nitrate   in   infections.     A.   Schatsky   and 

N.    Grjasnow    61 

Sodium    chloride   in    internal   haemorrhage.      R. 

von   den  Velden    764 

Sodium     cinnamate    in    tuberculosis.      Reynier 

and   Bluson    125 

Sodium    salicylate    in    rheumatism.      Stockman.  188 
Sodium  nucleinate  in  acute  infections.     Laine.  189 

Soy  bean  in  infant  feeding.     J.  Ruhrah 704 

Spirosal  for  rheumatism.     Otto  Lehmann 61 

Strychnine  in  paralyzed  limbs.     W.  Steele 125 

Styptol  in  the  treatment  of  dysmenorrhoea  and 

uterine   haemorrhages.     F.    Girardi    446 

Sulphuric    acid    in    carbuncles,    boils,    etc.      J. 

and  R.  J.   Reynolds   61 

Suppuration  of  renal  pelvis  and  ureters,  treat- 
ment   of,    by    lavage.      Garceau 447 

Of     the     accessory     sinuses,     treatment     of. 

Martens     764 

Subacute   alcoholism,    treatment   of.     Robin 509 

Suction    hyperaemic    treatment    of    gynecologic 

affections.     Seeligman    189 

Superficial  pneumococcal  affections.    V.  Morax.  316 

Sweating   feet,    treatment   of 126 

Syphilis   of  the   nervous   system,   treatment  of. 

G.   Koster   317 

Of  the  upper  respiratory  tract,  treatment  of. 

Livien    447 

Tamponing    in    the    treatment    of    prolapse    of 

rectum.     Sick    764 

The  knee-joint,  surgical  conditions  of.    Tenney.  317 


X-rays  in  epithelioma.     G.   E.   PfahlrT 126 

Typhoid  fever,   treatment  of.     J.   D.   S.   Davis..  320 
Treatment   of   ichthyosis.     Weill   and    Mouri- 

quand     3j,^ 

Treatment  of  aneurysm  of  the  neck.     Guinard.  318 

Of  appendicitis  in  pregnancy.     Rudaux 190 

Of   asthma.     Treupel    jgg 

Of    children    suffering    from    rheumatism    or 

chorea.     D.   B.    Lees    313 

Of   chronic   endometritis.     J.    H.    Rector 190 

Of  gastric  ulcer.     Borgbjaerrg   62 

Of     inoperable     carcinoma     of     the     uterus. 

Freund    jgQ 

Of  quinsy.     D.  J.  Guthrie  754 

Traumatic    injuries    of    the    extremities,    their 

treatment.  Walter  T.  Dannreuthcr.. ..  510 
Tubal  disease,  treatment  of.  Palmer  Findley.  316 
Tuberculin  treatment  for  infants  and  children. 

A.    Schlossman    3^9 

Of  pulmonary  tuberculosis.     P.   K.    Pel 765 

Tuberculosis,    tuberculin-arsenic    treatment   of. 

Mendel     32Q 

Tuberculous   affections   of   hip  joint,    treatment 

of.     Konig   44g 

Unmodified  sunrays  in  treatment  of  lupus  vul- 
garis.    J.    Goodwin    191 

Use  of  colloidal  silver  in  the  treatment  of  puer- 
peral infection.     Cyrille  Jeannin 191 

Uterine  hfemorrhage,  treatment  of,  with  serum. 

W.    Busse    448 

Vaccine  in  Bronchial  asthma.     D.  W.  Cormalt- 

Jones    765 

Vaginal    and    Cssarean    section,    technique   and 

indications  for  the.     Diihrssen    383 

Cesarean  section,  technique.     A.   Duhrssen...  575 
Varicose  veins  of  the  leg,  treatment  of.     J.   E. 

Jennings    510 

Veronal    in    the    insomnia    of    mental    diseases. 

Salluste    Roy    62 

Whooping-cough,   treatment  of.     Czerny 253 

Wood    cure   for   chronic   constipation.     Bluem- 

land   Ulrich    253 

X-rays      for      prostatic      concretions.        Gosta 

Forrsell    766 

Zinc  ions  in  the  treatment  of  ophthalmia  neo- 
natorum.    H.   K.   Ramsden   62 

Permanganate.     W.    A.    Puckner   and    W.    S. 

Hilpert    253 

MISCELLANEOUS. 

Greater  New  York  number  127 

The  American  Society  for  the  Study  of  Alcohol 

and   other   Narcotics    127 

ORIGINAL  ARTICLES. 

Action    of   glandular    extracts    upon    the    pupil. 

Isaac  Ott,  M.D.,  and  John  C.  Scott,  M.D.  493 


782 


INDEX. 


Acute  retention  of  urine  from  impaction  of  a 
phosphatic  calculus  in  the  penile  ure- 
thra, and  a  fatal  case  of  beriberi. 
Frank  T.   Woodbury,    M.D 304 

Aids  to  successful  results  in  the  Bassini  opera- 
tion for  the  radical  cure  of  hernia. 
Ernest  E.  Laplace,  M.D 47 

American  Proctologic  Society  abstracts— re- 
ported by  Lewis  H.  Adler,   Jr.,    M.D.  .562,  626 

A  question  in  therapeutics.     Brose  Home,  M.D.  425 

A  study  of  contemporary  workmen's  compensa- 
tion.     W.    H.    Allport,    M.D 612 

Baldness.     M.   L.   Ravitch,   M.D Ill 

Conclusion    in   regard   to    tubercular    ureteritis. 

Byron   Robinson,   M.D 356 

Erysipelas:  Its  etiology,  symptoms,  complica- 
tions, and  a  new  and  successful  method 
of  external  treatment.  Lucien  C.  Davis, 
M.D 293 

Fractures   of   the   patella  and    their   modern    op- 
erative treatment.     Aime  Paul   Heineck, 
M.D 751 

Headaches  and  their  treatment.  Guthrie  Ran- 
kin,    M.D 548 

Light   energy   in   the   treatment   of   disease.     J. 

Frank  Wallis,  M.D 681 

Medical  and  surgical  testimonials  on  the 
mummy    grove    potteries    of    Old    Peru. 

Albert   S.    Ashmead,    M.D 690,742 

Medical  missions.     R.   C.   Thomas,   M.D 41 

Medico-legal.     E.    S.    McKee..l08,    434,   557,    662,678 

Observation  on  the  effect  of  tasteless  cold  stor- 
age chicken,  used  as  a  food.  Ephraim 
Cutter    437 

Obstetrics  and  gynecology.     E.  S.  McKee,  M.D.  238 

Painful  heel.     C.   F.  Wahrer,  M.D 739 


Personal  observations  of  a  case  of  paralysis 
agitans  (shaking  palsy).  Parkinson's  dis- 
ease, with  multiple  complications.  T.  G. 
Stephens,    M.D 631 

Practical  analysis  of  the  gastric  contents.  Ed- 
Ward   C.    Hill,    M.D 371 

Preventive   medicine.     A.    J.    Burgholder,    M.D.  291 

Principles  of  the  modern  treatment  of  gonor- 
rhoea.   Joseph  L.  Boehm,  M.D 362 

Prophylaxis   of  gonorrhoea.     Thomas  W.    Rose, 

M.D 237 

Report  of  two  cases  of  intestinal  obstruction 
complicating  advanced  pregnancy;  op- 
eration; recovery.  John  A.  McGlinn, 
A.B.,  M.D 430 

Severe  types  of  typhoid  fever,  with  manage- 
ment and  treatment.     B.   L.   Hale,   M.D.  48S 

The   antidotal    effects   of   alcohol   upon    phenol. 

Harry  J.  Novack,   M.D 495 

The  borderland  of  success— The  Importance  of 
careful  attention  to  details  in  eye  and 
ear  work.     L.   Haines  Buxton,    M.D 483 

The   cancer  problem.     John   A.    McGlinn    230 

The  claims  of  psychology  and  allied  branches 
in  modern  medicine.  Charles  B.  Hardin, 
M.D 298 

The  efficiency  and  sufficiency  of  the  United 
States  Pharmacopoeia  and  National 
Formulary  preparations  for  the  general 
practitioner.  James  M.  Anders,  M.D., 
LL.D 164 

The  revision  of  the  laws  relating  to  child  labor, 
by  means  of  the  Roentgen  ray.  Thomas 
Morgan  Rotch,  M.D 369 

The  symptomatology  and  diagnosis  of  the  en- 
larged prostate.     H.  M.   Christian,   M.D.    44 

Tuberculosis  of  the  breast.  William  F.  Rod- 
man,   M.D.,    LL.D 173 

Uterine  moles,  with  special  reference  to  the 
hydatiform  mole.  J.  S.  Raudenbush, 
M.D 167 


ADVERTISEMENTS. 


33 


Mulford's 
Antitoxin 

and  the  New  Syringe 


Metal  PUmg-er  ~ 


Finger-rests 


Every  dose  furnished  in  this 
Perfected  Syringe 

ADVANTAGES  OF  NEW  SYRINGE:   ASEPSIS,  contammation  impossible. 
POSITIVE  WORKING:  The  metal  plunger  screws  into  the  rubber  plug,  adjusting 
pressure  and  making  action  positive. 

Metal  finger-rest  With  rubber  guard  at  top  of  syringe  pre\/ents  any  possibilitf 
of  syringe  breaking  or  injuring  operator's  hand. 

Needle  attached  With  flexible  rubber  joint  permits  motion  of  patient  without 
danger  of  tearing  the  skin— a  great  advantage  in  administering  to  children. 

Our   new  adjustable  rubber  packing  possesses  great  advantages;  it  is  readily 
sterilized,  does  not  harden,  shred,  absorb  serum  or  become  pulpy. 

Simplicity  and  accuracy— no  parts  to  get  out  of  order. 

Mulford's  Antitoxin  is  Accepted 
Everywhere  as  THE  STANDARD 

The  higher  potency  enables  us  to  use  much  smaller  syringes. 
Minimum  bulk— maximum  therapeutic  results 

BROCHURES    AND    WORKING    BULLETINS    SENT    UPON     REQUEST 

H.   K.   MULFORD  CO.,  Philadelphia 


New  York 


Chicago 


St.  Louis 


Minneapc'is 


San  Francisco 


In  writing  to  advertisers  mention  this  journal. 


34 


ADVERTISEMENTS. 


Notes  and  Comments 


F.  A.  DAVIS  COMPANY.  Publishers. 


A.  G.  CRANDALL.  Manager. 


THE  MODERN 
GENERAL  PRACTI- 
TIONER AND  THE 
SPECIALIST. 


The  division  and  sub- 
division of  the  practice  of 
medicine  into  specialties 
seemed  for  a  time  to 
threaten  the  very  existence 
of  the  old  time  general 
practitioner.  But  long  ago  the  current  set  in 
the  opposite  direction. 

While  there  are  specialists  who  command  the 
highest  respect  of  practitioners  and  patients  alike, 
they  are  usually  physicians  whose  range  of  clinical 
observation  has  been  wide.  They  are  competent 
to  give  excellent  advice  on  medical  subjects  of 
general  significance.  This  class  of  specialist  is 
not  greedy  to  absorb  the  "easy"  cases  which  can 
practically  fall  within  the  scope  of  the  family 
doctor.  They  stand  as  safe  advisers  for  their 
friends  engaged  in  general  practice  and  in  a  re- 
ciprocal manner  are  kept  in  touch  with  the  ad- 
vances in  the  general  field  of  medicine. 

As  a  result  of  this  friendly  co-operation,  the 
general  practitioner  is  taking  better  care  of  his 
cases  of  internal  growth,  nose,  and  throat,  ear, 
skin  and  venereal  disease,  and  not  only  serves  his 
patients  better  and  makes  more  money,  but  is  sav- 
ing money  for  his  patients  and  making  money  for 
his  specialist  associates  by  detecting  serious  con- 
ditions before  they  have  reached  the  hopeless 
stage. 

Obviously,  the  closer  the  association  between 
the  ambitious  general  practitioner  and  the  broad- 
gauge  specialist,  the  better  for  both  and  especially 
for  their  various  patients;  but  for  that  type  of 
specialist  whose  conception  of  the  science  of 
medicine  is  limited  to  the  treatment  of  a  small 
section  of  the  human  body,  there  seems  to  be  no 


glittering  financial  future  or  increase  of  prestige 
among  broad-minded  general  practitioners. 


PEDIATRICS— A 
GROWING  BRANCH 
OF  MEDICINE. 


The     competent     physi- 
cian sees  much  that  con- 
cerns him  in  the  national 
slogan  "Save  the  Babies." 
It  means  greater  apprecia- 
tion for  the  family  doctor,  a  closer  touch  with  the 
family   and   a   more    intimate   acquaintance   with 
the  constitutional  characteristics  of  the  family. 

During  the  growth  period  it  is  economy  for  the 
average  family  to  keep  children  under  frequent 
inspection  by  the  physician.  Under  previous  con- 
ditions this  custom  has  had  little  vogue;  but  with 
a  more  general  awakening  of  parental  responsi- 
bility engendered  by  the  increased  attention  now 
given  to  the  prevention  of  disease,  the  function 
of-  the  family  physician  in  time  of  apparent  health 
is  becoming  recognized.  This  is  a  step  toward 
giving  the  physician  a  fair  chance. 

Naturally  a  broadening  science  means  more  text- 
books and  the  time  has  passed  when  the  progres- 
sive general  practitioner  is  satisfied  with  a  single 
reference  book  on  pediatrics.  "Save  the  Babies" 
means  the  development  of  a  distinct  branch  of 
medicine  and  that  implies  the  best  literatiire 
available. 

Fischer's  "Diseases  of  Infancy  and  Childhood" 
is  one  of  the  great  books  in  this  important  depart- 
ment. It  is  a  large  volume,  copiously  illustrated, 
fully  abreast  of  the  times  in  every  respect  and 
possesses  some  distinctive  features  not  found  in 
other  treatises  on  this  subject.     No  physician  can 


Systematic  Shampooing  ot  the  Scalp 

has  become  an  established  detail  of  personal  hygiene.   In  recommending  an  effective 
application  for  the  purpose,  many   medical    men    have    long   given    preference   to 

PACKER'S   TAR   SOAP 

Experience  has  proved  the  wisdom  of  this,  for  the  purity,  superior  quality  and  special 
character  of  this  mild,  antiseptic  soap  adapt  it  peculiarly  to  the  restoration  and  maintenance 
of  normal  scalp  conditions. 

It  not  only  cleanses  perfectly,  but  dependably  tones  and  nourishes  the  tissues  of  the  scalp. 


V 


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