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Full text of "The Medical news"

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THE 



MEDICAL NEWS 



A WEEKLY MEDICAL JOURNAL 



VOLUME 86 



APRIL - JUNE, 1905 



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THE MEDICAL NEWS. 

A WEEKLY JOURNAL OF MEDICAL SCIENCE. 



Vol. 86. 



New York, Saturday, April i, 1905. 



No. 13. 



ORIGINAL ARTICLES. 

THE COAGULATION OF THE BLOOD.i 

BY LEO LOEB, M.D., 

OF PHILADELPHIA. 

In the following review of the more recent in- 
vestigations regarding the coagulation of the 
blood, it is intended to report on some of the more 
important facts in the first place and to briefly 
consider afterward what is usually termed the 
■' theory of the coagulation of the blood," which 
really, however, comprises only one phase of the 
process of coagulation. I shall not limit myself 
to a consideration of the vertebrate blood, but 
shall include in this review the blood of inverte- 
brates. It is clear that in elucidating difficult 
problems, containing many unknown factors, it 
is of advantage to have as large a number of 
equations as possible. The following report must 
necessarily be of a fragmentary character and 
can only consider certain aspects of the problem : 
I. The inclusion of invertebrate blood, as 
for instance that of the lobster, in this review, 
is justified because recent investigations have 
shown the great similarity which exists between 
the coagulation of vertebrate and invertebrate 
blood. This applies to the coagulation of the 
fibrinogen proper, which is present in a colloidal 
solution in the plasma. It also applies to the 
phenomena of agglutination, which in the case 
of vertebrates as well as invertebrates, precede 
the coagulation of the fibrinogen consisting in 
the former class of animals in an agglutination 
of the blood plates and in the latter in an agglu- 
tination of the ameboid blood cells. The con- 
ditions determining these agglutinative phenom- 
ena are different from those which determine 
the coagulation proper, although the changes tak- 
ing place in these cellular elements are in all 
probabilit)- of the greatest significance in the 
following coagulation. 

2. It is a well-known fact that the presence 
of foreign bodies may accelerate the coagulation 
of the blood or of the blood plasma. The rate 
of this acceleration diflfers in different kinds of 
plasma, and a close parallelism does not exist 
between the coagulative strength shown by cer- 
tain solid bodies and by other more specific agen- 
cies which accelerate the coagulation of the blood. 
In a blood plasma prepared in a certain way, the 
former may be very effective and the latter very 
inefficient and vice versa. One of the factors 
which seems to increase the efficiency of chemi- 
cally inert solid substances in accelerating the 
coagulation seems to be their power of absorbing 
water. The mechanism of the action of solid 



I Read by invitation before the Pathological Society of Phila- 
delphia, 



bodies is little known, and a comparative investi- 
.gation of the actions of different varieties of solid 
bodies would be of great interest. 

It is necessary to distinguish between the power 
of solid chemically inert substances of accelerat- 
ing the coagulation of the blood and another pro- 
perty of solid bodies, namely that of determining 
where the fibrin which has been formed is first 
deposited. In the latter case the action of the 
solid body is probably merely a mechanical one. 
The first fibrin formed sticks to the solid particles 
suspended in the fluid and retracts around them 
as their center. As we shall see later, there are 
certain solid substancs of animal origin, which 
have a specific influence upon the blood plasma 
causing the coagulation of the fibrinogen in their 
immediate neighborhood. 

The fibrin thus deposited around solid bodies 
has the appearance of a homogeneous gelatinous 
mass. Through certain mechanical agencies 
( traction and pressure) this gelatinous mass can 
be transformed into a system of fibers. In this 
connection it might be appropriate to mention the 
so-called coagulation centers described by 
Hauser. Under certain conditions fibrils of fibrin 
are seen radiating either from a dying cell, or 
from blood plates, or from chemically inert for- 
eign bodies. It seems very likely to me that 
also in this case the formation of fibers around 
these centers is only a secondary process, due to 
mechanical factors acting upon fibrin which was 
at first gelatinous. 

3. The influence of foreign bodies upon the 
blood becomes very apparent in the experiments 
of Freund and Haycraft, who succeeded in pre- 
serving the liquid state of the blood by keeping it 
in contact with vaseline or with fatty substances. 
Recently Bordet and Gengou undertook to prove 
that the influence of the glass, with which the 
blood is brought in contact, consisted in a conver- 
sion of the proferment into a ferment, a process 
which was accelerated by glass and which was 
not accelerated or only to a much less degree by 
such substances as paraffin. Bordet and Gengou 
found that the plasma after its coagulation had 
taken place, in the glass, contained more ferment 
than did the not yet coagulated plasma in the 
paraffin tube. It is, however, almost certain that 
this mode of action is not the only one exerted 
by solid substances. 

Another way in which foreign bodies may in- 
fluence the coagulation of the blood is by their 
action upon the cells of the blood. This can 
be best studied in the blood of certain arthro- 
pods, as for instance of Limnhts, which contain 
only one kind of blood cells. If we collect the 
blood of a Limulus by means of a verv clean can- 
ula from the heart of the animal and receive it 



578 



LOEB: COAGULATION OF BLOOD. 



[Medical News 



on a clean slide, instead of collecting it by merely 
pushing a fine scalpel into the heart, the blood 
may show no changes with the exception perhaps 
of a slight agglutination of a certain number of 
blood cells, which, however, remain oval or round 
and preserve their granules. Gradually the blood 
corpuscles sink to the surface of the slide, and 
those cells which have come into contact with or 
near the glass begin to show changes of form, 
sending out pseudopodia and gradually undergo- 
ing destructive changes, losing for instance, their 
granules. Notwithstanding these changes taking 
place in the cells, the supernatant plasma does not 
coagulate, because it contains very little, if any, 
fibrinogen. If, on the other hand, we collect in a 
similar way the blood of a lobster, which possesses 
fibrinogen, it is possible to delay but it is not 
possible to prevent the coagulation of the blood, 
the changes which gradually take place in the 
blood corpuscles causing the coagulation of the 
blood. At least I have not succeeded in prevent- 
ing the coagulation of the lobster blood by the use 
of a canula. Haycraft found that by collecting 
the blood in such a manner that it is surrounded 
by oil, its coagulation can be prevented. The 
blood corpuscles, which are completely sur- 
rounded by oil, do not send out pseudopodia and 
are, as I found, not at all or only very slightly 
changed. We see, therefore, that the same cir- 
cumstances, which according to Bordet and Gen- 
gou cause the new formation of fibrin ferment in 
the plasma, lead to ameboid movements of the 
cells and to destructive cell changes. This anal- 
ogy between the influence of external media upon 
ferments and cells is of great interest. In both 
cases the indirect results are identical, producing 
the coagulation of the fibrinogen. If we remove 
the cells as rapidly as possible from the blood 
plasma after the shedding of the blood, the coag- 
ulation of the lobster plasma can be prevented 
fo"- a much longer period than would otherwise 
be possible. The cells are therefore entirely or 
to a great extent responsible for the coagulation 
of the plasma. In order to determine the causes 
of the apparently spontaneous coagulation of the 
blood, it is of the greatest importance to analyze 
still closer the factors leading to these cell 
changes. 

Is a certain mechanical factor, namely the pres- 
sure of the narrow wound upon the outflowing 
cells, or is the influence of contact with the sur- 
rounfling tissue, e.g., muscle tissue, of the great- 
est importance in causing these cell changes 
in the case the blood leaves the body through 
the wound directly without the aid of a canula? 
If in the case of Linmhts we use instead a clean 
canula, a canula containing dust particles, or, if 
we collect the blood instead in a dry dish or 
on a clean slide, in a dish containing some sea 
water or a NaCl solution of corresponding os- 
motic pressure the cell changes are not prevented 
and are just as marked as if the blood had been 
collected in muscle extract, the cell changes 
simulating a true coagulation of the blood. We 



are, therefore, led to the conclusion that mechan- 
ical factors are of main importance in determin- 
ing the changes in the blood cells and indirectly 
the coagulation of the blood, and that the in- 
fluence of the tissue is not necessary for the rapid 
coagulation of the blood flowing out of wounds 
and, therefore, the main significance of the use 
of the canula consists in its safeguarding the cells 
which are of a labile character against the shock 
produced by the pressure of a narrow wound. 

4. These facts and considerations have signi- 
ficant bearing on the interpretation of the results 
obtained by Delezenne, who found that by col- 
lecting birds blood through a clean canula under 
conditions which prevented the contact of the 
blood with the tissues, the blood can remain liquid 
for many hours, and if freed from cells, for many 
days. Delezenne interpreted these results as 
mainly due to the absence of the action exerted 
by the tissues. That the tissue extracts have a 
powerful action upon the coagulation of the 
blood can easily be demonstrated. It can, how- 
ever, be only a question of such a slight amount 
of substance, which can be extracted from the 
tissues by the blood passing through a wound, 
that it becomes probable that the conditions are 
here analogous to those found in the blood of 
Li Junius. If the blood flows through an uneven 
wound, certain cellular elements of the blood un- 
dergo marked changes and substances accelerat- 
ing the coagulation are admixed to the blood. 
According to this hypothesis the mechanical con- 
ditions of the wound are of primary importance ; 
the action of the tissue coagulins would be a 
secondary one. For the understanding of the 
causes underlying the coagulation it would be of 
great value to determine experimentally what 
the relative importance of these two factors is. 
It is not possible to delay the coagulation of the 
blood of mammals as markedly as that of birds 
by collecting it through a canula. In this case 
again it is not unlikely that this difference is due 
to a different degree of sensitiveness of the cellu- 
lar elements in birds' blood on the one hand and 
in mammalian blood on the other. 

5. In connection with the effect of chemically 
inert solid bodies the action of another kind of 
foreign particles, namely the action of bacteria 
upon the coagulation of the blood may be con- 
sidered. The connection between intravascular 
clotting or thrombosis on the one hand and cer- 
tain infectious diseases or local infections around 
the blood vessels on the other hand, has long since 
been recognized. There exist, however, several 
possibilities of explaining this relationship. An 
experimental analysis of the different factors con- 
cerned is necessary and a direct examination of 
the effect of bacteria on the coagulation of the 
blood suggests itself in the first instance. Mucli 
as the influence of bacteria on a great variety of 
culture media and on the coagulation of milk has 
been investigated, the problem of the effect of 
bacteria on the coagulation of the blood has, to 
my knowledge, never been approached until re- 



April i. 1905] 



LOEB: COAGULATION OF BLOOD. 



579 



cently. The reason for this neglect has probably 
been the difficulty of getting blood plasma in a 
suitable condition for such an examination. For 
this purpose a plasma is required which can be 
jjrepared without the addition of chemical sub- 
stances which themselves might influence the 
bacteria or their products. Birds' plasma pre- 
pared according to the method of Delezenne satis- 
fies this condition. In experiments carried out 
in this way, typical differences were found to exist 
between different bacteria in their power of 
coagulating the blood. The Staphylococcus 
pyogenes aureus used in these experiments was. 
for instance, much more powerful than the Bacil- 
lus coli; furthermore it was found that by boiling 
the culture its efficacy was to a great extent de- 
stroyed. The action of bacteria is, therefore, not 
identical with that of chemically inert foreign 
particles. Combined with this action of the bac- 
teria on the fibrinogen may be a precipitating 
effect on albuminous bodies of the blood serum 
as described by Libman and others. Pathological 
conditions more than any other make a further 
working out of these problems yery desirable. 

6. As we mentioned before, it is necessary 
to remove all cellul?r elements from the blood 
either by means of centrifugalization or other- 
wise, in order to keep the normal blood liquid for 
a long period without addition of certain chemi- 
cally active substances. This holds good for the 
blood of birds which has been collected by means 
of a clean canula, as well as for mammalian 
blood vi'hich can be kept liquid, if received in a 
certain proportions of a 0.85 per cent. NaCl solu- 
tion previously heated to 56° to 57° C. and cen- 
trifugalized directly aftervi'ard. In a similar 
way it holds good for invertebrate blood. If we 
remove, for instance, the agglutinated cells (cel- 
lular fibrin) from the blood of the lobster and 
dilute the plasma in certain proportions with 
water, we can frequently keep it fluid for a con- 
siderable time. Coagulation can be delayed in- 
definitely if this plasma is afterward heated to 
45° to 52° C. for one hour. If to the plasma of 
birds or mammalian plasma, which has been de- 
prived of its cells, a piece of a blood-clot, or, if 
to the lobster plasma a piece of the so-called first 
clot, containing the blood cells is added, a rapid 
coagulation usually takes place. The same holds 
good if to birds' plasma and lobster plasma a 
piece of birds' and lobster muscle respectively is 
put. On the other hand, I have repeatedly ob- 
served that when to diluted bird plasma the cen- 
trifugalized goose blood corpuscles were added, 
their accelerating effect upon the coagulation was 
relatively slight, although in fresh, undiluted 
blood, the corpuscles have a distinct accelerating 
effect. It will be necessary to submit to a still 
closer analysis the condition under which the 
blood cells are active and under which they lose 
their efficiency. 

The conditions are similar in the case of lymph 
as in the case of the blood, as was rdTrently found 
by Repin. This investigator succeeded in keep- 



ing the lymph of the horse liquid when he col- 
lected it from the thoracic duct by the aid of a 
canula. This fact may become of importance if 
we take into consideration that in the case of 
the lymph we have principally to deal with one 
single kind of cells, the leucocjiies, and especially 
the lymphocytes in contradistinction to the com- 
plex character of the cells in the vertebrate blood. 
Nevertheless all the conditions necessary for the 
coagulation of the blood are present in the lymph 
and it might, therefore, be of some advantage to 
investigate the coagulation of the lymph or the 
coagulation of invertebrate blood, where the con- 
ditions are of a relatively simple character rather 
than to concentrate all efforts upon vertebrate 
blood. 

7. We see, therefore, that at least one or per- 
haps several elements accelerating the coagulation 
of the blood are derived from the blood cells. It 
is probably this same accelerating factor originat- 
ing from the blood cells, which is afterward, 
when the coagulation is finished, found in the 
serum perhaps in a modified form or aided by 
some new elements. This active principle cor- 
responds in part at least to the thrombin of Alex. 
Schmidt. A second factor exists, which is of 
prime importance, for the coagulation of the 
blood. Different tissues contain substances, 
which are very powerful in the coagulation of the 
blood, and these substances can be extracted by 
water. The substances present in the tissues 
were either in a somewhat modified form or 
mixed with other products known to the older 
investigators, as for instance Alex. Schmidt and 
Wooldridge. Alex. Schmidt usually used al- 
coholic extracts. Wooldridge used substances 
precipitated by acid and soluble in alkali. Both 
of these authors distinguished between the agency 
in the blood and the one present in the tissues. 
Later, however, when under the influence of the 
work of Arthus, Pekelharing and Hammarsten, 
the significance of calcium on the coagulation of 
the blood was clearly demonstrated, and when 
Pekelharing tried to prove the nucleproteid char- 
acter of the thrombin, there was a tendency to 
regard the chemical agencies present in the blood 
and those present in the tissues as identical. 
Pekelharing and Huiskamp believed to have iso- 
lated the active substance in the form of the cal- 
cium salt of nucleoproteid or of nucleohiston ; in 
the opinion of these investigators the active sub- 
stance of the serum as well as of the tissues being 
a nucleoproteid. From the thymus they isolated 
a nucleohiston. Recent investigations, however, 
tend to show the existence of a marked differ- 
ence between the character of these two sub- 
stances and make it therefore probable that they 
are not identical. 

8. Delezenne found that birds' blood which 
coagulates very slowly, if collected through a 
canula, coagulates very rapidly, if it is mixed 
with extracts of birds' tissues. He interpreted 
the power bird's tissues possess of accelerating 
the coagulation of blood as a compensatory 



!;8o 



LOEB: COAGULATION OF BLOOD. 



[Medical News 



inechanisni intended to make good for the corre- 
sponding deficiency in the coagulating power of 
the blood itself. Later Conradi tried a large 
variety of tissue extracts and found all of them 
very active in accelerating the coagulation of the 
blood. 

The fact found by Delezcnne and new observa- 
tions made on the blood of invertebrates led me 
to assume a specificity of the active principles of 
the tissue extracts, which I called tissue coagulins 
in analogy with the substances obtained by arti- 
ficial immunization. 

In a series of comparative investigations I 
found this specificity to e.xist in vertebrates 
as well as in invertebrates. The specific dif- 
ference in the action of tissues of dififerent 
classes of animals makes it possible to distin- 
guish between the muscles of two animals as 
nearly related as the lobster and the blue crab. 
In this case we have truly to deal with a " bio- 
logic test " for tissues, a test moreover for which 
no preliminary artificial inmnmization of the 
animals concerned is required. The blood of 
amphibia, reptiles and birds is especially favor- 
able for these investigations, less favorable is 
mammalian blood, which usually coagulates 
rapidly in contact with any tissue, although dif- 
ferences could be shown to exist in the relation 
of mammalian blood toward the tissue coagulins 
of certain classes of animals. Between dififerent 
birds and between dififerent mammals (and 
probably also between different reptiles and 
amphibia) it is not possible, except in the case of 
certain animals, to demonstrate the existence of a 
specificity. We have, therefore, to deal with a 
class specificity rather than with a species speci- 
ficity, although it is quite possible that a still 
further specificity does exist and that complicat- 
ing factors prevent it from becoming demonstra- 
ble. Such substances as the tissue coagulins 
might be called " specifically adapted " sub- 
stances, the term specific being frequently used to 
designate merely a difference in chemical charac- 
ter. I suggested on former occasions that the 
origin of such specifically adapted substances 
might be due to a process of auto-immunization : 
similar considerations might apply to the origin 
of other ferment-like substances. In the case of 
the active substances of the blood, a specific adap- 
tation exists only in so far as the thrombin, of 
vertebrates is without effect upon the blood of in- 
vertebrates. These results have recently been 
confirmed by Muraschew, who also found a speci- 
ficity of tissue coagulins and a lack of specificity 
in the case of the blood coagulins although the 
methods used by this investigator were in part 
at least based on probably incorrect conceptions. 

9. There exist further differences betjvcen 
these two substances: (a) They act diflfcrently 
on the blood plasma which has been deprived of 
calcium, as for instance fluorid plasma and 
oxalatplasma, in regard to which the active prin- 
ciple of the blood, the thrombin, is more eflfective 
than the tissue coagulins. (b) They act dif- 



ferentl}- on pepton plasma, which responds more 
or less easily to tissue coagulins and little or not 
at all to serum (thrombin), (c) They behave 
differently in regard to fibrinogen which coagu- 
lates under the influence of serum and not under 
the influence of tissue coagulins. In many, but 
not in all cases the latter, however, becomes 
active after addition of calcium to the fibrinogen, 
(rf) The active substances contained in the tis- 
sues are, provided putrefaction is prevented, 
more resistant than the thrombin. With rela- 
livel}- slight modifications the same diflferences 
exist in invertebrates between extracts of tissues, 
i.e., of muscle and extracts of the blood cells, 
which are contained in the so-called first coagu- 
lum. Of special interest is the fact that the tis- 
tus coagulins are to a great extent dependent on 
the presence of a certain amount of calcium, that 
the active substances of the blood on the other 
hand are active even without the presence of any 
or of more than a very small amount of calcium. 
A further difference I found to exist in verte- 
brates as well as in invertebrates, in the behavior 
of the two substances toward the dilution of the 
blood plasma, the tissue coagulins losing their 
activity much more rapidly if the blood plasma is 
gradually diluted than do tlie active substances 
of the blood, although in the undiluted plasma 
the tissue coagulins may even have surpassed 
in efficiency the thrombin of the serum. In all 
]M'obability. therefore, we have, in the case of 
the tissue and blood coagulins, to deal with two 
different substances. 

10. An interesting fact, which has already 
been observed by Alex. Schmidt, is that under a 
variety of circumstances, the combined action of 
these two substances, causes a decided increase 
in their efficiency. Equal amounts of blood 
and tissue coagulins act stronger than would 
the double amount of either blood or tissue 
coagulin alone. This fact has been recently con- 
firmed by Morawitz, who used for these experi- 
ments fibrinogen and who could show that even 
in cases in which tissue coagulins and calcium 
alone were without effect upon fibrinogen, a 
combination of these two with blood serum was 
much more effective than blood serum alone, A 
similar increase in activity I found if a combina- 
tion of these two substances acted upon fluorid 
I)lasma. In invertebrate blood I was unable to 
observe any marked increase in activity to exist 
in the case of a combination of blood and tissue 
coagulins. The fact that the combined action 
of two substances is greater than the sum of the 
action of each individual substance becomes of 
great interest if side by side with it certain facts 
found in the studies of immunity arc considered. 
Two substances, amboceptor and complement, 
combine to exert a bacteriolytic or a hemolytic 
action. Lecithin enables the active principle of 
cobravenom to become a hemolytic poison. Ac- 
cording to Alex. Schmidt lecithin seems to in- 
crease in a ^milar way the coagulative power of 
blood serum. A further analogy exists in the 



April i, 1905] 



LOEB: COAGULATION OF BLOOD. 



581 



case of trypsinogen which becomes active when 
combined with enterokinase. In the study of the 
coagulation of the blood, we meet, therefore, with 
phenomena related to those which have been 
very prominent in recent investigations in im- 
munity. Another fact which shows still closer 
the relationship between these two fields of in- 
vestigation, immunity and coagulation of the 
blood, has already been referred to above, namely 
the specificity of tissue coagulins which suggests 
their origin as being due to a process of auto- 
immunization. 

Surprising as this increase in activity of two 
combined substances may appear, similar phenom- 
ena have been observed in the case of several 
relatively simple inorganic reactions, in which the 
combination of two catalytically active inorganic 
salts increases markedly the rapidity of the proc- 
ess. A fact especially noteworthy is that in this 
instance both salts already act uncombined as 
catalysers. It is necessary to consider this as- 
pect of the problem of coagulation in greater de- 
tail because, as we shall see later, the fact of this 
increase in activity which is produced by the com- 
bination of tissue and blood coagulins, plays a 
very prominent part in the theory of the coagula- 
tion of the blood, and it is, therefore, necessary 
to collect all analogous facts in order to obtain 
a sound basis from which to judge certain theo- 
retical conclusions. Alex. Schmidt observed an 
acceleration of the coagulation to take place, when 
he combined the action of his thrombin, a watery 
extract of the alcoholic precipitate of blood serum 
and of tissue extract on the peritoneal fluid of a 
horse, one of those liquids which were called by 
him paraplastic. 

1 1 . Another somewhat similar phenomenon 
of activation has been recently observed by Bor- 
det and Gengou. In this case the addition of 
serum, which contained only a small quantity of 
active thrombin was able in causing the coagula- 
tion of diluted, salted plasma, to create in this 
plasma a large quantity of active thrombin, which 
was strong enough to produce the rapid coagu- 
lation of oxalated blood. We have mentioned 
that according to Bordet and Gengou a similar 
production of active thrombin was brought about 
by the effect of the contact with glass upon the 
plasma. These experiments of Bordet and Gen- 
gou are, however, complicated by an intervening 
coagulation of the fluid in which the new forma- 
tion of thrombin is later found to have taken 
place. These investigators bring about the coag- 
ulation of the plasma through the action of a 
mechanical or chemical agency. They compare 
the amount of ferment present in the blood 
plasma before the coagulation has started with 
the quantity of ferment present in the serum 
after coagulation has taken place and find 
the serum a much more active fluid than the 
coagulated plasma had been. They conclude 
that the agency bringing about the coagulation 
of the plasma was able of producing this result 
bv means of a creation of new ferment. This 



may be correct ; the argument would, how- 
ever, be still stronger if it were possible to 
demonstrate a production of active thrombin 
in serum, which does not coagulate instead 
of in plasma by the same mechanical or chem- 
ical agencies. In the course of the ordinary co- 
agulation of the blood, which apparently takes 
place spontaneously, a similar apparent new for- 
mation of thrombin can be noticed ; moreover, 
the maximum of the new formation of throm- 
bin was found by Arthus some time after com- 
pleted coagulation, so that one may assume that 
the new formation of the ferment continues even 
after the coagulation of the blood has been fin- 
ished. Another way of increasing the power of 
serum, which was already known to Alex. 
Schmidt and was recently confirmed by Fuld and 
Morawitz, consists in adding alkali or acid to the 
serum, and in subsequently neutralizing it. 

When we cause the coagulation of goose plas- 
ma by the addition of a piece of birds' tissue or 
of a piece of blood coagulin, there is no indica- 
tion that new thrombin has been formed in the 
plasma undergoing coagulation. The same ap- 
plies to lobster plasma, which clots under the in- 
fluence of a piece of lobster muscle or of the 
agglutinated blood cells of the lobster. It holds 
good also for goose blood, obtained by the 
aid of a clean canula. If we test at different 
periods the blood during the slow process of co- 
agulation, no appreciable amount of newly 
formed thrombin, which would be able to cause 
the coagulation of fluorid plasma can be found. 
We have, therefore, reason to believe that under 
these conditions the substances extracted from the 
coagulum or from the agglutinated blood cells 
and from tissues are sufficient to account for the 
coagulation of the plasma. 

12. There are, therefore, one or more sub- 
stances present in the blood cells, which accelerate 
the coagulation of the blood, and which are of 
decisive importance for the coagulation of the 
blood or lymph. It is certain that in the blood of 
the lobster this substance is found in the one va- 
riety of blood cells which this animal possesses. 
It is possible to extract this substance from the 
cells under certain conditions. I found a great 
difference to exist in the efficiency of different 
procedures of extraction. A pure sodium chlo- 
ride solution was found to be unfavorable as a 
means of extraction. The addition of calcium 
chloride improves the result of the extraction ; 
there are, however, probably other substances 
besides calcium of importance in this process. 
In this case as in so many other conditions an 
antagonism exists between the action of calcium 
and sodium. There can be little doubt that in 
the case of the lymph the active substances are 
contained in the leucocytes and especially in the 
mononuclear variety, the lymphocytes. 

13. The question is more complicated if we 
consider vertebrate, especially mammalian blood. 
Alex Schmidt believed the mother substance of 
the thrombin to be derived from the leucocytes. 



S82 



LOEB: COAGULATION OF BLOOD. 



[Medical News 



which, according to him, transmit it in part at 
least already to the circulating blood. Besides the 
zymoplastic substance (tissue coagulin), he be- 
lieves the leucocytes to contain a second substance, 
the prothrombin, as the mother substance of the 
active ferment was called. This substance, ac- 
cording to Schmidt, was also to be found in the 
other varieties of blood cells and in tissues. 
Other investigators, however, as Bizzozero, be- 
lieved the blood plates to be the source of the 
prothrombin. Pratt showed that in many cases 
there did not exist a direct relationship between 
the number of the plates and the coagulation 
time of the blood. Recently, however, Mora- 
witz succeeded in preparing an extract from 
blood plates, which behaved very much like the 
mother substance of thrombin toward fibrinogen. 
It is not unlikely that the blood plates do con- 
tain such a substance. The apparently similar 
behavior of the blood plates and of the blood 
cells of invertebrates, as for instance of the lob- 
ster, seems to favor such a view, both kinds of 
cellular elements undergoing rapid changes after 
the shedding of the blood, both sending out 
pseudopodia, in both probably partial processes 
of solution taking place and both agglutinating 
— this agglutination in the case of vertebrate, as 
well as of invertebrate blood, being independent 
of the coagulation of the fibrinogen. These an- 
alogies make it possible to assume that the blood 
plates are the source of the mammalian pro- 
thrombin. There are, however, some objections 
to be considered. The lymph coagulates without 
containing blood plates. I found, furthermore, 
the red blood corpuscles to accelerate the action 
of serum as well as that of the tissue extracts. 
In the latter respect the red blood corpuscles be- 
have, therefore, like the blood coagulin (the 
active substance of the serum). Morawitz found 
leucocytes, which he obtained from a sterile 
pleural or peritoneal exudate free from the 
blood coagulins, although the leucocytes were 
alive. This, however, does not absolutely dis- 
prove that these cells do contain the active sub- 
stance when circulating in the blood. We know 
that the production of ferment-like substances 
is dependent on a number of environmental con- 
ditions. It is, therefore, not certain that the red 
and white blood cells contain exclusively tissue 
coagulins. In this case we should expect extracts 
from white and red corpuscles to show the same 
specificity, which is characteristic of tissue ex- 
tracts. It would be of interest to undertake in- 
vestigations in this direction. It is believed by 
a large number of investigators that the blood 
plates are the extruded central substances of nu- 
cleated blood corpuscles, containing part of the 
nuclear substance. If this view is correct it 
would be difficult to see why the blood coagulins 
(prothrombin) should be limited to the nuclear 
substance of one kind of cellular elements. We 
see, therefore, that it is not very likely that the 
blood coagulins are solely derived from the blood 
plates, but that a number of facts render it more 



probable that other cellular elements may also 
be the source of this substance. 

14. In regard to the chemical character of 
these two substances, tiie blood and tissue coagu- 
lins, nothing definite is known ; they share this 
fate with the other organic ferment-like sub- 
stances. It is not certain that they are nucleo- 
proteids as Pekelharing and Huiskamp assume. 
According to Morawitz, it is possible to obtain 
extracts of tissues, which are still active with- 
out it being possible to demonstrate the presence 
of a nucleoproteid. Instead of trying to prepare 
the active principle from such organs as lymph 
glands and thymus, which are exceedingly rich 
in nuclein substances, it would perhaps be advis- 
able to use muscle tissue, which is also very ac- 
tive and contains only very little nucleoproteid. 
If we consider on the one hand the great differ- 
ence existing between the amount of nucleopro- 
teid of liver and muscle, on the other hand the 
great activity of muscle tissue, which i"n the 
case of birds is hardly inferior to that of the liver, 
it becomes unlikely that the nucleoproteids and 
nucleohistons of the different organs are the 
active principles, although at present it must be 
considered possible that the nucleoproteids or 
nucleohistons may have an accelerating effect 
upon the coagulation of the blood. 

15. Comparative study of the effect of differ- 
ent organs upon the coagulation of the blood 
would not be without pathological interest, if we 
consider the pathological importance of hemor- 
rhages. Liver and kidney of the dog are very 
active, the latter, however, is more active than 
the former. The pancreas was found to be less 
active, though not entirely ineffective. Very ef- 
ficient in causing the coagulation of the blood is 
the mucus covering the intestine, a fact not 
without significance in case of intestinal hemor- 
rhages. During autolysis of organs I found the 
tissue coagulins gradually to disajipear in the 
remaining solid substance which had escaped 
liquefaction. Conradi had observed that in the 
liquid produced by the splitting action of autolytic 
ferments, substances inhibiting the coagulation of 
the blood were formed. On the other hand, in 
organs undergoing the changes characteristic of 
phosphorus poisoning, I could not find any de- 
crease in the quantity of tissue coagulins, al- 
though in phosphorus poisoning the changes tak- 
ing place in certain organs have some similarity 
to autolytic processes. In the blood, however, 
marked changes are taking place during phos- 
phorus poisoning, as Corin and Ansiaux had 
found. They noticed a disappearance of fibrin- 
ogen and thrombin (blood coagulins). I could 
confirm these observations, and I found, more- 
over, that these two substances disappear in a 
similar ratio. The loss in the amount of fibrin- 
ogen varies in different cases of phosphorus poi- 
soning, and the amount of thrombin lost varies 
correspondingly. In this case it appears as if the 
liver was of direct or indirect importance for the 
formation of fibrinogen and of blood coagulin. 



April i, 1905] 



LOEB: COAGULATION OF BLOOD. 



583 



There exist a few more data in regard to the 
importance of different organs for the coagula- 
tion of the blood. Contejean and Delezenne 
found that the substance inhibiting the coagu- 
lation of the blood which is formed after injec- 
tion of pepton in dogs, can only be formed if the 
liver is present. Meltzer and Salant observed 
that after nephrectomy the coagulation of rab- 
bit blood is markedly delayed. It is at present 
impossible to state in which way the functioning 
of the liver affects the quantity of fibrinogen or 
fibrin ferment present in the blood, and in the 
case of the extirpation of the kidneys the cause 
of the delay in the clotting of the blood is as yet 
unknown. 

16. There are not only substances present in 
the tissues and in the blood itself causing or 
accelerating the coagulation of the blood, but 
also substances or mechanisms inhibiting it. 
Alex. Schmidt extracted from tissues or cells an 
inhibiting substance which he called cytoglobin. 
I found in the muscle of arthropods not only a 
substance accelerating the coagulation of the 
blood, but also another one inhibiting it. The 
effect of the muscle extract upon the blood is 
therefore equal to the sum of these counteracting 
processes. A similar substance complicates per- 
haps the action of the tissues of vertebrates. It 
has been found that in pepton blood or in fluorid 
and oxalat plasma, substances are present in- 
hibiting the coagulation of blood to which they 
are added. It is very probable that such in- 
hibiting factors exist in the normal plasma or 
serum, to which no chemical substances as ox- 
alates or fluorids have been previously added. I 
found such a substance, or more generally speak- 
ing, such a mechanism in the dog serum which 
inhi'~'ts the action of tissue coagulins upon the 
coagulation of pepton blood, and Muraschew 
found it to exist in the case of goose plasma. In 
both cases there are indications that these mechan- 
isms or substances are of a similar specific 
character as the tissue coagulins. 

Other substances exist inhibiting the coagu- 
lation of the blood, as, for instance, leech ex- 
tract, which acts on the thrombin of vertebrates, 
neutralizing it, and which is without action on 
invertebrate blood. There is a similar substance 
present in anchylostoma. Other inhibiting sub- 
stances of a different kind have been found in 
certain snake toxins, the action of which on the 
coagulation of the blood was investigated many 
years ago by Weir Mitchell and Reichert. From 
the investigations of Morawitz it is likely that 
in the case of cobra poison this inhibiting sub- 
stance acts mainly by antagonizing the tissue 
coagulins. A similar substance is present in 
the blood which has become uncoagulable after 
injection of tissue coagulins in the circulation of 
the blood. 

17. If we inject tissue extracts into the vein 
of an animal a rapid and extensive intravascular 
coagulation is produced. This is followed by 
the formation of a so-called negative phase, in 



which the blood coagulates less rapidly or not at 
all. If we inject, on the other hand, even acti- 
vated blood serum of the same species, no intra- 
vascular coagulation is produced ; the same holds 
good for small or medium doses of the serum of 
another species. The latter serum may, however, 
be able to produce intravascular clotting, if it 
is injected in very large quantities. In this 
respect intravascular blood behaves, like pepton 
blood, an analogy which led Wooldridge to be- 
lieve that pepton blood corresponded most close- 
ly to the blood in its natural condition. 

18. Let us now consider some of the so-called 
theories of the coagulation of the blood. The 
discovery that the coagulation of the blood is 
caused by substances which act as catalysers is 
due to Alex. Schmidt. He assumed that the leu- 
cocytes produce the proferment which, accord- 
ing to him, is already present in the circulating 
Ijlood. Under the influence of the zymoplastic 
substances derived from leucocytes and other 
cells, this proferment is transformed into the 
active thrombin, which alone causes the coagu- 
lation of the fibrinogen. Arthus, Pekelharing 
and Hammarsten showed that calcium was nec- 
essary for the coagulation of the blood. The 
two former believed at first that the calcium went 
into combination with the fibrinogen. Pekelhar- 
ing believed it also to be necessary for the for- 
mation of ferment out of proferment. Ham- 
marsten showed that the latter was the only 
function of the calcium, and that it did not com- 
bine with the fibrinogen to form fibrin. Re- 
cently Morawitz and Fuld undertook to combine 
both of these theories. According to Morawitz 
the blood plates shed the thrombogen. The 
latter under the influence of tissue coagulin 
which, in analogy to enterokinase. he calls throm- 
bokinase, is transformed into prothrombin; the 
latter combines with calcium to become the ac- 
tive ferment or thrombin. Thrombin would, 
therefore, be the only substance which has a 
direct action upon the fibrinogen, and the tissue 
coagulins, according to this theory, would act 
indirectly, namel}' as producers of the ferment. 

19. There are certain objections to be raised 
against the theory of Alex. Schmidt, even in the 
modem form given it by Morawitz and Fuld. 
This theory is mainly based on the fact that a 
combination of tissue extract and serum acts 
much stronger than the sum of the component 
parts would lead one to expect. This increase in 
strength is, however, not an essential factor. 
It is absent in the case of invertebrates, and if 
present can be explained in different ways: (i) 
An activation of a proferment may take place 
either in the serum or in the tissue extract. (2) 
Both substances may attack the fibrinogen in- 
dependently, each one acting in a different 
way. 

Under this condition they may strengthen each 
other's action, even if one of these two substances 
alone would be entirely powerless. (3) Inter- 
mediate reactions may take place during the 



584 



LOEB: COAGULATION OF BLOOD. 



[Medical News- 



process of coagulation, and these substances 
might accelerate such intermediate reactions. 
(4) This increase in strength might not at all 
depend on the action of the active principles 
which cause the coagulation, but might be pro- 
duced by another constituent of either serum or 
tissue extract, by providing favorable conditions 
for the action of the active agency. We saw, 
furthermore, that such an increase in strength 
was found by Alex. Schmidt to take place when 
he combined thrombin with the zymoplastic sub- 
stance and under conditions in which the presence 
of a proferment could be excluded. A similar 
increase in strength was observed by Bordet and 
Gengou when they combined the action of in- 
active with active serum. I have mentioned sim- 
ilar phenomena in the case of inorganic cataly- 
zers. By making use of the fact that tissue 
coagulins are specific, I could, moreover, show 
that the increase caused by the combination of 
serum and tissue extracts depends greatly upon 
the kind of plasma and fibrinogen on which this 
combination acts, and that the strength of this 
acceleration does not primarily depend upon 
the kinds of serum and tissue extracts used, but 
on the combination of tissue extract and fibrin- 
ogen. This proves that the tissue extracts attack 
the fibrinogen directly. Muraschew found simi- 
lar conditions, the significance of which he did, 
however, not recognize. There are other experi- 
mental facts, also favorable to this view, which 
cannot be discussed here. This explanation 
would make it, furthermore, easy to understand 
why the leucocytes of the lymph are able to cause 
the coagulation of the lymph fibrinogen, although 
the lymph does not contain blood plates, which, 
according to Morawitz, are the source of the 
thrombogen. It would also explain why, after 
intravenous injection, the tissue extracts cause 
such a rapid coagulation of the blood. To ac- 
complish this intravascular coagulation the 
presence of free proferment in the circulating 
blood would not be necessary, if we assume that 
the tissue coagulins are able to act directly upon 
the fibrinogen. It is, therefore, probable 
that two substances are of importance for the 
coagulation, the tissue and blood coagulins, both 
acting independently upon the filirinogen. It is 
possible, but not certain, that under certain con- 
ditions they act upon each other, thus increasing 
their strength. 

20. Eotli these substances are derived from 
cellular elements, the blood coagulins becoming 
free probably as a result of the changes which 
certain blood elements undergo on leaving the 
vessels. 

In the foregoing, the term " blood coagulins " 
was preferred to tliat of thromljogen, protlirom- 
bin or thrombin, as l)cing a very general expres- 
■ sion, not indicating tlic condition in whicli the 
substance leaves the blood cells. It is as yet 
uncertain if this substance is first liberated in 
the form of a distinct proferment, which, under 
the influence of certain mechanical or chemical 



agencies becomes converted into a chemically 
different substance, the thrombin, or if a part of 
the substance leaves the cell already in an active 
state, although another part might become acti- 
vated later by different means. It is also un- 
certain, whether such an activation would con- 
sist in the chemical transformation of one sub- 
stance into another or in some other process. 
The blood of invertebrates might prove to be a 
favorable material for further study of these 
problems. 

21. The blood remains liquid inside of the 
blood vessels because the blood cells suspended 
in a fluid of the composition of the blood plasma 
and surrounded by a smooth lining of endothe- 
lial cells, undergo no changes leading to the dis- 
charge of the blood coagulins. According to 
Overton lipoid substances are very prominent in 
the composition of the outer part of cells. The 
intact endothelial cells may, therefore, be sup- 
posed to act in a similar but more perfect way 
upon the blood cells, and directly or indirectly 
upon the coagulation of the blood, than oil, which 
prevents the ameboid movements, and the proc- 
esses of dissolution of the blood cells, and that 
prevents thus indirectly the coagulation of the 
blood. 

Cells, of course, arc probably constantly dis- 
integrating in the blood inside the body. This, 
however, does not necessarily lead to the setting 
free of thrombin. We found that in cells under- 
going autolysis a marked decrease in the quan- 
tity of tissue coagulins can be very readily ob- 
served. 

We might, therefore, conceive that blood cells 
which die gradually, have at the time of disso- 
lution become free from active substances, or 
that in the case they still possess a part of their 
coagulins, antibodies, whose existence in the 
l)lood seems probable, are able to counteract their 
influence. There is no indication that, as Briicke 
suggested, the entlothelium of the vessels con- 
tains a substance inhibiting the coagulation of 
the blood. Recently Gutschy believed to have 
])roven this hypothesis experimentally. In re- 
peating Gutschy's experiments, I did not, how- 
ever, find any evidence of the existence of such 
substances. 

22. So far tlic conditions under which the co- 
agulation of the blood or blood plasma is accel- 
erated or inhibited have mainly been studied out- 
side the animal body. Only little has been done 
to determine how far the factors accelerating the 
coagulation outside the body are present inside 
the organism and how different parts of the body 
behave in this resj)ect. I found that blood plasma 
of the goose injected into the jieritoneal cavity of 
different varieties of animals did not coagulate 
within the time of observation. Morawitz, who 
confirmed this observation, added tlic further 
fact that pepton ])lasma coagulated rapidly under 
similar conditions. There is here a new field for 
investigation, whicli will probably prove of in- 
terest for the pathologist. 



April i, 1905] 



MILLER: NEPHRITIS COMPLICATING MUMPS. 



NEPHRITIS COMPLICATING MUMPS. 

BY JAMES ALEX.\NDER MILLER, .\.M., M.D., 

OF NEW YORK; 

ADJUNCT ASSISTANT ATTENDING PHYSICIAN, BELLEVUE HOSPITAL; 

ATTENDING PHYSICIAN, SETON HOSPITAL. 

That inflammation of the kidneys may com- 
plicate acute infectious parotitis has been recog- 
nized, but the cases reported have been very few, 
and no attempt has ever been made to correlate 
the observations described. Many of the text- 
"books on diseases of children do not mention ne- 
phritis as a possible complication of mumps, and 
the others speak of it as a rare condition, of 
which only a few cases are on record. 

The following well-marked case has recently 
come under the writer's observation and is 
thought to be of particular interest, in addition 
to the rarity of the condition, because of the very 
unusual family predisposition to kidney disease, 
and also because of the superimposed occurrence 
of measles during the course of the other affec- 
tions : 

Ca\se. — E. S. G., a sturdy boy of four years. 
Previous History: Has never been ill, except for 
occasional digestive disturbances. Family His- 
tory: Paternal grandfather died of Bright's dis- 
ease at the age of fifty years ; paternal grand- 
mother died of acute Bright's disease at age of 
thirty-two years ; maternal grandfather died at 
■sixty years from chronic Bright's disease. 
Father has had an attack of acute inflammation 
■of kidneys, following exposure to cold, lasting 
two months. Urine now normal. Mother had 
very severe acute Bright's disease, following 
operation under ether. Urine now normal. Sis- 
ter had acute nephritis with scarlet fever. Urine 
now normal. The one remaining brother, ten 
3'ear' old, has had scarlet fever and measles 
"without kidney lesion. 

Present Illness. — January 17, 1904. When 
first seen, had well marked double parotitis, 
which had existed one day. No unusual symp- 
toms. Temperature 100° F. : January 22, 
swelling of parotids continues, no fever for two 
days : patient allowed up about the room ; brother 
in same house taken ill with measles ; January 
25, swelling less marked. Patient seems bright. 
Taut a little pale. No fever ; Januar}^ 27, anemia 
much more marked and very striking. Slight 
pufifiness of eyelids. Patient is languid. Tem- 
perature 101° F. Inquiry develops that urine 
"has been dark, cloudy and scanty for two days. 
Patient put to bed on milk diet ; January 28, 
specimen of urine first obtained. It is distinctly 
■" smoky," of greenish color, with considerable 
amorphous sediment. Acid specific gravity, 
1,022 ; contains five per cent, albumin, no sugar or 
indican, urea, 1.9 per cent. Numerous large 
and small granular, and especially pus casts. 
Very numerous red blood cells and leuco- 
cytes. Quantity, 12 ounces in twenty-four 
hours. Anemia very marked : hemoglobin 
45 per cent. Temperature, 100° 'F. Loud hemic 
murmur heard over apex and base of heart. 



January 30, patient very ill. Temperature 103° 
F. Swelling of left parotid has disappeared. 
February i, condition about same. Urine con- 
tains only three per cent, albumin ; quantity, 18 
ounces. February 2, slight rash of measles over 
face and neck. Temperature 104° F. Child 
very ill. Urine same as before. February 3, 
measles well developed. Temperature 103° F. 
Urine one per cent, albumin ; casts, blood and 
leucocytes, as before ; quantity 23 ounces. Feb- 
ruary 4, temperature has fallen suddenly to nor- 
mal. February 5, rash fading ; still slight swell- 
ing of right parotid. Urine, specific gravity 
1.020 with faint trace of albumin. Many hyaline, 
granular and pus casts ; few leucocytes ; no red 
red cells. February 8, rash has disappeared ; no 
albumin in urine, but casts persist. Swelling of 
right parotid has disappeared. Patient still an- 
emic ; hemoglobin, 50 per cent. February 19, 
patient entirely convalescent ; no albumin or 
casts in urine ; hemoglobin, 65 per cent. Eleven 
months later. Child still entirely well, and urine 
is normal. 

Suininary. — A case of acute exudative nephri- 
tis in the course of mild double parotitis, in a 
boy four years old, with a marked family pre- 
disposition to kidney disease, occurring in the 
twelfth day of the parotitis, which was further 
complicated on the eighteenth day by a moder- 
ately severe attack of measles. The measles exer- 
cised no influence upon the nephritis, which en- 
tirely disappeared in thirty-five days, and after 
several months had not recurred. 

A careful review of the literature has revealed 
reports of 29 similar cases. In addition to these, 
several observers mention the occurrence of 
febrile albuminuria during mumps as not infre- 
quent. Catrin, in particular, examined the urine 
carefully in a series of 130 cases. In 91 cases 
the examinations were made only in the presence 
of some clinical indication or complication. Al- 
buminuria was found in 6J4 per cent, of these 
cases. In 39 cases the urine was examined as 
a routine. Albuminuria was found in 30 per 
cent, of these cases. 

These results indicate the frequent occurrence, 
in mumps, of albuminuria due to acute renal 
congestion or degeneration, commonly designated 
■' febrile albuminuria," and of no great signifi- 
cance. The series of cases here collected, how- 
ever, includes only those in which there was evi- 
dently actual inflammation of the kidneys. 

SUMMARY OF 30 CASES. 

Age is mentioned in 17 cases: Under seven 
years in eight cases ; over sixteen years in seven 
cases ; twelve years in two cases ; youngest, four 
years ; oldest, twenty-four years. 

Sex is mentioned in 16 cases : Male, twelve 
cases ; female, four cases. 

Family history : Very marked predisposition to 
nephritis in writer's case. 

Previous history : Mentioned in four cases, all 
negative. 



S86 



MILLER: NEPHRITIS COMPLICATING MUMPS. 



(Medical News 



Reported 
by 



1 1 Pratolongo. 
2lBurne. 12 



Renard. 



Colin. 



Beale. 



Eichhorst. 



Isham. 



Sorel. 



Croner. 



Karth. 



Demme. 



Mettenhei- 
mer. 



M, 



M. 



24 



24 



M. 



M. 



M, 



M, 



M, 



Family 
History. 



Nega- 
tive. 



Gag«. 



19 Bezy. 



Catrin. 



Toussaint. 



Henoch. 



Henoch, 

Ocschist- 

er. 
n-fenoch.) 



Adult 



M. 



ii (A 

£15 



Neg. 














Other 






2S 


Time of 
Onset. 


Symptoms. 


Urine. 


Dura- 
tion. 


complica- 
tions. 


Result. 


Remarks. 


n rt 
















6^ 

Double. 
















■\fter sub- 


Anasarca ; 










In 1782. 




sidence of 


dyspnea, and 










l.e t t e r to 




jarotitis. 


iever. 










Borsieri. 


Double. 


Pour days 


Violent con- 


Very scanty ; 


Five 




Recovery 






after sub- 


vulsions ; 


pale; smol<y 


days. 










sidence. 


coma; suppres- 


greenish; much 












Sixteenth 
day. 
Two or 


sion urine. 


albumin. 












Edema of face 


Considerable 


Three 




Recovery 






three days 


and feet. 


albumin. 


weeks. 










after paro- 
















titis cured. 














Left. 


Second day 


General ana- 


300 c.c. in 24 


Twen- 


Orchitis. 


Death. 


Auto p s y. 




of paroti- 
tis. 


sarca ; head- 


lours. 


ty-four 


Double. 




!>arge white 




ache; albumi- 


Urea, 1.9%. 


days. 






kidney. Acute 






nuric retinitis; 


Albumin, 








exudative ne- 






dyspnea; con- 
vulsions ; 


2.2%. 








phritis, with 














considerable 






coma; death. 










conne c ti v e 
tissue mostly 
confined t o- 
cortical zone. 


Double. 


Five days 


Marked head- 


Trace a 1 b u - 


Five 


Orchitis. 


Recovery 






after sub. 


ache; pain in 


min. 


days. 


Double. 








of paroti- 


back. 














tis. 


















Acute hemor- 


Blood; a 1 b u- 


Eight 




Chronic 


Typical 






rhagic nephri- 


min. 


mos. 




nephritis 


picture f 






tis. 










seco n d a r y 
contrac t e ci 


















, 












kidney. 


Double. 


Second day 


Albuminuria; 


Much a 1 b u- 


Not 


Pericar- 


Recovery 






of paroti- 


after exposure, 


min; blood 


sure. 


ditis. 








tis. 


high fever ; 
delirium; dysp- 
n e a ; excited 
heart action. 


casts. 


Some 
time. 








Double. 


Five days 


Ferer; deliri- 


Albumin ; 


Few 


Orchitis. 


Aphasia 






after sub- 


um; slight mo- 


bloody mucus. 


days. 


Right. 


for some 






-iidence. 


tor aphasia. 








time. 














Recovery. 




Double. 


Tenth day. 


Malaise; ede- 


Scanty; 


Six 


Acute 
cervical 
lympha- 
denitis. 


Recovery. 








m a eyelids, 


bloody; large 


weeks. 










feet and 
hands: ascites. 


amount albu- 
min. 








My per- 
toxic. 


With onset 


Headache; 


Much albumin. 


Two 




Recovery. 




of paroti- 


sleeplessness; 




weeks 




Like diph- 






tis. 


edema eyes; 
high fever. 




two 
days 
longer 
than 
paroti- 
tis. 
Short. 




theria r 
scarlet in 
severity. 






10 u r i n g 


Like scarlet 


Glomerulo- 




Recovery. 


Obse r V a- 




subsidence 


nephritis. 


nephritis. 








tion in 117 




of paroti- 
tis. 
With paro- 












cases. 


Left . 


Much albu- 


Much albumin. 


Four 




Recovery. 






titis. 


min. 




days. 










Sixth to 


Fever; albu- 


Albumin, 


Very 




Recovery. 


Large num- 




'lev e n t h 


minuria. 




tran- 






ber cases in- 




day of par- 






sient. 






vesti gated 




ititis. 












for this pur- 
pose especial- 
ly- 
Quoted as 


None. 


During 


Dch'rium; no 


Scanty; smoky 


Few 




Recovery. 




epidemic. 


edena. 


much albumin. 


days. 






possibly case 
of mump ne- 
phritis, with- 
out parotid 
involvment 
as is some- 
times case in 
orchitis. 

Comby ad- 
mits possi- 
bility. 




Eight e e n 


Kdema of eye- 


Much albumin. 






Recovery. 


1 30 cases. 




days after 


lids; headache; 










91 cases ex- 




jure. 


vertigo. 










a m i n e d if 
any indica- 
tions — 6J^% 
albuminuria. 
3 9 cases 
all examined 
—30% albu- 
minuria. 


Double. 


Fifth day. 


Violent con- 
V u 1 s i n s ; 
joma; albumin 
'1 r i a ; scanty 
Urine. 


Mucli albumin. 


Two 

days. 


Orchitis. 
Right. 


Recovery. 




Double. 


One week 


/Mbuminuria. 


Blood and al- 


One 




Recovery. 


Also had 




after sub- 




bumin; epithe- 


week. 






whoo ping- 




sidence of 




lial cells; no 








cough at 




t>nrotitis. 




casts. 








time. 




Tenth day. 




Blood and %l- 

bnmin. 






Recovery. 






After par- 




Blood and al- 






Rpco\cry. 






otitis. 




bumin. 











April i, 1905] 



FLOERSHEIM: SUPRARENAL THERAPY. 



587 





Reported 
by 






Family 
History. 






2S 


Time of 
Onset. 


Symptoms. 


Urine. 


Dura- 
tion. 


Other 

complica- 
tions. 


Result. 
Recovery. 


Remarks. 


d 

2; 




< 








Oouble. 
















26 


Kerley. 


4 


M, 






Eighth day. 


Anemria ; ede- 


Almost solid 


Six 






Anemia for 














Moder- 




ma of eyelids; 


with albumin; 


days. 






some time- 














ately 




suppression; 


blood; hyaline 






















,evere. ' 




lever. 


and granular 
casts. 










27 


Granier. 


16 


F. 


Neg. 


Neg. 


Mild. 


Six weeks 
after paro- 
titis. 


Edema of legs. 


Albumin, 


Devel- 
p e d 
into 
chron- 
ic. 




Relapsed 
after ap- 
parent 
cure and 
died. 


Went out 
in cold and 
wet a few 
days after 
mumps a p- 
peared. 


28 


Granier. 


12 


M. 






Mild. 


Several 


Anemia ; ma- 
laise; edema 


Much albumin. 


Consid- 
erable 




Recovery. 


Exposed to 
wet in snow 
early f e w 
days of 


















feet and eye- 
lids; convul- 




time. 






















%ions; coma. 












29 


Sylvester. 


>7 


M. 






double. 


Third day. 


De 1 i r i u m ; 
convulsions; 
headac^ie fe- 
ver; suppres- 
sion; tender- 
ness over kid- 


Slight albu- 
min. 


Nine 
days. 


Orchitis. 
Left. 


Recovery. 




30 


Miller. 


4 


M. 


Nephritis 
in three 
grand- 
parents, 
both par- 
ents, one 




>ouble. 


Tw e 1 f t h 
day. 


Anemia; puffi- 
ness of eye- 
lids; fever; 
icanty urine. 


Smoky; scan- 
ty; 57o albu- 
min ; casts; 
blood and pus. 


Twen- 
ty-three 
days. 


Measles. 


Recovery. 


Anemia 
persisted for 
some time. 











sister. 






\ 






' 







Character of parotitis: Mentioned in sixteen 
cases ; double in fifteen cases ; mild or moder- 
ately severe in fifteen cases ; very severe in one 
case. 

Relation of onset to parotitis : Mentioned in 
twenty-nine cases. During course of parotitis 
in thirteen cases ; first to third day, five cases ; 
fifth to eleventh day, eight cases. 

After subsidence of parotitis, sixteen cases ; 
first week after, fourteen cases ; eighteenth day 
after, one case ; six weeks after, one case. 

Syrr_ ioms: Those of acute nephritis in all 
grades o'f severity. 

Other complications : Orchitis in five cases. 

Duration given in 23 cases. One week, or less, 
thirteen cases ; from one to two weeks, two cases ; 
two to six weeks, six cases ; developed into 
chronic, two cases. Result, permanent recovery, 
25 cases ; developed into chronic nephritis, two 
cases ; died, one case. 

Pathology : Autopsy in only fatal case showed 
large white kidney, with changes of an acute 
nephritis, with increased connective tissue. 

Conclusions. — i. Acute nephritis complicat- 
ing mumps may occur in either children or adults, 
and is much more frequent in males than in 
females. 

2. The parotitis is usually double, mild in char- 
acter, and the nephritis is more liable to occur 
during early convalescence. Exposure to cold 
may be a predisposing factor. 

3. The nephritis is usually moderately severe, 
of less than one week's duration, and ending in 
complete recovery. Rarely it may develop into 
chronic nephritis, or it may be so severe as to 
cause death. 

4. This complication of mumps is infrequent, 
but probably not as rare as usually considered. 
Febrile albuminuria is probably very common 



in mumps, but this, as well as more serious kid- 
ney lesions, is probably often overlooked. 

5. Careful urine examinations should be made, 
and strict precautions against exposure should be 
taken, in all cases of mumps, both during the 
acute symptoms and during convalescence. 

REFERENCES. 

Catrin. See. Med. d. Hop., Paris, 1893, X p. 624. 

Pratolongo. Receueil Mem. Med. Chir. Pharm. Milit., 1881, 
p. 509. 

Burne. Provincial M. & S. Jour., London, 1851, p. 623. 

Renard. L'Union Med., 1869, p. 431. 

Colin. L'Union Med., 1876, p. 465. 

Beale. Med. Times and Gazette, 1875, I, p. 416- 

Eichhorst. Lehrbuch d. spec. Path, und Ther., IV, p. 344- 

Isham. Amer. Tour. Med. Sc, 1878, LXXVL p- 367. 

Ssrel. Archiv d. Med. Milit., 1883, 11, p. 430. 

Croner. Deut. med. Woch., 1884, No. 9, p. 138. 

Karth. These d. Paris (See also Comby. L'Union Med., 
1893, LV, p. 145.) 

Demme. Wien. med. Blatt., 1S88, XI, p. 1614. 

Mettenheimer. Jahrbuch f. Kinderheilk. Bd. 32, p. 383. 

Gage. These d. Paris. 

Bezy. Soc. Med. d. Hop., Paris, 1893, X, p. 170. 

Toussaint. Arch. d. Med. and Pharm. Milit., 1893, XXII, 
p. 332. 

Henoch. Lehrbuch f .Kinderkrankh., 1895, p. 605. 

Kerley. Archiv. c£ Pediatrics, 1898 XV, p. 108. 

Granier. Jour. d. Med. and Surg. Prat., 1902, p. 154. 

Sylvester. American Medicine, August 23, 1902. 



THE STATUS OF SUPRARENAL THERAPY.^ 

BY SAMUEL FLOERSHEIM, M.D., 

OF NEW YORK. 

So much has been written and spoken of in rela- 
tion to the uses of the suprarenal that one knows 
not where to begin. The history of suprarenal 
therapy has been amply covered by different ob- 
servers, and it is needless for me to do more 
than simply mention the fact. As my time is 
limited I hope you will bear with me when I 
pass rapidly over most of the parts and give but 
a synopsis of each portion. 

Suprarenal is not a new drug. It is an old one 
but owing to an inert preparation, the use of the 

I Read before the Ninety-ninth Annual Meeting of the New 
York State Medical Society, at Albany, January 31, February 
I and 2, 1905. 



588 



FLOERSHEIM: SUPRARENAL THERAPY. 



[Medical News 



drug was discontinued and fell into oblivion until 
1892, when Dr. W. H. Bates, of New York, re- 
vived it. Some few years after this Dr. Bates 
had much trouble in enlisting medical men to 
experiment with the remedy and note its relative 
value as a therapeutic agent in the different dis- 
eases. At times he said he was most discouraged 
and despaired of ever getting one to use the drug. 
By his persistent efforts he has now succeeded 
in putting to work the whole civilized world. So 
wonderful are the properties and uses of this drug 
that in but an excedingly short time it has be- 
come one of the most widely known and most 
important in use. Upon hundreds of thousands 
of cases has the drug been administered internally 
or applied locally. It is a strange coincidence that 
in the immense amount of literature, commercial 
or otherwise, papers and lectures that have been 
published within the past two years, there has 
not been mentioned once the name of that inde- 
fatigable and painstaking worker, Dr. W. H. 
Bates, of New York, through whose untiring 
efforts, unassisted except by repeated antago- 
nistic remarks and stumbling blocks placed in his 
road, all the civilized nations have become ac- 
quainted with so wonderful, invaluable and now 
indispensable a remedy. 

I am convinced that the revival of this valuable 
drug is one of the greatest achievements of the 
past fifteen )'ears. It would please me to cite 
the good work of the many ardent workers on 
this drug, but it would take up too much time 
and space. Suffice is it to say that it has been 
conclusively proven by different observers in 
different parts of the world that the suprarenal 
extract and its active principle are not only of 
benefit but also of undoubted great value as an 
addition to our therapeutic armamentarium. 
Over three years ago I sent out over eight hun- 
dred communication to all parts of the civilized 
world requesting reports, favorable or unfavor- 
able, from the internal administration of the 
suprarenal. I received but eight replies stating 
that my letter was duly received and that it 
would shortly be jniblished. Up to this late day 
I have not received personally from this source, 
one report of a case treated with the drug. 

In the Nezv York Medical Journal for October 
6, 1900, I published my first paper entitled " The 
Use of the Suprarenal in Organic Diseases of 
the Heart — a Preliminary Report." In the same 
journal, in 1901, I published an exhaustive report 
on its use in organic heart disease. In the 
Medic.\l News for January 4, 1902, I published 
forty-five cases of hemorrhages from various 
causes treated with the suprarenal. In the Nczv 
York Medical Record for November 17, 1900. 
I published a report on the use of the suprarenal 
in diseases of the lower air passages. 

Preparations. — We have the dried and pow- 
dered suprarenal substance which is designated 
as suprarenal extract. We also have the alkaloid, 
better termed the active principle, which is called 
adrenalin. Solutions of the suprarenal extract 



do not keej). but solutions of adrenalin cliloride 
kee]) indefinitely, are reliable, and are non- 
irritating. Whenever in the future I speak of 
oidy suprarenal, as such, I also mean adrenalin 
chloride. 

Adnu)iistration. — The powder is administered 
internally in three-grain doses either as a powder 
or better in capsule form. The active principle 
is administered internally in the form of a solu- 
tion, the strength of which is i/iO,000 to I '1,000, 
in doses of from five to fifteen drops. To get 
the best results it should be administered fre- 
quently — from one to three hours or oftener as 
the case may require. The solution is dropped 
on or beneath the tongue for very rapid effects, 
or it can be swallowed. Some now advocate to 
use it hypodermatically and by electrolysis. As 
to the hypodermatic use of the drug I believe it 
is unnecessary and I have never been in favor 
of its use. If an adrenalin preparation is at hand, 
a few drops can be rapidly j)laced on or vmder 
the tongue and its action will become apparent 
in about the time it takes to get a hypodermatic 
syringe ready for action. An effect was pro- 
duced within twenty seconds when adrenalin 
chloride was dropped under the tongue. Most 
all of you know that when you are in a great 
hurry, the syringe often fails to work properly 
and much valuable time is lost. I have read in 
literature that the hypodermatic administration 
of the solution (otherwise called the subcutaneous 
injection) had been given in collapse and the 
site of the injection was often very painful and 
that this form of administration was dangerous. 
Solutions in the strength of 1/10,000 have been 
known to cause great irritation while stronger 
solutions have given rise to gangrene and sub- 
sequent sloughing. Some state that they have 
used it hypodermically without any deleterious 
results. Those who have not advised subcu- 
taneous administration advise intravenous injec- 
tion, 1)ut they also state that when adrenalin solu- 
tion is given by mouth, very rapid and beneficial 
effects are obtained with no danger whatever to 
keep the ])hysician on his guard when he so ad- 
ministers it. Why then, if we get very rapid 
results (often within twenty seconds), when it 
is given by mouth without the least danger to 
cause us any anxiety, should one use the hypo- 
dermatic or intravenous method with such dan- 
gers as are above portrayed? 

Surgically- it is applied locally to the nnicous 
membrane of the eye, ear, nose, throat, urethra, 
bladder, etc., in a strength of 1/5,000 to 1/30,000, 
with or witliout the addition of other remedies 
as the case may indicate. Some drugs destroy 
the active pro]5erties of the active principle in 
solution. Those most often employed, and which 
do not materially affect its valuable and powerful 
properties are cocaine, boric acid and normal salt 
solution. Cyanide and bichloride of mercury, 
zinc sulphate, pilocarpin, hydrochlorate and 
many otliers liave been used in the same solu- 
tion, hut I believe it is better to restrict, up to the 



ArRii, I, 1905] 



FLOERSHEIM: SUPRARENAL THERAPY. 



589 



present time, the addition to the three previous 
mentioned. 

Contra-indications. — It has none. 

Diseases Treated.- — The diseases in which the 
suprarenal was administered by me and the re- 
sults published were in all forms of organic heart 
disease, tracheitis, acute and chronic bronchitis, 
bronchial asthma, congestion and edema of the 
lungs, pneumonia, hemoptysis, pulmonary tuber- 
culosis, hemorrhage from the uterus from various 
causes, such as complete and incomplete abor- 
tions, benign and malignant tumors, post partum 
hemorrhage, metrorrhagia, menorrhagia, atonic 
conditions and at the menopause. I have also 
employed it in hematemesis, hematuria, in threat- 
ened attack of apoplexy and in apoplectic sei- 
zures. The suprarenal, and more lately, the 
adrenalin chloride solution has been used by many 
observers both medicinally and surgically in dis- 
eases of the eye, ear, nose, throat, larynx, in 
genito-urinary work, including the kidneys, in 
scarlatinal angina, asphyxia neonatorum, anes- 
thetic collapse, angioneurotic edema, edema of 
the glottis, hemorrhoids, hemorrhagic fecal fistula, 
gastro-intestinal hemorrhage, goiter, gonorrhea, 
lupus, morphine and carbolic acid poisoning, 
ulcer of the stomach, for lost voice and for 
diagnostic purposes. To simmer it down, the 
suprarenal extract and its principle are of value 
in organic heart disease, for performing blood- 
less operations, in most of the diseases ending 
in itis, as an astringent and as a liemostatic in 
hemorrhages generally. 

Heart. — The suprarenal is one of the most 
valuable of remedies in organic heart disease. 
When otb ■ drugs, including strychnine and 
digitalis have failed to be of any benefit, the 
solution of adrenalin chloride has given marked 
beneficial results. A detailed acount of its ac- 
tion can be found in one of my published papers. 
Adrenalin chloride has been used in pneumonia 
as a heart stimulant to tide the patient over a 
critical period. 

Lungs. — The suprarenal has often been of 
great assistance in relieving the symtoms of a 
stubborn laryngitis tracheitis and bronchitis 
when niany drugs failed to benefit. In con- 
gestion and edema and bronchial asthma the 
administration of the suprarenal has helped to 
tide the patient over a critical period and often 
was the only remedy administered. In pneu- 
monia it was given for its stimulating efifects 
on the heart and for hemorrhages whenever 
the latter were present. In pulmonary tuber- 
culosis is was administered chiefly to lessen the 
severity of the cough, to decrease the quantity 
of the expectoration, to clear the throat, to 
strengthen the heart and to tone up the patient 
generally. In hemoptysis from whatever cause, 
the administration of the remedy gave rapid 
evidence of its powerful yet harmless effects. 

Hemorrhages. — As a hemostatic the supra- 
renal preparations have no equal. They do the 
work when all other measures fail to benefit. 



In hemorrhages from almost any portion of the 
body, the internal administration of the drug 
was almost always followed by beneficial results. 
Some few cases were not benefited by the supra- 
renal powder, but on administering the solution 
of adrenalin, these cases were benefited. Sur- 
gical, traumatic or so-called idiopathic hemor- 
rhages, unless they are from large blood-vessels 
are almost always instantly checked by the local 
application of the drug. So powerful and so 
rapid are the properties of this greatly lauded 
remedy that with its help we are enabled to 
operate, should an operation be indicated, upon 
those poor, unfortunate individuals, the bleed- 
ers, without that dreaded danger of repeated 
severe and in many cases uncontrollable hemor- 
rhages. Secondary hemorrhages, at first so often 
reported and dreaded, after the use of the solu- 
tion of adrenalin chloride, I believe need not 
cause any further anxiety. Generally speaking 
they are not any more frequent than before the 
drug was employed. 

Apople.vy. — The timely internal administration 
of adrenalin chloride had to my mind prevented 
a number of attacks of true apoplexy. I can 
now recall the histories of six cases in which 
the symptoms were such as indicated that an 
attack of apoplexy was imminent. Adrenalin 
chloride solution was administered and the 
threatening symptoms rapidly passed away. All 
danger of an attack of apoplexy was apparently 
avoided. Some few weeks to months after- 
ward, I was informed by one of the family that 
the same patient was later very suddenly taken 
ill with exactly the same symptoms and the 
family called in another physician who admin- 
istered a much different medicine. The result 
was that the patient died within a short time, 
Adrenalin might and might not have saved these 
patients during their last attack, but I have had 
patients with more than one attack who were 
markedly benefited by the administration of 
adrenalin chloride. 

Uterus. — Hemorrhages from various causes, 
such as menorrhagia, metrorrhagia, at the meno- 
pause, malignant and benign growths, atonicity, 
complete and incomplete abortions, post-partum 
hemorrhage, idiopathic (so-called) hemorrhages 
and also from persistent oozing after curetting. 
Dr. Geo. Tucker Harrison, in a paper before 
the New York County Medical Association said, 
" Why should we endanger the life of a woman 
from infection, who is suffering from uterine 
hemorrhage by the local application of supra- 
renal extract to the interior of the uterus, when 
it acts almost as rapidly and as powerfully when 
administered by mouth without the slightest 
danger of causing infection?" Adrenalin chlor- 
ide has been used to diminish the size of an en- 
larged uterus. 

Stomaeh and Intestines. — Hematemesis from 
all causes has been rapidly checked by the in- 
ternal administration of the suprarenal powder. 
A few cases failed to be benefited by the powder 



590 



FLOERSHEIM: SUPRARENAL THERAPY. 



[Medical News 



but on administering the adrenalin chloride 
solution immediate and permanent relief was 
afiforded. In hemorrhage from the intestines 
from all causes, from fecal fistula, hemorrhoids 
and ulcers of the rectum, it has given good re- 
sults. It has also been reported to have been 
administered in cases of appendicitis, but I am 
not aware of the ultimate results. 

Eye. — The use of adrenalin chloride has given 
wonderful results in diseases of the eye. The 
value of the remedy in diseases of the eye is 
as a hemostatic and astringent in acute and 
chronic conjunctivitis, keratitis, choroiditis and 
almost all the other diseases that end in itis ; in 
gonorrheal ophthalmia, glaucoma, in inflamma- 
tion of the appendages. Cancer of the lid has 
been reported to have been cured by its use. 
As a surgical aid it has given most remarkable 
service as a hemostatic, controlling hemorrhage 
except from large blood vessels, thus enabling 
the operator to proceed with much more rapid- 
ity in his work, with greater precision and also, 
of no less importance, saving the patient's san- 
guine fluid, which is quite essential in many of 
the patients operated upon, especially those 
operated upon in the nose. With the aid of this 
drug an operator on the eye, ear, nose, throat 
and for the usual minor surgical work, can be 
rightly called " bloodless surgeon ;" and with 
the addition of cocaine to his armamentarium, 
we can add the " paiitiess surgeon." 

Ear. — Adrenalin chloride is chiefly used as an 
astringent in congestion of the auditory canal, 
the membrana t\nipani. in the Eustachian tube 
and in inflammations generally in the middle ear. 
It is also used to check hemorrhages from 
traumatism and to prevent hemorrhages during 
surgical operations. Polypi have been con- 
siderably reduced in size from the constant ap- 
plication of the drug. It is also used for severe 
congestion of ear, to make the tube permeable 
and by permitting free drainage to give relief 
to the patient. It has also relieved tinnitus 
aurium with success when all other remedies had 
failed. 

Nose. — The local application of adrenalin 
chloride has given marked benefit and when all 
other remedies had failed to give relief, it has 
worked wonders. Medicinally it has been em- 
ployed in hay fever, otherwise called hay asthma, 
atrophic and hypertrophic rhinitis, edema and 
congestion. Surgically it acts as the most power- 
ful hemostatic in hcmorhages from small blood 
vessels from various causes. It is most exten- 
sively employed in performing bloodless opera- 
tions on the nose and for the same reasons as 
in the eye. Continuous applications have caused 
a decrease in size of polypi. Reports from med- 
ical men who do special work on the nose and 
throat, have noted secondary hemorrhages from 
its use, after operations, but I believe tliat the 
hemorrhages have not been more frequent than 
before the drug was employed. 

Throat. — The suprarenal is mostly employed 



as a hemostatic whether the etiological factor 
has been external violence or is going to be a 
surgical procedure. In catarrhal conditions 
it is used as a vascular astringent of great 
value. 

Genito-Uriiiary. — In hematuria either from the 
bladder, kidneys, or urethra the use of adrenalin 
chloride administered internally or applied 
locally as a hemostatic has been followed by 
prompt beneficial effects. In strictures, when 
the passage of sounds was almost impossible, 
the installation of adrenalin chloride enabled the 
passage of the instruments, and even larger sized 
ones with comparative ease. It has been em- 
ployed to reduce extensive congestion of the 
prostate. 

Operations Generally.— \t has been extensively 
employed in operations generally as a hemo- 
static of exceedingly great value, especially in 
conjunction with cocaine, chiefly for tlie pur- 
pose of preventing hemorrhage. Operators have 
used the adrenalin chloride in operations upon 
the eye, ear, nose, throat, larynx, rectum, genito- 
urinary, nevi, benign and malignant tumors and 
whenever oozing and moderate hemorrhages are 
to be prevented. It thereby enables one to do 
clean work which previously was extremely 
bloody and gave a grave aspect to the case. 
It also enables the operator to inspect his field of 
operation without hindrance from intruding 
hemorrhage. 

Chloroform Syncope. — Collapse and Shock. — 
Adrenalin chloride has been administered with 
good and rapid results. Given before chloro- 
form anesthesia it acts as a preventive to 
cardiac syncope. Administered in drop doses 
of i/i,ooo solution into the mouth during the 
course of the chloroform anesthesia it obviates 
all danger of unforseen cardiac weal<ness or 
embarrassment. You are to understand that 
chloroform cannot be used indiscriminately, the 
signs and symptoms of shock neglected while 
adrenalin is being administered. Adrenalin 
chloride will act wonderfully in a failing heart 
and respiration when there is evidence of weak- 
ness, but when there is neglect and indiscriminate 
use of so powerful a drug as chloroform with 
so depressant actions seldom is anything of 
avail. Care in anesthesia must be the watch- 
word first and always. I hope I make this plain 
to you all. 

Purpura Hemorrhagica. — .\drenalin chloride 
has been of benefit in this disease. When the 
drug was administered internally further prog- 
ress of the disease was ra])idly checked and con- 
valescence was rapidly established. 

In conclusion, I wish to say that we may well 
be surprised when we reflect but a moment that 
with so powerful a remedy at our command and 
so extensively employed, no case of poisoning or 
great anxiety has ever been observed when it 
had been properly employed and in conservative 
dosage. 

.lio Rast Fifty-fir.st Street. 



April i, 1905] 



DENISON: THERAPY OF TUBERCULOSIS. 



591 



THE " SPECIFIC THERAPY OF TUBERCULOSIS." 1 

BV CHARLES DENISON, A.M., M.D., 



OF DENVER, COL. 



This splendid address of the distinguislied 
Italian physician is an incentive to discussion. — 
However it is one which I hesitate to take up, with 
my limited knowledge of the subject. That limita- 
tion is my excuse for intruding. It suggests 
queries which I should very much like some ex- 
perimentalist or laboratory expert to answer, if he 
will kindly do so. Though the subject seems 
to be purposely worked out on the serum-therapy 
side, as against what I shall term the direct toxin 
side, there is much in Maragliano's experiment- 
ations and conclusions which agrees with and 
strengthens our beliefs as to the specific treat- 
ment of tuberculosis. 

There is one important question suggested 
which needs to be settled ; that is, Has the indirect 
serum method an advantage over the direct toxin 
method? Is not the latter method preferable, 
when properly selected and refined in technic, 
both as to quality and dosage? In other words, 
admitting the high development of both antitoxic 
and bactericidal elements which Maragliano 
claims in an animal serum, transference to a 
tuberculous infected body preferable in ultimate 
results to properly exciting this antitoxic power 
in the animal or man treated ? 

As an exposition of the scrum side of the tuber- 
culosis treatment question, this paper is both the 
strongest and most authoritative I have any 
knowledge of. And yet we have to admit, 
throughout *-he whole of it, either an intentional 
or inadvertent ignoring of the work and views 
of those who would take the negative side of the 
above question. 

For instance, much is made of the effects of 
the " to.xins " of young cultures of bacilli to 
quote " the inflammatory and destructive action 
on the tissues with which they come in con- 
trast, due to the ' necrotic acid ' of De Schwei- 
nitz and Dorset," and he adds, " these poisons 
injected beneath the skin, they cause inflam- 
mation with purulent fibrinous exudation and 
Ijring about necrosis of the tissues," etc. 

What is this " necrotic acid " and what quanti- 
ties of the extracted poisons does he refer to 
as producing the inflammatory and necrotic 
•eflfects ? 

Of course, everything depends on the size of the 
dose. Virchow found, post mortem, these necrotic 
results of reckless experimentation, and Koch 
Iiimself (through insufficient limitation as to size 
of dosage) may have been largely to blame for 
many failures through similar effects. But it is 
manifestly unfair to present these gross results 
of massive doses as representative of the direct 
method of specific medication in tuberculosis. 

Second, what will yovi say of Maragliano's 
claim of a " double series of poisons — the bacilli 

I .'\nent Prof. E. Maragliano's lecture, delivered before the 
Henry Phipps Institute, in Philadelphia, March 28, 1904. See 
^Medical News, April 2, 1904.) 



and the accompanying proteins?" Is it to be 
inferred that he claims such a mixed toxin is 
always used in the direct method? On the con- 
trary, does not success come through the single- 
ness and purity of the toxin used? 

Third, is it true that the theory of " mixed 
infection" was first proclaimed by Prof. Mara- 
gliano? If so, certainly great credit is due him; 
for this period in the course of active tuber- 
culosis is the most critical one in its history. 

Fourth, several paragraphs have relation to 
the same question to which I wish to call par- 
ticular attention. Maragliano says " The richest 
in antitoxic materials is the serum of a healthy 
man." Again, " the triple power of the blood 
serum, bactericidal, antitoxic and agglutinating, 
increases considerably if a healthy animal is in- 
jected with tuberculous matter." Again, speak- 
ing of the ordinary and extraordinary means of 
defense which the healthy animal organism pos- 
sesses, he says, " The extraordinary means are 
also antitoxic and bactericidal and develop prin- 
cipally in the presence of tubercle bacilli that 
penetrate the tissues." 

In view of such remarkable statements, the 
truth of which is not questioned, I want to ask 
where is the warrant for expecting any better 
efl:"ect from the antitoxin previously developed 
in another animal over and above that slowly 
created in a given diseased organism? 

Maragliano says, referring to the materials 
of defense created by the inoculation of healthy 
animals with tuberculous matter, " From this 
was born, by a logical association of ideas, the 
suggestion of antituberculous serum-therapy." 
Was it not rather a birth of hope that the same 
curative result could be worked out of an anti- 
tuberculous serum as that so brilliantly ob- 
tained from an antidiphtheric serum? Is not 
this expectation simply a theoretical assump- 
tion, since the two diseases, tuberculosis and diph- 
theria, are so dissimilar? 

When the American Medical Association met in 
Tuiltimore, in 1895, and Dr. Paul Paquin brought 
three tuberculous patients from St. Louis to illus- 
trate the curative results of his antituberculous 
horse serum, I invited him and Dr. Karl von 
Ruck to come over to my hotel, where we could 
quietly examine these patients with the stetho- 
scope. Dr. von Ruck and I concluded, after a 
careful study of these cases, that we were unable 
to detect any evidence of other effect than the 
transmission of tuberculin through the horse's 
blood. 

Afterward I experimented somewhat on my own 
account. I had a puppy injected every twelve 
hours with 2^ c.c. crude tuberculin (Koch's) and 
then, twelve hours after a total of 10 c.c. had 
been given, the little animal was killed and his 
blood, brain and glands made into a serum (?). 
On experimenting with this product it took me 
only a little while to see that I was getting a 
double (perhaps fermenting) effect and to 
abandon its use. 



592 



DENISON: THERAPY OF TUBERCULOSIS. 



[Medical News 



Then, again, after trying antituberculous 
asses' serum with only fair success, Fish's anti- 
tuberculous horse serum was brought out with 
great expectations for its curative power. We 
understood that this serum was being crowded 
full of supposed antitoxic energy by increasing 
toxic doses injected into horses. I faithfully 
tried the advancing dosage, expected to confer 
immunity, and, on close observation of effects, 
determined to my own satisfaction that there 
was a cumulative process set up in patients 
treated. I suspected that this was due either 
to the excessive dosage of tuberculous toxin 
given the horses, or to obtaining the serum too 
soon afterward, or to some unsolved mystery 
which ought to discredit the plan. 

Ever since that time I have not wanted in my 
therapy, any asses', goat's or horse's serum, 
with their uncertain constituents, unstable meas- 
ures, and with their rash-producing effects, 
showing that there are present other ingredients 
than the antitoxin we are after! This objection 
holds, even if we admit that there is included 
a given quantity of antitoxin raised to a high 
degree of potency. Supposing it is there, the 
question is, does it excite in the injected invalid's 
organism a greater amount of defense, than the 
original toxin would if properly given? 

The question is almost answered by the essay- 
ist himself when he explains that " this im- 
munization is not wholly passive. It arises with- 
out doubt in the animal organism through the 
energies of the organism itself. The antibodies 
and the antitoxins exist in the blood of animals 
thus injected in much larger quantities than was 
injected." And again, in his finding " an in- 
crease of defensive substances in the blood of 
injected animals greater than the geometrieal 
proportion " he is convinced " that the participa- 
tion of the organism is necessary to this increase 
because it did not take place " in subjects that 
were very sick." Now. if we are to take Prof. 
Maragliano's dictum, that it is the injected 
organism itself that creates its own antibodies 
and antitoxins, what more do we want, except 
to know the minimum dosage, to which that 
organism is sufiiciently susceptible, in order to 
create these defensive substances? If, as is true. 
we need diluents to get down to a safe and 
proper dosage, for the most favorable influence 
upon that particular organism, are there not 
liquids more antiseptic, germicidal and leu- 
cocyte producing, and at the same time more 
stable and certain in strength than any blood 
serum of any other animal ? 

It is " up to " the manufacturers of these in- 
direct antituberculous sera to bring forward 
their proofs : for the refined tuberculin prepara- 
tions (all of the culture fluid and everything 
possible except the toxins from the germ spores 
being excluded), arc capable, under suitable con- 
ditions and technic, of accomplishing just what 
the best of those sera will do toward producing 
" new antit'j.xins or new antibodies." 



Possibly some roundabout way, via-the-serum 
route, may suit cases unfit for the direct method. 
But, generally speaking, if resistance to tuber- 
culosis is nil because of the destructive processes 
which have already culminated, and because the 
organism, what is left of it, is already super- 
saturated with toxin, it is useless to try anything 
on these specific lines. 

But for curable or arrestible cases, Prof. 
Maragliano's conclusion applies as well to the 
direct (extract) as to the indirect (serum) 
method. He says, " For the rest, serum-therapy 
does nothing more than reproduce the process 
followed by nature in spontaneous cure, adding 
its good effects to those of hygiene." 

Fifth. Even if time remained for the pur- 
pose, I do not know that I should want to take 
much of it in considering Prof. Maragliano's 
scheme for the " vaccination " of healthy persons 
to immunize them against tuberculosis. Cui 
bono? If a person does not have to have a dis- 
ease why should he be vaccinated against it? 

From mv own conception of the nature of 
tuberculosis' we do not individually have to have 
it and it is sufficient to start in to fight it. or 
ought to be. when we get it. Why burden the 
organism with seeking an artificial immunity be- 
fore the natural immunity, the gift of every one 
in health, is lost? I should as soon think of 
vaccinating against syphilis as against tuber- 
culosis. But tuberculosis is vastly different in 
necessitating a peculiar susceptibility to it, which 
I)rerequisite is absent in the other infection. 

This susceptibility being an essential part, we 
should perhaps look at tuberculosis as a thing 
of degree — a dyscrasia or entity which has con- 
sumed, say 10 to 20 per cent, of its course 
before that form of vegetable decay, the fungus- 
growing germ — the tubercle bacillus — reputed as 
the cause of the disease, has come into existence. 
The line of dcmarkation between such dyscrasia 
and actual infection is at least not a definite 
one. By the crude tuberculin test I have proved 
latent tuberculosis to exist in 47 out of 53 cases 
in which there was either no sputum to examine 
or only glandular and other suspicions of in- 
fection. 

Let us say there has been an advance possiljlv 
of 20 to 40 per cent, more of the course of the dis- 
ease by the time the " mixed infection " period de- 
termines a still further stage in this process of 
decay. W'hat is going on is a constant battle 
between susceptibility and resistance to this 
toxic influence. If we were able to determine 
the faults of our civilization, which cause this 
susceptibility, we could belter understand the 
character of this conflict ; for then we would com- 
]ireliend that this disease tuberculosis is but a 
natural harvest from such degenerate soil. 

If we do not take our punishment for our un- 
hygienic living in one form of degeneration we 



I Scc^ " DcviLilized ,\\v — 'I'oxemia, a l^rimc Cause of Tuber- 
culosis." read at flic T^oiulon Tuberculosis Congress. 1901. Nov. 
9 anrl 16. iQoi, N. \. Mcrlical Journal. 



April i, 1905] 



HUGGINS: INTESTINAL ILEUS. 



593 



will have to take it in another. There must be 
some place where e.xhausted nature may lie down 
to die! It is my prediction that as we approach 
the eradication of tuberculosis, as some think we 
are doing, the mortality from associated de- 
generative processes, as from Bright's disease 
and cancer, will proportionately increase. 

Since writing this paper my attention has been 
called to the following pertinent data gleaned 
from the report of the Northwestern Mutual 
Life Insurance Company : " Percentage of deaths 
from tuberculosis, from 1857 to 1897, 15.62; same 
from 1897 to 1904, 10.67. Percentage of deaths 
from nephritis, from 1857 to 1897, 4.89; from 
1897 to 1904, 7.90. Diabetes from 1857 to 1897, 
1. 11; from 1897 to 1904, 2.08. There has been 
a slight decrease in pneumonia and a slight in- 
crease in cancer and diseases of the heart." 



INTESTINAL ILEUS WITH STRANGULATION. 

BY R. R. HUGGINS, M.D., 

OF PITTSBURG^ PA. 

In spite of the fact that the symptoms and 
pathology of acute intestinal obstruction are so 
often discussed and brought before the profes- 
sion, it is very evident, especially to one doing 
abdominal surgery, that many patients die every 
year because of delayed diagnosis, and as a 
result of this, late operative treatment. Every 
surgeon must be impressed by the large number 
of these cases which come under his care when 
the time for satisfactory operative measures has 
passed, and in spite of palliative treatment they 
either die or become subjected to prolonged and 
tedious convalescence. There is nothing in sur- 
gery which gives an operator as much comfort 
and sati faction as the result which follows the 
release of a piece of imprisoned bowel beneath 
a band of adhesions, the initwisting of a volvulus, 
or reduction of a hernia before strangulation, 
wliich are mechanical conditions, and without 
operative treatment mean certain strangulation 
of the bowel followed by peritonitis and death. 
Unfortunately, many of these cases are not seen 
early enough by the surgeon to realize this very 
happy and satisfactory result. Why is this true? 
I cannot believe it is because they are unrecog- 
nized or unsuspected by the average practitioner 
but rather that they do not adopt operative mea- 
sures until they have exhausted all other means 
of relief. While this delay is sometimes advis- 
able, the danger in so doing is very great because 
in these cases every hour of procrastination 
means a lessening in the prospect of recovery for 
the patient. If the symptoms are those of stran- 
gulation an exploratory laparotomy is much 
less dangerous than the expectant treatment. 

Syiiil)toms. — The symptoms of this condition 
as a rule are fairly typical. A patient previously 
well 'is suddenly sized with a pain in the ab- 
domen which is more or less severe; oftentimes 
there is severe shock accompanying the onset 
of pain, this shock and collapse is said by Reichel 
to be due to the escape of bacteria and other 



products into the peritoneal cavity, these sub- 
stances when resorbed produce the symptoms 
of collapse. Early nausea and continuous vomit- 
ing are the most characteristic symptoms, es- 
pecially when preceded by pain and accompanied 
by obstipation, first the contents of the stomach 
are expelled, then biliary, and finally fecal vom- 
iting ensues ; neither gas nor feces are expelled 
from the rectum. In some cases if the ab- 
dominal wall is very thin the loop of bowel 
which is strangulated will be so greatly dis- 
tended that it may be outlined by palpation, or 
it may be felt within the abdomen, upon rectal 
examination or sometimes a distended intestine 
may be apparent on the surface of the abdomen. 
There is the anxious face and a pulse increasing 
in frequency. These are the syinptoms in the 
early stage; later, of course, there is paralysis 
of the intestines and general abdominal disten- 
tion. The length of time until this occurs de- 
pends upon the degree of strangulation ; if it 
be complete, gangrene may ensue in twenty-four 
hours or even sooner. If we can rule out acute 
appendicitis our diagnosis is usually certain, and 
I hold that an early laparotomy is to be advised 
in every suspicious case, because the danger in 
this is less than in the expectant treatment. I 
would also mention the necessity of careful ex- 
amination for hernia in these cases. 

I report four cases to show the marked con- 
trast in the result between early and delayed 
operative treatment. 

Case I. — Mrs. C, aged twenty-eight years. 
Seen in consultation with Dr. Anderson. Pre- 
vious health good. Pregnant four months. Was 
seized suddenly with pain in abdomen referred 
to epigastric region, after a few hours localized 
to the lower right quadrant. I saw the case 
thirty-six hours after the beginning of attack; 
she complained of severe pain in region of the 
appendix, vomiting continuously, temperature 
about 100° F., pulse no; on local examination 
extreme tenderness over the appendix and some 
rigidity of right rectus muscle. I could feel on 
palpation a distended loop of intestine in upper 
right quadrant of abdomen, bowels had not been 
moved. Made a diagnosis of appendicitis to- 
gether with acute intestinal obstruction. The 
diagnosis of obstruction was based upon the con- 
tinuous vomiting and distended loop of intestine. 
As we seldom see cases of simple acute appendi- 
citis with such persistent vomiting, for so long 
a period, I concluded that an obstruction of the 
bowel had also occurred. The patient was re- 
moved to St. Francis Hospital, and the abdomen 
opened forty hours after the beginning of the 
attack; found the appendix in the state of acute 
inflammation, as yet unruptured, but contained 
about one-half dram of pus. The ileum was 
strangulated about 20 inches from the cecum, 
due to its imprisonment beneath a peritoneal 
band, probably the result of a former attack 
of peritonitis. The band was severed and the 
intestine freed ; fortunately gangrene had not 



594 



HAMMOND: OVARIAN CYST. 



[Medical News 



yet set in and after the application of hot saline 
solution for several minutes the circulation was 
restore'd. In a few hours more a resection of 
the bowel would have been necessary, thus pro- 
ducing a very serious if not fatal complication. 
The patient left the hospital in three weeks, fully 
recovered, and was delivered of a living child 
five months later. 

Case II. — This patient was seen in consulta- 
tion with Dr. Mcintosh. Child of ten months. 
Patient had been vomiting continuously for 
thirty-six hours. Cried without ceasing from 
the iseginning of attack. No bowel movement 
after colon was evacuated, abdomen somewhat 
distended, temperature normal, pulse rapid. On 
examination could not outline any tumor through 
abdominal wall. Introducing finger into rectum 
I could feel a distended loop of bowel forced 
into the pelvic cavity. No blood had been dis- 
charged from the rectum. Diagnosis: Obstruc- 
tion of the bowel from intussusception or a vol- 
vulus. Patient removed to St. Francis Hospital 
and operated upon thirty-eight hours after be- 
ginning of attack. Found a volvulus of the 
ileum, intestine very much discolored ; in a few 
hours it would have been gangrenous. The twist 
seemed to be due to a long mesentery. Patient 
made a rapid recovery and left hospital in ten 
days. 

in contrast to these I report two cases treated 
upon the expectant plan : 

Case III. — Mr. R., aged forty-two years, was 
seen in consultation with Dr. McCullough, of 
Freeport, five days after beginning of attack. 
Abdomen enormously distended, pulse rapid and 
weak ; vomiting continuous. No bowel movement 
since beginning of symptoms. Condition seemed 
hopeless ; however, under local anesthesia, an 
opening was made into the bowel relieving the 
distention and freeing it from gas. Condition 
of the patient would not bear exploration suffi- 
cient to ascertain the cause of the obstruction. 
The bowel was stitched into the abdominal 
wound. Death ensued in eighteen hours. No 
autopsy. 

From the severe pain and collapse, this was 
probably a volvulus. 

Case IV. — Mr. G. Brought into the hospital 
six days after the beginning of symptoms. Ab- 
domen distended to fullest extent. Vomiting 
and hiccough. General peritonitis. Peristalsis 
absent. No gas or feces had passed from bowel. 
Enterostomy. Lived four days. Autopsy. Old 
adhesions throughout abdomen as result of for- 
mer peritonitis. Transverse colon bound down 
and strangulated by adhesions. Appendix lo 
inches in length but not seat of acute disease, 
had probably caused former peritonitis. 

Many cases similar to III and IV constantly 
occur in every community and could nearly al- 
ways be saved by early operation. 

The results of the above cases show plainly 
that it is very necessary to make a correct diag- 
nosis early in the attack, and be ready, if pos- 



sible, to carry out the proper surgical measures, 
before sufficient time has elapsed to cause 
serious pathological change in the strangulated 
intestines. 

REPORT OF A CASE OF A LARGE PAROVARIAIf 

CYST, AND TWO CASES OF LARGE 

OVARIAN CYSTS.i 

BY FRANK C. H.^MMOND, M.D., 

OF PHILADELPHIA; 

DEMONSTRATOR OF GYNECOLOGY IN THE MEDICAL DEPARTMENT OF" 

TEMPLE COLLEGE, AND CHIEF OF THE GYNECOLOGICAL 

DISPENSARY, SAMARITAN HOSPITAL. 

In view of the aggressive modern teaching of 
gynecology, large ovarian cystomas are compar- 
atively rare ; for these neoplasms are recognized 
early and submitted to early operative interfer- 
ence ; unless they should fail to give rise to symp- 
toms, and are accidentally discovered by the pa- 
tient. This occurred in all three of the cases. 
These patients were operated upon within a 
period of eight weeks at the Samaritan Hospital 
last summer. 

Kelly- gives the following table of 141 cases- 
of large tumors of the ovary differentiated macro- 
scopically in the operating room: 

Multilociilar ovarian cysts 38 

Unilocular ovarian cysts 36 

Parovarian cysts 22 

Papillary tumors 20 

Dermoid cysts 25 

"A thorough sifting of this material, however, 
in the pathological laboratory has served to dem- 
onstrate the necessity of a careful microscopical 
examination in every case in order to establish 
the diagnosis on a scientific footing." 

Case I. — F. O., single, twenty-one years of age, 
saleslady ; was referred to the gynecological dis- 
pensary of the Samaritan Hospital, August 25, 
1904, by Dr. Leon Van Horn, when the following 
history was obtained : Father and mother living, 
the former is forty-four years of age and in poor 
health, due to intestinal disease ; the latter is 
forty-two years of age and in good health. Had 
one brother. There are two sisters living and 
one dead. During childhood the patient had 
measles and mumps. Puberty at thirteen, menses 
regular, painless, lasting five to seven days and 
profuse, last menstruation three weeks ago. 
When fifteen years of age she suffered from a 
very heavy cold which checked her menstruation. 
During the next five months she suffered con- 
stantl\- with pelvic imflammation. Since then 
tlicrc have been various attacks of oophoritis and 
vaginitis. About six weeks ago she noticed an 
enlargement of the right side of the abdomen, 
which lias gradually increased. No pain. Siglitly 
constipated. 

Upon making a bimanual examination a very 
small conical cervix was found, displaced some- 
what to the left. The entire right half of the 
pelvis was occupied by a fluctuating tumor which 

1 Read before the Obstetrical Society of Philadelphia, Febru- 
ary 2. 1905. 

2 Opcr.ilivc Gynecologry, VoT. IT, p. 247. 



April i, 1905] 



HAMMOND: OVARIAN CYST. 



595 



extended up to the umbilicus. It was absolutely 
impossible to outline the uterus. This tumor 
was on the right side of the abdomen for its lower 
portion, but about midway between the pubis and 
the umbilicus ; it extended to the left of the median 
line for about three inches. It was freely mov- 
able. A diagnosis of a unilocular, broad liga- 
ment cyst was made. The patient was admitted 
■ to the Samaritan Hospital July 31, 1904, and 
was operated upon the next day. Upon opening 
the abdomen the cyst sac was seen not to have 
the pearl gray color usually found in ovarian 
cysts, but was pink. A hand was introduced into 
the abdominal cavity and passed around the cyst 
which was found to be free from adhesions. The 
sac was tapped and emptied of a clear, light-straw 
colored fluid. Marked difficulty was experienced 
in dissecting out the sac from the broad ligament. 
When this was accomplished the floor of the pel- 
vis was seen laid bare, and the ureter was found 
to be uninjured. There was troublesome bleed- 
ing from the pelvic wall which was not entirely 
controlled by ligatures and required a gauze 
packing. The opposite ovary was enlarged and 
contained a few follicular cysts, which were punc- 
tured and the ovary dropped back. The uterus 
was of the infantile type, and pushed well to the 
left. An uneventful recovery followed, the pa- 
tient being discharged from the hospital three 
weeks subsequent to operation. Pathological 
diagnosis, unilocular parovarian cyst. 

Case II. — R. J., thirty years of age, married, 
housewife : applied for treatment to the gyneco- 
logical dispensary of the Samaritan Hospital, 
August I, 1904, giving the following history: 
Father living and well ; mother died at the age 
of thirty-seven from cardiac disease ; two sisters 
and two brothers living and in good health. She 
had the usual diseases of childhood. Puberty- at 
thirteen, menses regular, painless, lasting twenty- 
eight days. Has just finished menstruating. Mar- 
ried ten years, and has two children ; normal 
labors and puerperiums. During the summer of 
1903 she had a miscarriage, being about two 
months pregnant. During the latter part of De- 
cember. 1903, she first noticed an enlargement in 
the left side of the abdomen, which has gradually 
increased but without discomfort. During the 
past week there has been pain in the left iliac 
region. Upon examination there was found an 
incomplete laceration of the pelvic floor ; the 
uterus was in good position and freely movable. 
A large fluctuating, freely movable tumor was 
found on the left side above the pelvic brim. A 
diagnosis was made of a unilocular ovarian cyst 
of the left side. The patient was admitted to the 
Samaritan Hospital August 8, 1904, and operated 
upon the next day. After doing a Hegar's 
perineorrhaphy, the abdomen was opened. A 
cyst, free of adhesions, was found arising from 
the left ovary. The pedicle was long, and con- 
tained five twists ; this was possibly the cause of 
the pain which she experienced during the week 
prior to operation. The sac was tapped and 3;-< 



pints of a clear straw-colored fluid escaped. The 

pedicle was ligated and the cyst removed. 

The opposite ovary was slightly enlarged and 
the seat of numerous small superficial follicular 
cysts. The cystic area was resected. Pathologi- 
cal diagnosis, unilocular adenocystoma. The pa- 
tient made an uneventful recovery, and was dis- 
charged from the hospital on the nineteenth day. 

Case III. — E. M., thirty-eight years of age, 
married, housewife. She was admitted to the 
Samaritan Hospital September 13, 1904, when 
the following history was taken : Father died at 
the age of sixty-nine years from pulmonary tuber- 
culosis ; mother living and well at the age of sixty- 
three years. She had the usual diseases of child- 
hood. Puberty at eighteen, menses regular, pain- 
ful, lasting three to four days. Last menstruation 
one week ago. Married thirteen years. She has 
had six children. All of her labors were normal ex- 
cepting the fifth, which was instrumental. (I at- 
tended her in this labor and applied forceps owing 
to partial extension of the fetal head and its fail- 
ure to engage at the superior strait.) The last 
child was born January, 1904. Subsequently to the 
birth of her fifth child she noticed a swelling of 
the abdomen, which gradually increased, and 
was attributed to being " a big stomach." When 
she became pregnant the last time the abdomen 
was so markedly enlarged that the physician who 
attended her thought she had a plural pregnancy, 
the cyst not being detected. The cyst did not 
interfere with this gestaricn or labor. After the 
birth of this child the abdomen rapidly increased 
in size. I saw her a few days before her admis- 
sion to the hospital, when she consulted me for 
her abdominal enlargement. At that time there 
were no pressure symptoms, no inconvenience, 
and no interference with the gastric, respiratory 
or circulatory functions. She was slightly ema- 
ciated, but attributed this to her household work. 
Appetite good until the past few weeks ; bowels 
regular. 

The following measurements were taken : 

Circumference at umbilicus 42 cm. 

Circumference at the xiphoid ap- 
pendage 23 cm. 

Distance from xiphoid appendage to 

umbilicus 9^ cm. 

Distance from umbilicus to symphysis 
pubis 1014 cm. 

Umbilicus to right anterior superior 
spine II cm. 

Umbilicus to left anterior superior 

spine 9 cm. 

Upon making a bimanual examination, an in- 
complete laceration of the pelvic floor was found. 
The cervix was in normal position, but it was im- 
possible to outline the body of the uterus. Upon 
percussion, a flat note was elicited over the entire 
anterior wall of the abdomen, excepting very high 
up, where it was tympanitic. Tympany was also 
obtained deep down in the flanks. A diagnosis 
was made of a unilocular ovarian cyst of the right 
side. 



596 HAMMOND: OVARIAN CYST. [Medical News 

The patient was operated upon September 14, ference with ovarian growths are, the inipossi- 
1904 (the day following admission to the hos- bility of deciding with certainty that the tumor is 
pital). Owing to the size of the cyst, and the not malignant; the possibility of rupture at any 
possibility of complications, it was deemed best moment ; torsion of the pedicle with its disastrous 
to open the abdomen first, and then, if the patient consequences; inflammatory changes may super- 
was in good condition, to do the plastic work on vene ; adhesions may form and suppuration may 
the pelvic floor. Upon opening the abdomen and take place, adding greatly to the gravity of an op- 
introducing a hand, numerous adhesions were eration ; with delay comes exhaustion, interfer- 
found between the cvst and the anterior abdomen ence with the functions of the bowels and blad- 
wall. All of these w'ith two exceptions were read- der ; and, the probability of hydro-ureter from 
ily broken up, the latter were torn loose at the pressure. Also digestive respiration and circu- 
expense of the cyst sac, and required ligatures latory symptoms. 

to control the bleeding. There were no adhesions Had it been possible to diagnose pregnancy in 
laterally or posteriorly. The sac was tapped and Case III, immediate operation was demanded just 
seven liters of a clear straw-colored fluid evac- the same, because the cyst would have greatly 
uated. A small quantity of pseudomucin re- interfered with the gravid uterus, and always im- 
mained in the sac. The cyst was readily ligated plies exposure to the danger of rupture, infection 
and removed. The opposite ovary was sclerotic and gangrene. Werder covers this point very 
and was also removed. The uterus was found nicely as follows : " When we consider the sen- 
enlarged, and thought to be subinvoluted. As the ous nature of the complication of pregnancy with 
patient was in good condition upon the comple- an ovarian cyst and the safety and ease with 
tion of the abdominal operation, an Emmet's per- which most tumors can be removed, no long ar- 
ineorrhaphv was done. guments should be necessary in favor of the op- 
At the eiid of fortv-eight hours, a slight vaginal erative treatment of such complications no matter 
bleeding occurred, unaccompanied by pain, fol- at what period the pregnancy and what size the 
lowed in about three hours bv the expulsion of a uterus or condition the tumor. In fact, delay and 
two months' fetus. As the abortion was incom- procrastination seem to me much less excusable 
plete it was necessary to empty the uterus. Owing during pregnancy than at any other time, because 
to the absence of subjective and objective signs the immediate dangers to the patient are much 
and symptoms of pregnancy, the abortion may greater. That pregnancy is no contraindication 
be attributable to too much handling of the to any necessary abdominal operation, is now 
uterus. This patient made an uneventful recov- well understood, and the results obtained at this 
ery and was discharged at the end of three weeks, time are equally as favorable as at any other time. 
The following measurements were taken previous Admitting then that the safety of the mother de- 
to her leaving the hospital. mands an immediate operation as soon as the 
^. " , , ... diagnosis of ovarian cvst is made, what efTect 
Qrcum ference at the umb.hcus .... 29 cm. ^^.^^ .^ treatment have On the child ? Abortion 
Circumference at the xiphoid ap- . ^ . ^ ^i ^i j- ^ i.^ r i.u 

oendaee ''S cm ^^ "*^t infrequently the direct result of the pres- 

Distance from' the "xiphoid appen- ' ence of an ovarian tumor, as shown by Remy, 

dage to the umbilicus 6 cm. who found that among 321 cases of pregnancy 

Distance from the umbilicus to complicated by ovarian cysts 55 or 17 per cent. 

symphysis pubis 5 cm. aborted without operation. Among Orgler's 142 

Umbilicus to right anterior superior cases who survived operations, pregnancy was 

spine 5'/2 cm. interrupted in 3 or 22 5/10 per cent., a result 

Um1)ilicus to left anterior superior slightly in favor of the expectant plan of treat- 

^P'"'^ ° '^"''- ment from the standpoint of the child. Statis- 

Pathological diagnosis, multilocular adeno- tics of other operators, however, are more favor- 
cystoma. There were several small daughter- able, viz. : Bovee reports 38 cases of removal of 
cj'sts on the inner wall, otherwise there were no both appendages with one maternal death fol- 
trabeculre or other evidence of the large sac hav- lowed by only four abortions or 126/10 per cent, 
ing been multilocular. The removal of both appendages therefore during 

Catgut was used throughout in each case for pregnancy neither increases the danger to the 
all ligatures and sutures. To all of these patients mother nor does it increase the liability to mis- 
eserine salicylate was administered subsequent to carry ; on the contrary, there is a smaller percent- 
operation. These patients have all been seen age of abortion then when treated without oper- 
within the past three weeks. They are enjoying ation. The earlier the tumor can be removed 
good health, and are increasing in weight. and the smaller the gravid uterus is at the time 

The treatment of ovarian tumors is undoubt- of operation, the less will the progress of preg- 
edly by extirpation as soon after the discovery of nancy be interfered with because a large gravid 
the tumor as the physical condition of the patient uterus will necessarily render the operative tech- 
will permit. All of these patients were in good nic more difificult and will be subjected to more 
condition at the time diagnosis was made, and handling and manipulation and possibly injury, 
were operated upon as soon as a bed could be thus increasing the tendency to abortion. It has 
obtained for them. The reasons for early inter- been fully demonstrated that the removal of one 



April i, 1905] 



MEDICAL PROGRESS: SURGERY. 



597 



or both appendages in itself exercises very little 
if any influence on the pregnant uterus ; the safety 
of the child is therefore no contraindication to 
the operation." 

MEDICAL PROGRESS. 



SURGERY. 

The Preparation of Catgut. — A simple and reliable 
method of preparing catgut, as described by C. E. 
CoNGDON (Am. Jour. Obstct., January, 1905), is as fol- 
lows : Take dry catgut in ten foot strands, test for 
weak points and irregularities and wind in a single 
layer on a glass cylinder such as an ordinary drainage 
tube. Secure each end and submerge in a 3 per cent, 
formalin solution. No. 4 is allowed to remain in four 
hours. No. ,3 is allowed to remain in the solution three 
hours and five minutes. No. 2 for two hours and fif- 
teen minutes. No. i for one hour and thirty-five 
minutes. The catgut is then removed and immediately 
places in running water for the same length of time 
that it has been in formalin solution. It is then dried 
and put away for future use. Catgut thus prepared 
may be sterilized for use by boiling and handled pre- 
cisely like silk. The approximate time for which 
material thus prepared may be depended upon to fur- 
nish support to the tissues is as follows : No. 4, seven 
days ; No. 3, five days ; No. 2, three days, and No. i, 
thirty-six hours. The employment of a five per cent, 
solution of formalin will cause the catgut to resist 
absorption twice as long as the use of the three per 
cent. 

The Misuse of Tendon Trcinsplantation. — Before 
undertaking this operation, the surgeon should always 
assure himself that the pathological process which fur- 
nishes the indication for the transplantation, must be 
at a standstill and not progressing. That sufficient 
care in selecting cases is not always shown, is the opin- 
ion of Oppenheim {Bcrl. klin. IVoch., February 13, 
.1905), who reports three cases in which operation was 
done where the palsies were due to progressive central 
lesions. The first of these was a case of progressive 
nmscular atrophy, where the tendon of the relatively 
well functionating triceps surs was split and grafted 
upon the peroneus longus without any favorable re- 
sults no abduction of the foot being secured. In the 
second case a spinal form of progressive muscular 
atrophy was present as the result of a chronic 
anterior poliomyelitis. Here also, in spite of the 
progressive character of the disease, the tendon 
of the extensor hallucis longus was grafted on the 
tibialis anticus. In the third case, an elderly woman, 
there had been present for some time pain and weak- 
ness in one leg, for which a muscle transplantation was 
done, although similar symptoms were beginning in the 
other leg. No relief was secured and an examination 
liy the author, three months later, showed that the 
trouble was due to pressure on the lumbosacr^il seg- 
ments of the cord by a tumor which was probably 
malignant. This was confirmed by the X-ray. The 
duty of the orthopedic operator in such cases is evident, 
and in every case submitted for operation, the precau- 
tions already noted as to the character of the disease 
should be noted. 

Results of Fourteen Hundred Operations for the 
Radical Cure of Hernia in Children, Performed at 
the Hospital for Ruptured and Crippled Between 
1891 and 1904. -\\'. T. Bull and W. R. Coley {Med. 
Rec, March i8, 1905) report in detail the re- 
sults of T,424 hernia operations, of which all but 



20 were on children under the age of fourteen years. 
It has been the custom of the authors to treat all 
their cases of hernia in children, with certain few ex- 
ceptions, for a period — usually one or two years — -with 
a truss before advising operation. If at the end of 
this time no improvement is observed, operation is 
advised. Under the age of four years a very consider- 
able number of cases of inguinal hernia, and nearly 
all cases of umbilical hernia, can be cured by truss treat- 
ment. Of the 1,424 operations reported, 1,354 were 
for inguinal hernia, 35 for femoral, 10 for umbilical, 8 
for ventral, 2 for congenital hernia of the umbilical 
cord, 2 for epigastric, and i for lumbar hernia. The 
great majority of the operations for inguinal hernia 
were performed according to Bassini's method, using 
chromicised kangaroo tendon for suture material. In 
most cases an extra suture was placed above the cord. 
Excision of the veins of the cord seems unnecessary, 
at least in children. Operation without transplantation 
of the cord appears to give less satisfactory results, 
though this is not yet certain, owing to the disparity in 
the numbers of the cases treated by the two methods. 
Twelve operations were performed for strangulated 
hernia, and the cases show that strangulation is 
more common during the first two years of life than 
during the next decade. The seat of strangulation in 
every instance was the result of constriction by the 
tight external ring. Eleven relapses in all were noted, 
and the authors conclude that the majority of recur- 
rences take place during the first six months after 
operation, and about 90 per cent, occur during the 
first year. A comparison of cases operated with and 
without rubber gloves shows suppuration in 4.4 per 
cent, without gloves, and 2.3 per cent, with gloves. 
There were four deaths during the series. 

A Simple Heat Method of Sterilizing and Storing 
Catgut. — WiLLARD B.\RTLETT {The Interstate Medical 
Journal, No. 3, 1905). The treatment of raw catgut 
is as follows: (i) The strands are cut into convenient 
lengths, say thirty inches, and made into little coils 
about as large as a silver quarter. These coils in any 
desired number are then strung like beads on to a thread 
so that the whole quantity can be conveniently handled 
by simply grasping the thread. (2) The string of 
catgut coils is dried for one hour at a temperature of 
t8o° F., and then for a second hour at 220° F., the 
change in temperature being gradually accomplished 
(3) The catgut is placed in liquid albolene, where it 
is allowed to remain until perfectly " clear," in the 
sense that the term is used in the preparation of his- 
tological specimens. This is usually accomplished in 
a few hours, though it has been my custom to allow the 
gut to remain in the oil ocer night. (4) The vessel 
containing the oil is placed upon a sand bath, and the 
temperature raised during one hour to 320° F., which 
temperature is maintained for a second hour. (5) By 
seizing the thread with a sterile forcep the catgut is 
lifted out of the oil and placed in a mixture of iodine 
crystals, one part in Columbian Spirits (deodorized 
methyl alcohol), one hundred parts. In this fluid it 
is stored permanently, and is ready for use in twenty- 
four hours; the thread is then cut and withdrawn. It 
seems important that the gut should be thoroughly 
" cleared " before the oil is heated, in order that the 
temperature of the center of the strand becomes as 
high as that of the oil outside. It may be noted fur- 
ther that the oil is not removed from the gut before 
placing it in the storing solution. This is done pur- 
posely, since catgut which is perfectly free from oil 
is so very sensitive to the action of water that it readily 
untwists and becomes tangled after it is used in a 



598 



MEDICAL PROGRESS: MEDICINE. 



[Medical News 



wound but a few moments. This storing fluid simply 
takes off enough oil from the exterior of the strand 
so that it is not too slippery for use, and the albolene 
being a bland, non-irritating substance, there is no 
reason why it cannot be safely left in the gut. The 
iodine rapidly permeates the strand ; the same will be 
found stained black after a few hours, and conse- 
quently the surgeon will have the assurance that he 
is introducing an antiseptic as well as a thoroughly 
sterile suture material. 

MEDICINE. 

City Dust and Patent Medicine Advertisements. — 

Robert Hesslek (Am. Med., March 5, 1905) traces 
the relationship existing between the amount of 
infective du£t in a city and the number, kind, and 
size of patent medicine advertisements in the news- 
papers. City dust diflfcrs from country road dust 
in the presence of spittle. In spitting and in taking 
patent medicines we certainly excel. Medical ad- 
vertisements may be divided into three classes: (l) 
Patent medicines proper, of unknown composition 
and proprietary. (2) Those of quacks. (3) Of lo- 
tions, pennyroyal pills, syringes, etc. Patent medi- 
cines can be divided into groups, according to their 
use; the largest group may be designated as the dust 
group, because it refers to diseases and conditions 
that depend on infective dust. In patent medicine 
advertisements there is a large list of names that in 
most instances, when applied by the laity in self- 
diagnosed cases, must be regarded as synonyms of 
dust infection; among these names are the follow- 
ing: Catarrh, colds, cough, grip, tonsillitis, pleurisy, 
rheumatism, backache, kidney disease, lumbago, 
muscular rheumatism, nervousness, biliousness, etc. 
Their names may be grouped by marking names of 
respiratory affection like catarrh, colds, cough, in 
red; those referring to rheumatic conditions in blue; 
nervous conditions in yellow, etc., a general idea of 
this dust group of patent medicine advertisements 
may be obtained. The amount of space occupied 
by medical advertisements varies greatly in different 
papers and in different countries. In Indiana news- 
papers the amount varied from 2.5 per cent to 14.5 
per cent.; dust advertisements varied from one per 
cent, in a comparatively city up to ten per cent, in 
a dusty one. When one-eighth of the total space 
of a newspaper is occupied by patent medicine ad- 
vertisements, whose existence rests mainly on the 
condition of the streets and sidewalks it may be 
well to inquire if there is not something wrong with 
that municipality. There is also a seasonal varia- 
tion; low ebb is reached in the summer, high tides 
occur in the fall and spring. The hot rays of the 
sun and street sprinkling in the summer and the 
lack of free ventilation in winter are powerful fac- 
tors. Patent medicine men may not know why their 
nostrums are in demand, but they know that it pays 
to advertise in certain towns — dusty towns, and 
where the spitter is unmolested. What the people 
save by not keeping their city clean they arc com- 
pelled to spend in a vain attempt to counteract the 
evil influence of the dust. 

Digestion of Caseins and their Relation to Certain 
Problems in Infant Feeding. — T. S. Southworth 
(Med. Rcc. March 4, 1905) says that the nature of 
casein digestion is an important feature in the man- 
agement of artificially-fed infants that has not re- 
ceived the consideration it deserves. Hammerstcn's 
erroneous conclusions have been copied and accepted 
without question by so many authors that it is only 



very recently that it has been shown that much of 
the teaching of the past requires recasting. The fer- 
ment first formed in the stomach of the young is 
the rennet ferment, which changes casein into para- 
casein. At first this is digested in the intestine, but 
as hydrochloric acid begins to be secreted this com- 
bines with the paracasein, forming hydrochloride 
of casein, which is fitted for peptic digestion. The 
greater the amount of acid present, the tougher will 
be the curd; but at the same time more pepsin is 
secreted, so that as the infant develops the work 
performed by the stomach is regulated automatic- 
ally. ./Vn excess of acid causes the formation of a 
less digestible dihydrochloride of paracasein; but 
if the acid is so abundant that some of it is uncom- 
bined, or free, the new substance is readily digested. 
The presence of lactic acid in sour milk may greatly 
modify the digestive processes in the infant's stom- 
ach, and this question, as well as the rationale of 
adding alkalies to food mixtures, is discussed in 
detail by the author. 

Acne and Its Treatment. — G. T. J.^ckson (^Med. 
Rl-c, March 18, 1905) says that acne is even commoner 
than eczema, and that while it is true that the disease 
is often stubborn, the majority of cases can be greatly 
lieiiefited in a short time, and very many of them cured 
l)romptly. The indications for treatment are as fol- 
low.s ; ( I ) Improve the condition of the skin, so that 
it will no longer be a suitable culture ground for the 
bacillus. (2) Empty the follicles of the skin of the 
colonics of bacilli. (3) Keep the skin constantly asep- 
tic, so that any bacilli that escape on it will be killed, 
and no new infection of the skin will be possible. The 
first indication is met by attention to tlie patient's gen- 
eral health by means of baths, diet, exercise, attention 
to hygiene, and lastly, drugs. The follicles are emptied 
by the use of the curette, the acne lancet, and the 
comedo cxpres.sor. The best local application is sul- 
lihur. preferably in the form of the old lolio alba, the 
formula for which is : Zinc sulphate and potassium 
sulphuret, of each, 3i-ii ; rose water, q. s. ad. yv. This 
is to be shaken up before using. Resorcin is also use- 
ful, as w-ell as sulphur soap. The u.se of the X-ray 
should be limited to intractable cases, and requires 
great caution to prevent doing harm. 

Cholecystitis as a Complication of Lobar Pneu- 
monia. — J. M. Anders (Am. Med.. March 18, 1905) 
rcporls three cases. Although an analysis of these 
cases does not warrant drawing any general conclu- 
sions still the clinical observations may serve to direct 
attention to cholecystitis as a complication in rare cases 
of lobar pneumonia. The local symptoms and physical 
signs are characteristic, but the type of the condition 
is not severe. It is to a great extent overshadowed by 
the pneumonic condition. Although no general or con- 
stitutional .symptoms, distinctive of the lesions, arc 
recognizable, Anders is pretty fairly convinced that 
the clinical course of pneumonia cases is not, as a rule, 
materialy modified by the complications of catarrhal 
cholecystitis except in cases in which chronic hepatic 
disease existed previously, when the toxemic symptoms 
may be intensified by the development of an acute, wide- 
spread cholangitis and cholecystitis. Two of the cases 
terminated in recovery but Anders states this result 
was not due to any special method of treatment, a? at- 
tention was mainly bestowed upon the serious primary 
affection. A mild saline laxative was employed in one 
of the cases and small doses of mild mercuric chlorid 
in the other. In the case which terminated fatally 
nothing but the general treatment of the pneumonia 
was carried out, because the grave pneumonic features 



April i, 1905] 



MEDICAL PROGRESS: PHYSIOLOGY. 



S99 



and the cardiac and pulmonary complications called 
for active measures. 

Urine Examination. — I. R. C. Cabot {Journal A. M. 
A., March 18- J5) slates that incited by a statement of 
Council man that the chemical and microscopic examui- 
ation of the urine failed to give certain information of 
the character of the renal lesions, as well as by dis- 
crepancies coming under his own observation, he has 
compared critically the records and post-mortem find- 
ings in the cases that have come to autopsy in the 
Massachusetts General Hospital since 1893. Although 
the number of cases is not large, he thinks they war- 
rant the following conclusions: (i) Many cases of 
acute glomerular nephritis occur and are unrecognized 
by any known methods of examination. (2) The diag- 
nosis is at fault in some cases of subacute and chronic 
glomerular nephritis, but in the great majority of cases 
the condition of the urine, taken in connection' with 
other symptoms, foretold the autopsy findings. (3) 
In chronic interstitial nephritis the diagnostic resources 
appear to be neither so sufficient as in the chronic 
glomerular form, nor so inadequate as in the acute 
glomerular nephritis. In about a third of the cases the 
diagnosis was correctly made before death. (4) .^mong 
other conditions mistaken for nephritis by too much 
reliance on the urinary findings are senile and arterio- 
sclerotic condition, mistaken for chronic nephritis, 
while in conditions involving passive congestion or 
acute kidney degenerations, the urine occasionally sim- 
ulates that of acute nephritis. Even where no lesions 
are found at autopsy the urine is sometimes highly al- 
buminous and full of casts. (5) In ordinary urinary 
examinations the common errors are: (o) The at- 
tempts to estimate urea without accurate knowledge of 
the patient's metabolism. (6) Stating that renal cells 
are present when all that is seen are small mononu- 
clear cells, perhaps from the kidney tubules, perhaps 
not. (6) Cryoscopy and other attempts to test the 
renal permeability more directly are not yet capable 
of supplementing in clinical work the older methods 
of examination. Cabot holds that the vast majority 
of estimations of urinary solids, including urea, are a 
waste of time, since they are not and can not be made 
part of a general metabolism experiment, and that the 
attempt to estimate the anatomic condition of the kid- 
ney by measuring albumin and by searching for casts 
is fallacious. The most reliable data are the twenty- 
four hour quantity, the specific gravity and the color. 

PHYSIOLOGY. 

Physiological and Pharmacological Investigations 
on the Uterus. — The uterus when removed from the 
body reveals a number of important phenomena which 
indicate that it has an inherent set of capacities inde- 
pendent of the rest of the economy. E. M. Kurdinow- 
SKi {Arch. f. Anat. und Physiol, December 28, 1904) 
finds that at all periods of the sexual life, the womb 
is endowed with an automatic contractility. This is 
true of the virgin uterus also. This automaticity ex- 
hibits itself in waves separated by pauses. The uterus 
reacts to mechanical and thermic stimuli, but is only 
slightly susceptible to electrical stimuli. Toward the 
end of pregnancy the e.xsected uterus is capable of 
parturition. The broad and round ligaments take a 
useful part in the general contractions of the organ. 
The uterus is but little dependent upon the central 
nervous system. The isolated organ presents peculiar 
advantages for the investigation of the pharmacology 
of the uterine drugs. Hydrastinin causes indepen- 
dently of the nervous system a tetanic contraction of 
the uterus. So far as this drug affects the blood ves- 



sels of the uterus, it does not cause this narrowing by 
acting locally, but by acting upon their governing 
nerve-centers. Sphacelic acid acts similarly to hydras- 
tinin. Adrenalin, even in the smallest doses, causes 
a powerful reaction, producing an increased contrac- 
tion of a tetanic character, and also increasing uterine 
irritability. It narrows very markedly the uterine ves- 
sels. Narcotic poisons of the fatty acid series (chlo- 
ral hydrate and alcohol) have relatively little effect 
on the isolated uterus. Only relatively large doses 
of these poisons paralyze the contractile power of the 
organ. 

Ligature of the Pancreatic Duct. — It has been 
found by W. Lombroso {Jour, dc Physiol, January 
'5. 1905) that ligature or excision of the duct of 
VVirsung does not necessarily lead, at least in the 
dog, to atrophy or sclerosis of the pancreas, al- 
though frequently either one of these changes may 
partially occur. This supports the view that besides 
its digestive secretion, the pancreas has another 
function which persists after its digestive activity 
has been abolished. 

The Participation of the Acini in the Internal Se- 
cretion of the Pancreas. — The injection of oil into 
or the ligature of the duct of Wirsung, causes an 
increase in the glycolytic power of the blood. This 
was shown twelve years ago by R. Lepine {Jour. 
de Physiol, January 15, 1905), who now finds that 
the increased pressure in the pancreatic ducts has 
hardly any effect upon the islands of Langerhans. 
It would appear, therefore, as if the ligature of the 
duct of Wirsung augments the glycolytic power of 
the blood only by compressing the cells of the acini, 
thus causing them to pour their secretion more 
copiously into the blood-vessels. This research 
tends to belittle the role of the islands of Langer- 
hans in the elaboration of products that favor gly- 
colysis, giving this function to the cells of the 
acini. There is some evidence, not yet published, 
that trypsin is not without influence on glycolysis. 

Alkalescence of Blood. — Various methods are in 
vogue for determining the alkalinity of the blood; 
some enable an estimation of the total alkalinity, 
while others disregard the basic principle in union 
with the proteids and only give an idea of the in- 
organic alkali present. By careful experiments, A. 
Land.\u {Arch. f. e.xp. Path. u. Pharmak., Vol. 52, 
Nos. 3 and 4) has shown that only the former 
methods (especially titration with acid and lack- 
moid as indicator) gives valuable results, since in 
acid intoxication, part of the acid will also replace 
the proteid alkali, so that this factor should not be 
disregarded. The author proceeds as follows: Five 
c.c. of blood are mixed with a small amount of 
sodium oxalate and then titrated with one-twentieth 
normal sulphuric acid, using lackmoid as indicator. 
Fifty-four per cent of the total alkali was found com- 
bined with proteid and the remaining 46 per cent, 
express the mineral alkalescence in normal rabbit. 
When rabbits were poisoned with phosphorus or 
hydrochloric acid, the total alkalescence was much 
less, but the proportion between organic and mineral 
alkali remained about the same. The acid united 
to the proteid is apt to do more damage than the 
acid combined with inorganic bases since it will be 
excreted less readily. 

Properties of Hirudin. — Hirudin, an active princi- 
ple obtained from the heads of leeches, has recently 
been introduced to prevent the coagulation of blood, 
and the experiments of A. Bodong {Arch. f. exp. 
Path. u. Pharmak.. Vol. 52, Nos. 3 and 4) prove that 



6oo 



PATHOLOGY AND BACTERIOLOGY. 



[Medical News 



this substance is indeed a great help in physiological 
experiments. Blood which remains fluid owing to 
the addition of hirudin, cannot be made to clot again, 
even if strong styptics, such as chloride of iron, are 
employed. The relation between hirudin and the 
principles which bring about clotting in the blood, 
seems to be a definite one, so that the necessary 
amount may be calculated for every given propor- 
tion of blood. If clotting has once started, the ad- 
dition of hirudin will inhibit the process. Injected 
into animals, hirudin will not materially influence 
circulation or respiration and to.xic symptoms were 
never observed. If 23 milligrams per kilogram 
body-weight are employed, clotting will not occur 
until one hour after injection; with 51 milligrams, 
this period will be lengthened to four hours. The 
excretion occurs chiefly through the kidneys, so that 
the urine of animals treated with hirudin will also 
inhibit clotting. 

Effects on Heart Rate and Blood Pressures of Se- 
vere Hemorrhage and Subsequent Infusion of So- 
dium Bicarbonate. — .As the result of a primary hem- 
orrhage in the dog, the pulse rate is much increased, 
according to P. M. Dawson {Jour, of Exper. Med., 
February 25, 1905). This acceleration depends upon 
the extent of the tonic activity of the vagus at the time 
the bleeding was begun. Secondary hemorrhage is 
followed either by no increase at all, and sometimes 
by a diminution of pulse rate. Hemorrhage causes a 
fall of blood pressure, but the extent of the fall does 
not depend closely upon the amount of blood with- 
drawn. If sodium chloride be infused after severe 
hemorrhage, the immediate effect is an increase of the 
blood pressures, of which the systolic pressure is the 
most nearly restored to normal. If, now, to solutions 
of the chloride an increasing percentage of sodium bi- 
carbonate be added, the rise in the pressures is mark- 
edly increased. The addition of one-half per cent, 
bicarbonate to the chloride causes a maximum rise in 
the blood pressure, which may reach 115 per cent, of 
its original value. One must be cautious in drawing 
inferences with regard to the clinical value of infu- 
sions of sodium bicarbonate. The experiments indi- 
cate that the addition of sodium bicarbonate to the 
infused fluid may be expected to have a beneficial ac- 
tion. In extreme cases of shock due to loss of blood, 
the addition of from one-half to one per cent, of the 
bicarbonate to the soHition of .8 per cent, sodium 
chloride may be of advantage. The rise in all the 
pressures, especially the diastolic pressure, is more 
pronounced than when the pure chloride is used. The 
quantity of fluid required is smaller than is the case 
with the pure chloride, and hence the greater is the 
rapidity with which the solution can be hurried into 
the circulation, a matter of some importance in des- 
perate cases. There is, however, a possibility of over- 
working the heart. The author suggests that in the 
beginning the intravenous infusion should contain bi- 
carbonate, hut later it miglit be omitted. 

Certain Aspects of Experimental Diabetes.— The 
results obtained by Herter in inducing glycosuria by 
means of painting the surface of the pancreas with 
adrenalin have been also obtained by F. P. Under- 
HILL (Amer. Jour. Physiol., February, 1905), who 
painted the pancreas with piperidine. The author 
found that the same results are obtained by painting 
the spleen; by intraperitoneal injection, or by direct 
introduction into the blood. He believes that the ex- 
perimental diabetes is not due to an irritant action 
upon, or an " insult " to, the pancreas. The action of 
piperidine and other drugs in this respect is not spe- 



cific. Glycosuria is provoked by piperidine, potassium 
cyanide, ether, chloroform, morphine, carbon, monox- 
ide, strychnine, pyrogallol, pyrrol, pyridian, coniine, nico- 
tin, curare, etc. A tentative explanation is advanced 
that these drugs produce glycosuria by acting, not in 
the pancreatic cells, but in the respiratory center in 
producing dyspnea. The latter calls forth a marked 
glycosuria without the intervention of drugs. The 
administration of oxygen in the experimental diabetes 
produced by piperidine, inhibits the sugar output. The 
conclusion is reached that experimental diabetes is due 
to diminished oxidation of carbohydrate material; with 
the consequent accumulation of the latter in the blood 
and its elimination by the kidneys. 

The Laws Governing the Chemical Composition of 
Urine. — .\ careful study of twenty-four normal 
urines secreted under dift'erent standards of diet re- 
vealed interesting results to O. Poller {Amcr. Jour. 
Physiol, February, 1905). The distribution of the ni- 
trogen in urine among urea and the other nitrogenous 
constituents depends on the absolute amount of total 
nitrogen present. The distribution of the sulphur 
among the three chief normal representatives — inor- 
ganic sulphates, ethereal sulphates and " neutral " sul- 
phur — depends on the absolute amount of sulphur 
present. The part played by the kreatinine as a factor 
in the relative distribution of the urinary nitrogen is 
of great interest. The absolute quantity of kreatinine 
eliminated in the urine on a meat free diet is a con- 
stant quantity for different individuals, but wholly in- 
dependent of quantitative changes in the total amount 
of nitrogen eliminated. When the total amount of 
protein metabolism is greatly reduced, the absolute 
quantity of uric acid is diminished, hut not nearly in 
proportion to the diminution in the total nitrogen, and 
the per cent, of the uric acid nitrogen in terms of 
the total nitrogen is therefore much increased. With 
pronounced diminution in the protein-metabolism, 
there is usually, but not always, a decrease in the ab- 
solute quantity of ammonia eliminated. Urea is the 
only nitrogenous substance which suffers a relative 
as well as an absolute diminution with a diminution in 
the total protein-metabolism. In ten different cases the 
author was able to reduce the amount of urea 60 per 
cent, of the total nitrogen. The urinary indican is not 
to any extent a product of the general protein-metabo- 
lism, is therefore probably, as is generally supposed a 
product of intestinal putrefaction, and may consequent- 
ly be assumed to indicate approximately the degree of 
putrefaction in the intestinal tract. The ethereal sul- 
phates can only in part be due to intestinal putrefac- 
tion, but they represnt. on the contrary, a form 
of sulphur metabolism which becomes more prominent 
when the food contains little or no protein. The vol- 
ume of urine eliminated depends directly upon the 
amount of water consumed. The greatest volumes of 
urine frequently occur on days when the body gains 
in weight. The volume of urine eliminated in normal 
persons is largely a personal peculiarity, and is probably 
to a great extent inversely in proportion to the amount 
given off through the pores of the skin 

PATHOLOGY AND BACTERIOLOGY. 

Pathology of Gout. — In two cases of gout that 
had died owing to a chronic interstitial nephritis, F. 
RosF.NBACn iVirchow's Archiv, Vol. 179, No. 2) foinid 
the characteristic changes of gout, namely necrotic 
areas with deposits of crystals of uric acid, in the bone 
and bone-marrow as well as in the usual sites. In 
the bone a disintegration of ground-substance was 
found, which can only be a result of the chemical action 



April i, 1905] 



MEDICAL 'PROGRESS: THERAPEUTICS. 



601 



of the acid; the bone-marrow on the other hand shows 
a proHferation of dense fibrous tissue which was infil- 
trate with lymphocytes and giant-cells. It is probable 
that even in the usual locations, the necroses are the 
real and primary lesions and are not the manifestations 
of atrophy secondary to the deposit of the crystals. 

Treatment of Night-Sweats. — One of the most 
disagreeable symptoms of early pulmonary tuberculosis 
is nocturnal perspiration, since it robs the patients of 
sleep and weakens them considerably. The cause of 
these night-sweats is not known, but they are probably 
a result of the action of the toxins of the tubercle 
bacillus on the central nervous system. According to 
H. Ulrici {Thcrat>. Monatshft., December, 1904) the 
treatment is very unsatisfactory and hence the number 
of drugs recommended, legion. Antipyretics and 
atropine have been warmly recommended but the for- 
mer very often aggravate the condition while a toler- 
ance is very soon established for the latter. Agaricin 
is very uncertain in its action and may cause diarrhea 
and the same applies to camphoric acid and its com- 
pounds. The author has invariably seen the best re- 
sults after the use of veronal in doses of 0.3 grm., 
rarely increased to 0.6 grm. In conjunction with this, 
the patient should sleep in a cool room with open win- 
dow and use one of the many dusting-powders recom- 
mended. 

Effect of Altitude on the Blood. — In order to 
study the effects of a high altitude on the blood, K. 
BiJRKER (Miinch. med. Woch., February 7, 1905) 
analyzed the amount of iron contained in the organs 
of animals in the mountains as compared with control 
animals. Even after a short stay in the mountains, a 
marked reaction is noticed since both liver and blood 
soon become rich in iron. Probably reserve depots 
are opened and more hemoglobin is passed into the 
blood; since this is used up more rapidly, more iron 
will be deposited in the liver. After the second or 
third week the hemopoetic apparatus will cease its 
overproduction and the liver will now give up its iron 
to the blood. As a result, the iron contents of the 
blood will gradually increase, while those of the liver 
will first rise and then fall. This observation is in 
perfect accord with the result of blood-counts made 
at high altitudes. The chief stimulant is probably the 
rarefied air, but it is also likely that radio-activity, 
which is present to a marked degree in the mountains, 
plays a prominent part. 

Eosinophilia in Anchylostomiasis. — In 500 cases of 
. anchylostomiasis e.xamined by H. Bruns, D. Liefm.\n" 
and V. Makel {Miinch. mcd. Woch., February 7, 1905), 
an increase of eosinophiles over five per cent, was 
found in 92.1 per cent. In only rare instances more 
than 20 per cent, were found and in one case 42 per 
cent, were counted. The blood was obtained from 
miners who had eggs in the stools and from such who 
were supposed to be cured and whose feces were no 
longer infected. There does not seem to be any defin- 
ite relation between the degree of infection and the 
number of eosinophile leucocytes in the blood and it is 
probable that a high percentage of the latter persist 
half to one year after all worms are e.xpelled. The 
examination of the feces is preferable to the blood 
examination since it is more rapid where a large num- 
ber of individuals is concerned and since it will not 
include among the positive cases those who are already 
cured. The blood examination is, however, of value in 
detecting deception ; thus, if many eosinophiles are found 
and the repeated examination of the feces is negative, 
the stool should be voided in the presence of a respon- 
sible person. Where no eggs are found in a very sus- 



picious case, the entire stool may be placed in the in- 
cubator for several days to permit the larvs to develop. 
Ultramicroscopic Examinations. — Further examin- 
ations have convinced L. Mich.aelis {Virchow's 
Archiv, Vol. 179, No. 2) that various dyes behave dif- 
ferently when examined with the new ultramicroscope. 
Thus, fluorescent solutions never show the presence 
of small particles no matter how high the magnification, 
while the very opposite holds with the sulfo-acids 
with large molecules (indulin, aniline blue, etc.). An 
intermediate position is occupied by fuchsin, picric 
acid, etc. ; that is, numerous particles are seen but 
the great majority are too small to give separate im- 
pressions. It seems that those dyes which are held in 
finest suspension possess an elective action to either 
nucleus or protoplasm while those in coarsest suspen- 
sion stain more diffusely. The instrument is hardly 
applicable for the study of stained specimens since all 
solid particles are surrounded by rings of colored light 
which makes their identification difficult. In blood 
films the author has, however, been able to see very 
small basophile granulations which could not be identi- 
fied with the usual methods. .-Mbumin in solution 
behaves like fuchsin, that is, a portion appears in the 
form of fine granules while another portion is not ren- 
dered visible by even intense focal illumination. It is 
for this reason that quantitative estimations of albumin 
are not reliable if conducted with the ultramicroscope, 
as has been recommended. The character of the solu- 
tion in which the albumin is suspended is also of im- 
portance. Thus, with distilled water more particles 
will be visible than' with physiological salt solution, 
even if the concentration of the albumin is exactly the 
same. 

Origin of Acute Miliary Tuberculosis. — All the 
autopsy records of four years were carefully investi- 
gated by H. SiLBERGLEiT {Vircho'u's Archiv, Vol. 179, 
No. 2) in order to decide how a local tuberculous pro- 
cess generally becomes disseminated. In 95 per cent, 
of the cases tubercles of the vessels or of the thoracic 
duct were found which had permitted the bacilli to 
gain the blood-stream. It is well known that Rippert 
strongly opposes this theory since he has frequently 
hunted in vain for tubercles large enough in the walls 
of the vessels in his cases, to account for the large 
number of metastatic deposits in the body. Further- 
more, he states that the focus is not always ulcerated 
and that the different size of the tubercles especially in 
the lung argues for a different age. It seems more 
probable to him that an active proliferation occurs into 
the capillaries and that the blood is constantly con- 
taminated from this source. The author states how- 
ever that the capillary focus is generally inadequate 
and that it is often present even where there is no 
miliary tuberculosis. The unequal size of the tubercles 
is due to the fact that the same number of bacilli is 
not transported to all parts of the body and that differ- 
ent tissues do not permit an equal development. 

THERAPEUTICS. 
Serumtherapy of Pneumonia. — The antipneumonia 
serum of Romer was originally intended for the 
treatment of ulcus serpens, w-hich is usually caused 
by pneumococci. The serum is polyvalent in two 
senses, in that it is a mixture of the sera of different 
animals, treated with different strands of cocci, 
pathogenic to man. H. Passler (Dentsch. Arch. f. 
klin. Med., Vol. 82, Nos 3 and 4) has tried it in 
24 cases of lobar pneumonia and reports as follows: 
One to six doses were injected, varying from 10 to 
30 c.c. ; the largest total amount employed was no 



6o2 



PRESCRIPTION HINTS. 



[Medical News 



c.c. An injurious action was never seen. An im- 
provement in the general condition was almost al- 
ways observed directly after the injection and the 
temperature generally dropped after six to twelve 
hours. A migration of the process was not com- 
mon, but the serum never retarded the consolidation 
in the affected lobe. A pronounced symptom was 
the remarkable improvement in circulation: when 
pallor, cyanosis and feeble heart-sounds were pres- 
ent, the serum frequently restored normal cardiac 
action. Pleural complications were present in a 
few cases, but never assumed marked proportions. 
The number of leucocytes usually remained un- 
altered before and after injection. Pneumococci 
could be grown from the blood in six cases; of those, 
three died and three recovered. Altogether, the dis- 
ease was fatal in four cases. The author believes 
that the serum undoubtedly affects the pneumonic 
process, for complications are less frequent and the 
crisis seems to appear earlier. He concludes by 
stating that its use is not indicated in all cases since 
it is too expensive and there is no advantage in 
giving it early. In severe cases a trial is however in 
place, especially if the germs can be recovered from 
the blood or if the hyperleucocytosis changes to 
hypoleucocytosis. A diminished, vital resistance, 
such as is found in the aged, in alcoholics or in those 
suffering from cardiac failure, is also an indication. 
In threatening cardiac paralysis and pulmonary 
edema, the serum may do more good than any other 
form of medication. If the first injection is without 
effect, little is to be expected from a second, but 
improvement, even if only temporary, will call for 
a repetition. 

The Limitation of the Value of Nitroglycerin as a 
Therapeutic Agent. — H. P. Loomis (Med. Rec, 
March i8, 1905) has tested the effect of this drug on 
arterial pressure in patients by means of the sphygmo- 
manometer, and also in animals, and finds that high 
arterial pressure in man is not perceptibly affected 
by it nor is dilatation of the blood-vessels apparent. 
Some of the conclusions reached are as follows: The 
usual dose of nitroglycerin of i-ioo grain is too small 
to produce any effect in pathological conditions ; 1-50 
grain is a minimum dose. It is a perfectly safe drug 
to use. Even in large and repeated doses the author 
has never seen any ill-effects. Its effects are very 
transient, as shown by the experiments on the dogs, 
and the ordinary dose of i-loo grain every four hours 
could not possibly have any effect on the arteries. 
Nitroglycerin is said to increase the quantity of urine 
in chronic Bright's disease, but after keeping accurate 
records of the daily amount of urine passed, the author 
was never able to satisfy himself that any increase 
seen was due to this drug. In conditions due to arterial 
spasms, so-called, such as angina pectoris, migraine, 
asthma, nitroglycerin may be of benefit, in full doses 
often repeated, but not in arterial sclerosis where the 
arteries themselves are more or less changed. 

Pyramidon in Tuberculosis. — The fever of consump- 
tives is managed as follows by R. Schulz (Zcitsch. 
f. Krankenpflegc, November, 1904) : As soon as 
the patient reaches the hospital he is put to bed. 
If the fever does not disappear spontaneously after 
five to six days, he receives 5 grains of pyramidon 
in half a glass of water, which he is instructed to 
swallow slowly during half an hour after his midday 
meal. If effective, the dose may be diminished after 
several days, while sometimes it may be necessary 
to give more. With inverse type of fever, the drug 
must be administered during the early morning 



hours. Bad after-effects are rare and never amoimt 
to more than urticaria, profuse perspiration or dark- 
ened urine. A marked improvement will be noticed 
in the condition of the patients as soon as the fever 
has disappeared; they will increase in weight rapidly 
and the process in the lungs will tend to recede. 

Toxicity of Cresols. — With a number of animals 
Urogs, mice, rabbits, cats) examined by K. Tollens 
{Arch. f. exp. Path. u. PJiarmak., Vol. 52, Nos. 3 and 
4), the three isomeric cresols behaved differently. 
Paracreso! is decidedly more poisonous than car- 
bolic acid for both carniverous and herbiverous 
warm-blooded animals ; orthocresol is equally as 
to.xic as carbolic acid but metacresol is less toxic. 
In frogs, however, all three cresols are less toxic. 
A number of crude and saponified samples of cresol 
on the market were also examined. Contrary to 
the usual statements, they gave rise to the same 
symptoms in about the same dosage as carbolic 
acid and some of the crude samples even exceeded 
the latter in toxicity. The presence of soap does 
not seem to diminish the intensity of action and the 
same is true for carbolic acid for the latter plus 
soap, introduced into the stomach of an animal, kills 
just as rapidly as carbolic acid alone. 

Hermetine, a New Antiseptic. — The beneficial ef- 
fects of sea-bathing may in some cases be due to 
active therapeutic properties of the water. M. 
Legourd {Rcpcrt. dc Tlierap., February, 1905), in 
the gj'necological service of Dr. Lebloud at Saint- 
Lazare, calls attention to the new and powerful an- 
tiseptic, hermetin. This is merelj' sea-water which 
has undergone electrolysis. It contains oxygenated 
compounds of chlorine in a nascent state. It is 
non-toxic, neutral, and from the viewpoint of its 
large content in chlorine, it is not to be distinguished 
from Labarraque's solution. The author reports 
favorable results from the use of this antiseptic in 
affections of the vulva, vagina and uterus. 



PRESCRIPTION HINTS. 

Treatment of Acute Coryza. — 

R Phenic acid 5i 

Liq. ammonia 3i 

Proof spirits 5ii 

Water 3iv 

Pour 20 drops on blotting paper and breathe the va- 
pors through tlie no.se everv hour. 

Or 

R Boric acid 5i 

Menthol grs. x 

Cocaine grs. v 

Proof spirit 1Tl,v 

Talc powder .''ii 

To be used as snuff. 

R Iodide of sodium .3i 

Syrup of bitter orange 3i 

.Syrup of lemons Ji 

Water 5vi 

.•\ talilcspofinful three times a d:iy in milk. 

Bronchial Asthma with Emphysema. — 

R Euquina' gr. v 

.'\tro|). sulph gr. Vix 

Dionini gr. V« 

Dr. tal. doses No. xii. Sig. : i powder three time-- 
a day. 

R lodipini 5 iii 

01. menth. pip gtts. v 

Sig.: Teaspoonful three times a day. — Bjorkman. 



April i, 1905] 



EDITORIAL. 



603 



Xhe Medical News. 

A WEEKL V JOURNAL 
OF MEDICAL SCIENCE. 



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SATURDAY, APRIL i, 1905. 

ANTIVIVISECTION. 

The New England Antivivisection Society, 
like other " antis " which might be named, ap- 
pears to be drawing its last useless breaths, and 
that without the use of any anesthetic (even 
curare), strange as it may seem. It, or at least 
its activity, so baneful to human and animal 
weal, seems to be exhausted. This is mainly 
because its diet of misrepresentation and of 
zoophilistic hysteria no longer nourishes in the 
atmosphere of public and legislative opinion 
which begins, at last, really to understand that 
the physicians and physiologists of Massachusetts 
are not criminals, hul rather ill-paid benefactijrs 
to mankind. 

At the hearing of the seventh or eighth pro- 
posed antivivisection bill on March 7 and 8 
before the Committee of Probate and Chan- 
cery of the Massachusetts Legislature, M. W. 
Green, the president of the society, was not 
present, nor was the obvious high-priestess of 
the movement. Airs. Ward, although the latter 
sent her usual contribution to the antivivisec- 
tional literature, and it was read by an unin- 
formed clergyman, with the usual benefits to the 
cause of animal experimentation. Then, as al- 
ways, emotion failed to fill the yawning chasm 



which the lack of facts revealed. The same old 
recital of statements as to things which perhaps 
took place in Europe forty or fifty or sixty years 
ago, before the discovery of anesthetics, was lis- 
tened to — respectfully almost, and one heard of 
fancied cruelties which would make the spirit of 
Tilierius Csesar groan with pity, and to the un- 
supported but oft-repeated assertion that these 
things were taking place to-day in the labora- 
tories of Harvard University and of Tufts Col- 
lege, under the oversight of men like President 
Eliot and the late President Capen. Yet no sin- 
gle instance of any cruelty in the colleges of 
Massachusetts or of America was shown. Dr. 
Leffingwell came up from New York apparently 
to say that he had, many years ago, when 
younger, done experiments on animals himself, 
and that to-day cruelty was rampant. Ex-Gov- 
ernor Brackett said that he had never seen any 
animal experimentation himself, but that he un- 
derstood that the medical profession, in its 
researches on animals, was unspeakably cruel. 
The editor of the Transcript spoke feelingly of 
Professor Osier's famous joke and remarks, and 
used them as a basis for supposing the existence 
of cruelty in experiments on animals. And so 
for nearly three hours the committee of eleven 
lawyers were entertained. 

The next day for three hours this committee 
heard the other side, and they heard facts and 
not stale and long-refuted suspicions, science and 
not mere hysterical sentiment. The prominent 
surgeons, the hospital superintendents, the State 
boards of health and of cattle commissioners, 
nearl}- all the city and town boards of health in 
the State, practically all the colleges, practitioners 
— all these told them so much of accomplished 
fact and future promise from animal experimen- 
tation that it made an impression. One or two 
members of the conunittee who came with anti 
feelings went to luncheon with a sort of respect 
even for a physician who was a vivisector, and a 
few days after helped to swell the majority 
against a favorable reporting of the bill. Thus 
it was that the committee, by a vote of nine to 
two, reported the usual " leave to withdraw." 
and the two said not a word. 

The fund which it is reported has been given to 
earn.- on the agitation continually, will likely 
enough insure a further officious effort on the 
part of Lawyer French next spring, but the soul 
of the movement probably is dead, killed by 
facts and common sense. Soon the Great and 



6o4 



EDITORIAL. 



[Medical News 



General Court of Massachusetts (the ancient 
name for the legislature) will come to think of 
the annual antivivisection spasm as a necessary 
movement — until the fund shall fail. Then no 
longer will it be annually claimed, even before a 
dozen citizens, that the hospitals, boards of health, 
and universities of the old Bay State are crimi- 
nal because of inhuman cruelties, when in fact 
these institutions owe their very existence to 
philanthropy and to real philozoism — to which 
indeed each continually ministers, as even a busy 
public appreciates. 



THE NEXT NOBEL AWARDS. 

Americans are usually said not to miss oppor- 
tunities nor to fail to try for the prizes that ma\ 
possibly come their way. There can scarcely fail to 
be the impression among those who realize the 
conditions that obtain in the matter of the Nobel 
])rizes ; for, as was suggested some time ago by 
the Journal of the American Medical Association, 
the medical profession of this country seems to be 
neglecting precious opportunities. These prizes, 
amounting to $40,000 each, five in all, are awarded 
each year for the best work in physics, in chem- 
istry, in medicine, in literature, and, curiously 
enough, since their founder made his fortune in 
the manufacture of high explosives, for the best 
work for the promotion of peace. So far not one 
of these prizes, though the awards have been 
made some three times altogether, has come to 
America. In medicine there are surely features 
of successful investigation that would deserve 
recognition even in such an international compe- 
tition. 

It must be remembered that it is entirely to 
.American initiative that we owe the present state 
of our knowledge of appendicitis, one of the 
most important problems that any generation has 
had to face in medicine. Even more striking than 
that, however, is the American solution of the 
yellow-fever problem. This work was accom- 
plished under the typical conditions for which 
the Nobel prizes are meant by their founder to be 
awarded. Only too often, here in America, scien- 
tific investigation, though this is less true in medi- 
cine than other fields, is carried on entirely with 
the idea of the pecuniary benefit that may be 
reaped from it. There was none at all of this in 
the yellow-fever work, and it was successfully 
carried through amid the most unselfish exposure 
of themselves to sickness and death on the part 
of the investigators. Probably no medical dis- 



coveries made in our generation will save more 
lives and suflfering than the results arrived at by 
the American medical men who solved the prob- 
lem of Cuba's more than a century old scourge. 
Already we can point to years of freedom from 
the disease and a complete sense of security that 
replaces the unavailing terror of the past. 

For the award of the Nobel prizes the names 
of those deemed worthy of the consideration of 
the committee must be presented by some scien- 
tific association or University. It has been sug- 
gested that the American Medical Association 
might take up this work, but in the present stress 
of business, due to modification of status and 
reorganization, such a work is likely to be 
delayed or neglected. It would seem more espe- 
cially the duty of a select body, like the .Ameri- 
can Physicians, or of the American Association 
for the Advancement of Science, to take up the 
work of preparing the report to be made to the 
Nobel Prize Committee. This matter should not 
be longer neglected, for it seems too bad that 
America should not claim and obtain her place 
among the nations of the earth as a great scien- 
tific benefactor. The presentation of the report 
will be an easy matter now, and the rewards will 
come to those who so bravely did the work, 
though one of them is already beyond earthly 
reward, and time may further render the award 
abortive. This matter deserves to be taken up 
now. 



NITROGENODS METABOLISM. 

In a recent editorial we have called attention 
to the influence which modern research has had 
in modifying the older concepts of the process of 
albuminous digestion, and have pointed out that 
there is good evidence to show that albuminous 
.synthesis may take place beyond the intestinal 
barrier, and possibly in the tissues of the body at 
large, from substances which are much less com- 
|)lex in composition than the albumoses. Granted 
that this may be the case, it would almost follow 
as a matter of necessity that our concept of the 
process of nitrogenous metabolism also would 
have to be modified accordingly. 

Two notable hypotheses regarding this subject 
have been brought forth since the time of Liebig. 
of which one was formulated by Voit, and the 
other by Pfliiger. Both views are based essen- 
tially upon the assumption of an absorption of 
albumins from the gastro-intestinal tract, and 
the existence of such "circulating" albumin, in 



April i, 1905] 



EDITORIAL. 



60s 



contradistinction to that which is built up in the 
form of ceUular protoplasm, Voit's "organized" 
albumin. According to Voit, then, the circulating 
albumin, when present in excess of a certain 
more or less fixed normal, is catabolized by the 
cellular elements of the body, but without first 
becoming an integral part of the latter. With 
Pfliiger, on the other hand, the circulating albu- 
min is largely catabolized after being transformed 
into bioplasm, i.e., after having become an integ- 
ral component of the living tissue. 

Both doctrines have proven very useful as 
working hypotheses, but it can scarcely be said 
that either satisfactorily explains all the observed 
facts. Objections have been repeatedly raised 
against both, but until recently no substitute had 
been offered that could seriously be considered a 
rival. It seems to us, however, that Folin's 
recently promulgated theory of protein metabo- 
lism, and his researches which form the experi- 
mental basis of his theoretical deductions mark 
a distinct epoch in the history of the subject. 
Folin shows quite conclusively that there must be 
two forms of albuminous metabolism ; one, which 
tends to be constant ; and a second form, which 
is variable. The first represents the tissue or 
cellular metabolism proper — the endogenous 
form, while the second or e.vogenoiis type is 
intermediate. 

At first sight these two forms seem to repre- 
sent the older hypotheses of Pfliiger and Voit, 
but as a matter of fact there is a wide difference. 
Voit and Pfliiger thus both assume that albu- 
minous catabolism takes place in the same tissues 
and by means of chemical processes quite similar 
to those which affect the decomposition of fats 
and carbohydrates. In other words, albuminous 
catabolism is regarded essentially as an oxidation, 
and the greatest amount of albuminous catab- 
olism is supposed to take place, where the great- 
est amount of oxidation occurs, viz., in the 
muscles. Folin points out, however, that the 
albuminous nitrogen exists in the form of amido 
or imido groups, which can be very readily 
removed by hydrolysis, more readily in fact than 
by oxidation. From this standpoint, therefore, 
there is no necessity for assuming that the nitro- 
gen catabolism occurs by the same method or in 
the same tissues as the carbohydrate and fat catab- 
olism. There is strong additional evidence fur- 
ther to show that in all probability the catabo- 
lism of the exogenous nitrogen does not occur in 
the muscles at all, or if so, only to a very slight 



extent. Urea is only found in the muscles in 
traces, and other possible precursors of the sub- 
stance, barring kreatin, are not present in quan- 
tities which could be considered as at all adequate 
to account for the amounts found in the urine. 
Kreatin, however, is not converted into urea in 
the liver, where according to generally accepted 
views the formation of urea largely takes place. 

We are thus forced to look elsewhere for the 
antecedents of most of the urea occurring in the 
urine. It is known that during albuminous diges- 
tion ammonia is liberated through the action of 
the proteolytic ferments, and Nencki has shown 
that this portion is not utilized in the reconstruc- 
tion of the albuminous molecule, since the blood 
coming from the intestines at the height of diges- 
tion contains two or three times as much 
ammonia as the blood beyond the liver. Folin 
draws the inference that the greater amount of 
albumin by far, after having been hydrolyzed to 
comparatively simple units, looses its nitrogen — 
largely in the liver — and that the non-nitroge- 
nous residue is then transported in part to the 
different tissues and at once supplies material for 
oxidation, wherever needed, while another por- 
tion is converted into fats, or at least into car- 
bohydrates, and then becomes subject to the laws 
governing the catabolism of these two groups of 
food products. That oxidation processes are 
probably at work in the transformation of the 
non-nitrogenous residue into carbohydrates can- 
not be doubted, but the removal of the nitrogen 
from the amido acids resulting on proteolytic 
digestion certainly demands no oxidation. 

This in brief is an outline of Folin's recently 
proposed theory of protein metabolism, so far as 
the exogenous nitrogenous catabolism goes. 
Regarding the corresponding endogenous pro- 
cesses, in the muscle tissue at least, his researches 
seem to show conclusively that the catabolic proc- 
esses here end with the formation of kreatin and 
its elimination in the urine as kreatinin. Kreatin 
is thus at once brought into a prominent position 
among the products of albuminous catabolism, 
while heretofore very little was known of its 
significance. 

Folin's theory, in our judgment, is more in 
accord with known facts in animal metabolism 
than the older hypotheses of Pfliiger and Voit, 
and bids fair to lead to far-reaching theoretical 
as well as practical conclusions. It readily ex- 
plains the persistent tendency on the part of the 
organism to maintain nitrogenous equilibrium, 



6o6 



ECHOES AND NEWS: NEW YORK. 



[Medical News- 



even when this involves the formation of ex- 
cessive quantities of urea. All living protoplasm, 
according to Folin, is suspended in a fluid rich 
in albumins, and on account of the habitual use 
of more nitrogenous food than the tissues can 
use as albumins the organism is ordinarily in 
possession of approximately the maximum 
amount of reserve albumin in solution that it can 
advantageously retain. When the supply of 
food albumin is stopped, excess of reserve albu- 
min inside the organism is still sufficient to cause 
a rather large destruction of albumin during the 
first day or two of albuminous starvation. After 
that the albuminous catabolism is very small, 
providing that a sufficient amount of non-nitrog- 
enous food is available. But even then and for 
many days to follow the cellular protoplasm has 
still an abundant supply of albumins in solution, 
and the normal activity of such tissues as the 
muscles is not at all impaired or diminished. 
When 30 to 40 grms. of nitrogen have been lost 
by a healthy adult during a week or more of 
abstinence from nitrogenous food the living 
muscle tissues are still well supplied with all the 
albumins that they can use. This is indicated 
not only by the unchanged kreatinin elimination, 
but also by the fact that there is no special feel- 
ing of fatigue or inability to do our customary 
work. Because the organism at the end of such 
an experiment still has an abundance of avail- 
able albumins in the nutritive fluids, it is at once 
seemingly wasteful with nitrogen when nitrog- 
enous food is again ingested. This is why it 
only gradually, and only under the prolonged 
pressure of an excessive supply of food albumin, 
again acquires its original maximum store of 
this material. 

This interpretation of nitrogenous equilibrium 
constitutes a strong reason why the so-called 
standard diets are unnecessarily rich in albumins, 
and opens up new avenues of research on the 
subject of nitrogenous food consumption both 
in health and disease. 



ECHOES AND NEWS. 



NEW YORK. 

The Theory of Evolution.— The New York Phar- 
macal Association has had prepared an attractive 
panel on this subject, which may be had on applica- 
tion. 

Eastern Medical Society. — The Eastern Medical 
Society held a concert and ball last Tuesday, March 
28, 1905, at Terrace Garden. It was a marked suc- 
cess. 



Percentages of Hospital Appointments. — In rela- 
tion to a recent editorial in the Medical News, which 
stated that only 50 per cent, of medical graduates 
secure hospitals, it is interesting to note the per- 
centages from the College of Physicians and Sur- 
geons. In 1901 that institution placed 70 per cent, 
of its graduating class; in 1902 69 per cent.; in 1903. 
64 per cent.; and in 1904 71 per cent. The number 
in each class who do not try the hospital examina- 
tions is about 15 per cent., leaving only 15 per cent, 
who are unsuccessful. 

Society of the Medical Inspectors of the City of 
New York. — Stated meeting of the above society 
will be held on Tuesday, April 4, 1905 at 8.30 p.m. 
sharp, at the Chemists' Club. 108 West Fifty-fifth 
street, Manhattan. Order of business is as follows: 
I. E.xecutive session; II. Addresses by the Honorary 
Members of the Society: Thomas Darlington, M.D., 
Commissioner of Health; Hermann M. Biggs, M.D., 
Medical Officer; Walter Bensel, M.D., Assistant 
Sanitary Superintendent; John J. Cronin, M.D., As- 
sistant Chief Inspector. III. Collation, 

Recent Hospital Appointments. — The foljowing 
men in the class of 1905 at the College of Physicians 
and Surgeons have been appointed to hospital in- 
terneships: Rochester General, C. D. DriscoU; Mt. 
Sinai, first, H. M. Hays, J. C. A. Gerster, H. Neu- 
hof, A. R, Chamberlain, L. C. Kampfer, W. J. Hei- 
mann, R. W. Pettit, J. Wansansky. Appointed as ex- 
ternes: R. M. Ottenberg, I. Rubin, A. E. Jaffin. 
Bellevue, first, R. R. Ryan, J. C. Mabey, G. B. Emory. 
The remaining three places were filled by Cornell 
men. St. Catharine's, S. E. Ryan; Brooklyn City, first, 
J. A. Bennett, W. S. Smith, M. D. Prentiss, J. J. 
Valentine. 

Ground Broken for Manhattan Eye and Ear In- 
stitution. — Ground for the new Manhattan Eye, Ear 
and Throat Hospital was broken last week with ap- 
propriate exercises. The new building will be on 
the south side of East Sixty-fourth Street, between 
Second and Third avenues. The hospital is now at 
Park .''ivenue and Forty-first Street. Mrs. C. R. 
Agnew, widow of Dr. Cornelius R. Agnew, removed 
the first shovelful of earth. John Sinclair, President 
of the hospital, presided. Dr. Andrew H. Smith re- 
viewed the history of the institution, and the Rev. 
Dr. Stephenson, of the Fifth Avenue Presbyterian 
Church, offered prayer. 

Mount Sinai Buys Land. — The Mount Sinai Hos- 
pital has bought ;i plot of nearly eight lots on the 
south side of One Hundredth Street, directly oppo- 
site the hospital buildings which occupy the block bound- 
ed by Fifth and Madison avenues and One Hundred 
and First streets. Isaac Wallach, President of the 
Mount Sinai Hospital, said that the property had 
not been acquired with any view of adding imme- 
diately to the hospital's buildings, but that the Trus- 
tees had thought it advisable to secure the lots 
and hold them in reserve against the future needs of 
the institution. The lots had not been bought, Mr. 
Wallach said, as the result of any particular gift 
to the hospital, but added that a number of dona- 
tions since the last annual report was published had 
made possible the purchase out of the general fund 
of the institution. 

Charities Directory. — The growth of a new line of 
charitable activity is shown in the addition of a 
chapter to the 1905 edition of the Charities Directory 
published by the Charity Organization Society. This 
new chapter gives information of organizations 
which send nurses to the homes of needy persons,. 



Al'KIL I, 1905] 



ECHOES AND NEWS: NEW YORK. 



607 



as distinct from the nursing of the poor in hospitals, 
convalescent homes, fresh-air cottages and other in- 
stitutions. There are twenty-five titles in the chap- 
ter, showing a wide variety of societies which send 
visiting nurses into the tenements. A large number 
of them are religious in character, but some- of the 
large general societies have added visiting nurses to 
their staff of employees, and the Department of 
Health is sending nurses to the homes of consump- 
tives to care for them and teach them means for 
preventing the spread of the disease to their families 
and neighbors. The Charity Organization Society 
movement shows a steady growth. Since the 1904 
Directory was published about twenty new societies 
have been added to the roster of such organizations 
in the United States, making igo in all, and the relief 
societies listed in Europe and Australia now total 
210. Canada has seven. The Directory contains 
2,000 names of societies, institutions and other char- 
itable organizations in Manhattan Borough, about 
half as many in Brooklyn, and nearly one hundred 
in Queens. The entries include a brief description 
of the work of the organization named, how and 
where and from whom to secure its services, and 
the names of officers and executive employees. The 
book contains 675 pages. Published by the Charity 
Organization Society, 105 East Twenty-second 
Street, New York, in cloth, $1, postpaid. 

Hospitals in Straits. — That the private hospitals 
of New York are confronted by very serious' finan- 
cial difficulties, which must be remedied, was the con- 
sensus of opinion at a conference of hospital repre- 
sentatives held last week in the United Charities 
building. The conference, which was called by the 
Association for Improving the Condition of the 
Poor, was attended by representatives of every 
large hospital in the city and many of the smaller 
institutions. All admitted the gravity of the situ- 
ation as shown by constantly increasing deficits in 
some of the hospital reports. The hospital situa- 
tion which led to the calling of last week's confer- 
ence was first brought to notice a year ago by Frank 
Tucker, in an article in Charities. Since then, it was 
said, the problem has grown worse instead of bet- 
ter. R. Fulton Cuting, chairman, said, in opening 
the meeting, that it had become so serious that the 
interests of the poor were gravely menaced. "' One 
after another the hospitals are reporting enormous 
indebtedness," said Mr. Cutting. "Why is it? This 
city is the most generous in the world and its hos- 
pitals are the equal of any. What is the reason 
that the hospitals, which should appeal to the people 
more than all other charities, are supported insuffi- 
ciently? " Mr. Cutting said he believed it was be- 
cause the matter had not been brought properly before 
the public. He suggested a uniform system of account- 
ing, so that the hospitals could compare notes of ex- 
penses and the formation of a committee to gather 
information and bring the public to a sense of the 
situation. , 

Mr. Tucker, who has been investigating the con- 
dition of the hospitals, said that of ten suggestions 
made by representatives of the hospitals whose 
views had been asked, that of educating the public 
to give more was the only one really fundamental. He 
advocated the creation of an independent body of 
men or women, chosen for their knowledge of social 
conditions, who should gather the facts about exist- 
ing conditions, secure the adoption of a uniform sys- 
tem of hospital reports and educate the public on 
its responsibility for hospital maintenance accord- 



ing to the best standards of medical and surgical 
science. He suggested that the cost per capita, 
which each hospital now has a different way of 
computing, should be figured out by an independent 
body and given to the public. The public, he said, 
had an idea that $5,000 was enough to endow a bed, 
whereas $20,000 was really needed to-day. Oakleigh 
Thorne, Treasurer of the Presbyterian Hospital, 
suggested monthly reports from each hospital. Isaac 
Wallach, of Mount Sinai Hospital, suggested that 
each hospital have a roll of members, such as Mount 
-Sinai has, each of whom is pledged to give annually 
from $10 up, and who should have the right to vote 
for officers and thus have an interest in the hospital. 
This plan, he said, yielded an annual income of $120,- 
000 to Mount Sinai. Another suggestion made by 
Mr. Wallach, which seemed to meet with great ap- 
proval, was that the city should subsidize the hos- 
pitals in proportion to the amount each hospital 
contributed to the support of the sick. " I believe," 
said he, "' that the city is not helping the hospitals 
as it should by the per capita per diem system as at 
present." 

Dr. John W. Brannan, president of the trustees of 
Bellevue and allied hospitals, said less money would 
be needed if the waste in hospitals was stopped. 
This was the fault of the American system. In the 
German hospitals, where physicians and nurses were 
paid, attention was given to details of administra- 
tion and economy by every one in a hospital. " In 
our hospitals," said Dr. Brannan, " our house staffs 
no sooner become experienced than they leave. The 
nurses are not paid anything, either, and are shifted 
about. This is all right from the standpoint of the 
nurses, but not for the public. The hospital is the 
only American institution which has not come under 
the modern methods of bookkeeping for finding out 
where every cent goes." 

Dr. Brannan pointed out that the plentiful sup- 
plies of bandages and dressings encouraged in hos- 
pitals waste unknown in private practice. " Less 
waste and you'll get more money from the people," 
he observed in closing. Other representatives were 
in favor of the hospitals combining to make a de- 
mand on the city for a greater allowance for pa- 
tients, the amount now paid, 60 cents for a medical 
patient and 80 cents for a surgical case per day, 
being, it was declared, ridiculously low as compared 
with the per capita case of the different hospitals. 
It was resolved that Mr. Cutting should name a 
committee of twelve to study existing hospital con- 
ditions, consider the suggestions made, and report a 
practical scheme of improvement at another meeting. 

A Measure to be Repressed. — The medical profes- 
sion must act as the osteopathic bill has been reported 
favorably by the Senate Committee on Judicary — con- 
sisting of Edgar T. Brackett, chairman, of Saratoga 
Springs ; George A. Davis, of Buffalo ; Nathaniel A. 
Elsberg, of New York; William W. Armstrong, of 
Rochester ; Jotham P. Allds, of Norwich ; Spencer K. 
Warnick, of Amsterdam ; Merton E. Lewis, of Roches- 
ter; George H. Cobb, of Watertown ; Alfred R. Page, 
of New York ; John Raines, of Canandaigua ; Patrick 
H. McCarren, of Brooklyn ; Jacob Marks, of New 
York, and Thomas T. Grady, of New York. 

Dr. E. Eliot Harris, chairman of the Committee on 
Legislation, calls the attention of the medical profession 
of this State to a bill introduced in the Legislature by 
Senator Davis, of Buffalo, entitled an " Act Regulating 
the Practice of Osteopathy in the State of New York," 
and asks that the members of the Senate and Assembly 



6o8 



ECHOES AND NEWS: PHILADELPHIA. 



[Medical News 



be petitioned in the interest of individual and public 
health to defeat the osteopathic bill for the following 
reasons : 

To summarize the objections to the osteopathic bill : 
First. Osteopathy, so-called, is an agent or method 
used in the treatment of disease, and is included in the 
general practice of medicine. 

Second. Osteopathy should not be made a special 
branch of medicine by an act of the legislature, but 
should come under the present State laws, which govern 
all the .special branches as well as the general practice 
of medicine. Any licensed physician has now the right 
to practice osteopathy as a specialty. 

Third. The legislature should protect the public by 
denying the endorsement of the State to any person, 
as being capable of treating the diseases of the human 
body, unless such person can make a diagnosis of the 
condition of the human body, to do which requires a 
full knowledge of the science of medicine as taught 
in the medical colleges of this State, including the use 
of drugs and other valuable therapeutic agents. 

Fourth. If the so-called osteopathic bill becomes a 
law, all candidates who fail to pass the Regents' ex- 
aminations to obtain a license to practise medicine in 
this State may, in this State, treat all diseases of the 
human body by holding a diploma from any regular 
osteopathic college in the United States, a privilege 
which would lower the standing of this State in the 
educational world. 

And finally, it would be more reasonable for the legis- 
lature to separate the special branches of criminal, cor- 
poration, and real estate law from the general practice 
of law and establish for each of them a special examin- 
ing board, so as to make it easier for the candidates 
for admission to the Bar who desire to practice as 
specialists, than it would be for the legislature to 
select one special therapeutic agent used in the treat- 
ment of disease and separate it from the general prac- 
tice of medicine as a panacea for all diseases at the 
request of those enthusiasts who now ask for a special 
osteopathic examining board. 

PHILADELPHIA. 

Donation Day. — On last Saturday the Sisters of 
St. Francis received donations at the St. Mary's 
Hospital. 

Bill Passed. — After a somewhat concise speech, in 
which Mr. Plummer told the legislature of the ad- 
vantage of consumptive camps, this body passed the 
bill appropriating $400,000 to establish and to main- 
tain two such camps. 

Charity Ball Profits Divided. — According to the 
secretary of the German-American Charity Ball 
Committee, the profits of the ball, held February 6, 
were $2,310.54, which sum will be divided equally be- 
tween the Hahnemann and the Children's Homeo- 
pathic hospitals. 

Neurological Society Entertained. — Dr. Charles K. 
Mills entertained 75 members and friends of the 
Charles K. Mills Neurological Society of the Uni- 
versity of Pennsylvania March 24. .^mong the guests 
the following physicians were noted: Drs. Hearn, 
Keen, Dercum, Frazicr, Clark, Spiller, Potts, Turn- 
bull, Marshall, Hirst, Pickett, Lloyd and Deaver. 

Hospital Quarantined. — For three hours the Med- 
ico-Chirurgical Hospital was placed under quaran- 
tine owing to the fact that a case of smallpox got 
into the receiving ward. The case was sent to the 
Municipal Hospital and the ward was fumigated. 
Several of the nurses who attended the patient were 
isolated. The source of the infection is not known, 



but it is the purpose of the hospital authorities to 
determine if possible how it arose. 

Doctor's Reports on Public School Visits. — The 
weekly reports of the physicians of the Bureau of 
Health show that last week 319 schools were visited 
and 4.601 pupils examined. Thirty-three required 
vaccination, 207 suffered from defective vision, 11 
from defective hearing, 7 from defective speech and 
70 from defective teeth. In the industrial schools 
927 children need to be vaccinated. 

The Spread of Meningitis to be Prevented. — Or- 
ders have been issued to Vare Brothers directing 
theiTi to clean the streets at once. Dr. Martin 
claims that the streets are filthier now than they 
have been for years, and particularly in that portion 
where the greater number of cases have developed, 
viz., the section bounded be Broad Street on the 
west, Delaware River on the east. Spruce street on 
the north and Washington .A.venue on the south. 

College of Physicians gets Bureau of Health's Li- 
brary. — These books were taken to that institution, 
where they will be known as the " Abbott Collec- 
tion." The collection contains 250 volumes which 
were gathered by Dr. W. H. Ford, who had been 
president of the Board of Health for thirty years. 
It contains the report on the cholera epidemic in 
1873 and the report of the Bureau of Agriculture 
on the sw-ine plague of 1884. Dr. Martin will issue 
a permit to any physician who wishes to consult the 
collection. 

Hahnemann Hospital's New Clinic. — On March 20 
Mrs. George D. Widener presented to the Hahnemann 
Hospital a new clinic amphitheater, which she erected 
ill memory of her father, the late William L. Elkins. 
As a preface to his first clinic in this new structure, 
Dr. William B. Van Lennet described the building 
to the student body and pointed out the various 
rooms and their purpose. He laid considerable 
stress upon the fact that they now have two private 
wards where patients can be taken to recover from 
the anesthetic. 

Pharmacists Meet. — At a meeting held at the Col- 
lege of Pharmacy the following papers were read: 
" Ethical Pharmaceutical Practice and its Recom- 
pense," by Prof. Henry P. Hynson, of the Univer- 
sity of Maryland; '"Professionalism Versus Com- 
mercialism in Pharmacy," by Dr. William C. Alpers; 
" The Evolution of Nostrum Vending and its Re- 
lation to the Practice of Medicine and Pharmacy," 
by George M. Beringer, Ph.M. Prof. J. P. Reming- 
ton, who presided, told of an attempt made to pass 
a bill requiring applicants to graduate from a re- 
putable college of pharmacy as a prerequisite for 
examination. 

Section on Ophthalmology of the College of Phy- 
sicians. — This Society met March 21. The scientific 
program was opened by Dr. S. D, Risley, who read 
a paper on " Unusual Changes in the Refraction of 
the Eye." Dr. John T. Carpenter read one on " Epi- 
phora Unassociated with Laryngeal Obstruction." 
The next paper presented was that of Dr. de 
Schweinitz upon " Metastatic Ophthalmitis follow- 
ing Labor, with Histological Examination of the 
-Specimens." Dr. Veasey read the last paper; it was 
upon " Recovery, with Useful Vision, from a Severe 
Nitric Acid Burn involving the whole External Por- 
tion of the Eyeball." 

Surgeons to Check Idiocy. — The legislature has 
passed a bill the text of which is as follows: "On 
the first of July after the passage of this bill it shall 
be compulsory for every institution intrusted exclu- 



April i, 1905] 



ECHOES AND NEWS: CHICAGO. 



609 



sively or especially for the care of idiots and im- 
becile children to appoint at least one skilled neurol- 
ogist and one skilled surgeon to its staff. In con- 
junction with the physician it will be the duty of 
these men to examine the mental and physical condi- 
tion of the inmates. If, after one year's test at the 
institution, there is no evidence or prospects of im- 
provement, in the minds of these experts, it shall 
be lawful to operate upon idiots in order to pre- 
vent procreation." 

Pathological Society. — The society held its regu- 
lar meeting March 23, at which Dr. E. A. Shuman 
exhibited "' Malignant Tumors of the Ovaries." Dr. 
VV. M. L. Coplin read a paper on " Acute Pulmonary 
Edema." He showed a rabbit in which edema was 
produced by the injection of solution of adrenalin. 
He also exhibited a specimen of a dissecting aneur- 
ism in the aorta of a rabbit which had received ad- 
renalin chloride. Dr. D. J. McCarthy read a paper on 
on " Abnormal Types of Nerve-cell Degeneration." 
He also showed two specimens illustrating " Hem- 
orrhagic Conditions of the Cerebrum.'' 

The American Society of Tropical Medicine.— This 
society held its annual scientific meeting March 24. 
The Panama Canal Zone was the subject under dis- 
cussion. Dr. Seneca Egbert read a paper on " The 
History of the Republic of Panama and the Panama 
Canal." Dr. Joseph McFarland gave an illustrted 
lecture on the " Canal Zone." Dr. Roland G. Curtin 
read a paper on "The Medical Conditions' of the 
Isthmus of Panama." The discussion was to be 
opened by Dr. Samuel D. Risley and Dr. W. W. 
Keen, but both were absent. At the business meet- 
ing Dr. Roland Curtin was elected president of the 
society, Dr. Joseph McFarland secretary. Dr. John 
M. Swan assistant secretary, and Dr. Sinkler 
treasurer. 

Philadelphia County Medical Society. — This so- 
ciety hold a meeting jNIarch 22 on a Symposium of 
Pneumonia. Dr. Thomas Darlington. Commissioner 
of Health of New York, was scheduled to speak first, 
but being unavoidably delayed his talk was post- 
poned until later in the evening. Dr. 'W. T. Long- 
cope read a paper on "' Some Recent Developments 
in the Etiology and Pathology of Pneumonia." Dr. 
J. C. Wilson read of the " Symptomatology and 
Diagnosis of Atypical Forms of Pneumonia." Dr. 
H. A. Hare prepared a paper on "The Medical 
Treatment of Pneumonia." He was unable to attend 
but sent his paper, which was read by Dr. Landis. 
In the absence of Dr. R. H. Harte, Dr. John Gibbon 
outlined the " Surgical Treatment and Complications 
of Pneumonia." The discussion on these papers was 
opened by Dr. John H. Musser; he was followed 
by Dr. John B. Roberts. The following also took 
part in the discussion: Dr. Tyson, Dr. Deland, Dr. 
Woodberry and Dr. Anders. 

CHICAGO. 

Hospital Beneficiaries. — St. Luke's, Mercy, Alex- 
ian Brothers' and the Chicago Presbyterian Hospital 
have each been bequeathed $2,000 by the will of the 
late John Murphy. 

Brokaw Hospital Beneficiary. — By the terms of 
the W'ill of Abram Brokaw. the eccentric million- 
aire of Bloomington, 111., the hospital in that city 
"which bears his name will receive $175,000. 

Memorial Tab/et to Dr. N. S. Davis Unveiled. — A 
memorial tablet to the late Dr. N. S. Davis was un- 
veiled March 24, in Davis Hall of the Northwestern 
University Medical School. Addresses were de- 



livered by Drs. Geo. W. Webster, E. Wyllys An- 
drews, E. C. Dudley, W. O. Krohn and Dean Hol- 
gate, of the University. The tablet was presented 
by the senior medical class of the school. 

Crime. — Figures have been compiled by Dr. F. 
H. Wines, former secretary of the Illinois Board 
of Charities, and a statistician of note, which show 
that the belief that crime is widespread in the 
United States and is increasing in proportion to the 
population is not true of Chicago. lu 1880, when 
Chicago had a population of 503,181, there were 24.- 
480 arrests here, or 487 to every ten thousand people. 
In 1890, when the population was 1,099,850, the num- 
ber of arrests was 62,230, or 566 to every ten thou- 
sand people. In 1900, when the population was 
1,698,575, there were 70,439 arrests, or 415 to every 
ten thousand people. Dr. Wines' analysis of his 
figures shows that, in proportion to population, the 
number of petty crimes in Chicago decreased 66 per 
cent., and the number of serious crimes 50 per cent, 
between i8go and 1900. 

GENERAL. 

Departure of Dr. Cushny.— Dr. Arthur R. Cushny, 
professor of materia medica and therapeutics in the 
department' of medicine and surgery at the University 
of Michigan, left New York last week on his way 
to Europe, to take a similar chair in the University 
of Medicine in London. Dr. Charles W. Edmunds 
has been chosen to take charge of his work at the 
University of Michigan. 

Honor System at Michigan. — All examinations in 
the medical department of the University of Michi- 
gan are conducted on the " honor system." Each 
class in its first year adopts the plan and adheres to 
it throughout the four years' course. The operation 
of the plan relieves the examiner from guard duty 
over his class and puts each student on his honor 
not to give or receive aid in writing his paper. All 
accusations of dishonesty are investigated by a stu- 
dent committee which recommends to the Faculty 
whatever action is in its judgment required by the 
nature of the offense. 

Congress of French-Speaking Alienists. — The fif- 
teenth congress of the alienists and neurologists of 
France and French-speaking countries will be held 
this year at Rennes, from August i to 7, under the 
presidency of Dr. A. Giraud, Medical Director of 
the Lunatic Asylum of Saint- Yon in the Seine-Inferi- 
eure Department. The following are the questions 
proposed for discussion: (l) Hypochondriasis, (2) 
forms of ascending neuritis, (3) baths and hydro- 
therapy in the treatment of mental diseases. Com- 
munications should be addressed to the General 
Secretary, Dr. J. Sizaret, Medecin en chef de I'Asyle 
Public des Alienes de Rennes. 

Dartmouth Medical School. — Definite plans are 
rapidly progressing whereby a practically new medi- 
cal school will be created to replace the old school, 
which dates from 1798, when Dr. Nathan Smith was 
made professor of medicine at Dartmouth College. 
The first step toward this end will be the erection 
this summer of a building of large and handsome 
proportions facing the south adjoining the present 
one. The proposed cost of the new building is 
$30,000, a large proportion of which has already been 
raised among the alumni. The laboratories will be 
open to all students, and special efforts will be made 
to give a thorough, up to-date training in modern 
m.edicine. The courses of instruction will be the 
same as at present, but special attention will be given 



■6io 



ECHOES AND NEWS: GENERAL. 



[Medical News 



to the theory and science back of these courses. 
The medical school will also offer in connection with 
the summer school a course of graduate instruction, 
open to all physicians. 

Boston Medical Library Meeting in conjunction 
with the Suffolk District Branch of the Massachu- 
setts Medical Society. — The last meting was held at 
the Library ;\Jarch 22. Dr. Geo. G. Sears was in the 
chair. Dr. H. F. Hewes read a paper on " A 
Study of the Objective Methods of Diagnosis of the 
Stomach in a Medico-Surgical Clinic with Report of 
Cases." Dr. Hewes went over in detail the routine 
treatment of stomach cases in his clinic during the 
past si.K months, especially as regards the early 
diagnosis of cancer and ulcer of the stomach. In 
these two conditions the question as to the presence 
or absence of stasis, dilatation, malformation and 
malposition of the stomach, blood, lactic acid, hy- 
per- or hypoacidity and bacteria and yeasts was to 
be determined. The methods used to determine 
these things were described, especially the. guaiac 
test for blood, somewhat discredited in this country, 
and the correct test for lactic aid by means of an 
ether solution of stomach contents and ferric chlor- 
ide. The value of the study of sediments obtained 
in gastric contents and what could be learned from 
the presence or absence of various bacteria and cells 
was emphasized. In making a diagnosis it was the 
grouping together of certain findings rather than the 
presence of any single one of them which was of 
value. As regards results, out of about 18 cases 
diagnosed as cancer previous to operation or au- 
topsy, all were found to be correct; 12 cases were 
diagnosed as gastric ulcer; at operation 10 were 
found to be ulcer, one a cancer and one perigastric 
adhesions. The paper was of great interest and 
emphasized a very important and rather neglected 
part of a routine physical examination. Dr. J. G. 
Mumford spoke on ''The Recent Surgical Concep- 
tions of Non-Malignant Disease." He showed as 
well as was possible, by means of a table prepared from 
stomach operations based on statistics from such 
men as Mayo, Moynihan, Munro and others, the 
immediate and end results of operations for the pur- 
pose of draining the stomach in non-malignant cases. 
The time was altogether too short in the great ma- 
jority of instances to get any real idea of end re- 
sults. Although a great many operations had been 
done, men either reported them at once without 
Jwaiting for results or else did not report them at 
all, or without sufficient detail to be of value. In 
his own experience the reader found Finney's op- 
eration to be the best. The others were described 
and discussed. 

Dr. Rottomlcy spoke for Dr. Munro and himself, 
stating the results in their cases. He rather took 
the ground that the time was coming when chronic 
indigestion or dyspepsia would prove to be a surgi- 
cal condition. 

Dr. F. B. Lund described his experience in stom- 
ach surgery, and spoke of the great relief given to 
most hopeless and distressing cases. 

Dr. E. P. Joslin emphasized the fact that in gas- 
tric ulcer, treated medically, the end results were 
far better in private practice outside a large hospital 
than in one. He thought too much was left to house 
officers in these cases. 

Preliminary Program of the Medical Association 
of Georgia. — The fifty sixth annual session will be 
lield at Atlanta, Ga., April 19, 20 and 21, 1905. The 
following papers arc announced: "The Doctor and 



the Public Schools," by Theo. Toepel, M.D., of At- 
lanta; " Bromide Poisoning," by C. C. Stockard, 
M.D., of Atlanta; "Occult Hemorrhage, Its Diag- 
nostic Value in Cancer and Ulcer of the Stomach," 
by L. Amster, M.D., of Atlanta; "The Cause and 
Treatment of Lacrimal Stenosis in Infants," by 
Dunbar Roy, M.D., of Atlanta; "X-rays in External 
Treatment," by M. B. Hutchins, M.D., of Atlanta; 
" Journals for Revenue Only." by Ralph M. Thom- 
son, M.D., of Savannah; "Corneal Abscission," by 
J. M. Crawford, M.D., of Atlanta; " La Grippe," by 
J. W. Palmer, M.D., of Alley; "Croup and Mem- 
branous Croup," by S. Visanska, M.D., of Atlanta; 
" Some Points out of my own Experience in Refrac- 
tion and the Fitting of Glasses," by Ross P. Cox, 
M.D., of Rome ; " Is Bilateral Operation for Cataract 
Ever Justifiable; if not, How Soon After Operation 
on the First Eye is it Safe to Extract the Second 
Cataract?" by A. W. Calhoun, M.D., of Atlanta; 
" The IModern Application of the Galvano-Cautery, 
with Some of Its Uses and Abuses," by A. G. Hobbs, 
JiI.D.. of Atlanta; "Recurrent Ocular Paralysis with 
Pain," by A. W. Sterling, AI.D., of Atlanta; "The 
Physician's Duty to the Pregnant Woman," by Jno. 
W. Daniel, M.D,, of Savannah; "Appendicitis, Med- 
ical and Surgical," by R. R. Kime, M.D., of Atlanta; 
" Medical and Surgical Hodge-Podge," by W. B. 
Hardman, M.D., of Commerce; "The Mode of In- 
fection in Uncinariasis," by Claude A. Smith, M.D., 
of Atlanta; " Character in a Physician is Like Beauty 
in the Statue; it asks for Infinite Pains," by E. Mor- 
gan, M.D., of Arlington ; " The Prompt Repair of 
Laceration of Female Generative Organs After 
Labor," by E. C. Davis, M.D., of Atlanta; "Preven- 
tion and Treatment of Puerperal Infection," by L. 
C. Fischer, M.D., of Atlanta; " Report of Cases of 
Tuberculosis Treated with Bacillus X (Maher)," by 
T. E. Oertel, M.D., of Augusta; "Report of Case of 
Myasthenia Gravis." by J. Cheston King. M.D., of At- 
lanta; "Pneumonia, its Etiology, Pathology and 
Treatment." by A. C. Davidson, M.D., of Sharon ; " Al- 
buminuria," by E. B. Block, M.D., of Atlanta; "Diag- 
nostic and Therapeutic Importance of the Recent 
Advances Made in the Examination of the Feces," 
by H. F. Harris, M.D., of Atlanta; "The Clinical 
Consideration of Tumors," by W. F. Westmoreland, 
M.D.. of Atlanta. 

The Medical Society of London. — The one hun- 
dred and thirty-second anniversary dinner of the Medi- 
cal Society of London was held at the Whitehall 
Rooms, Hotel Metropole, on March 15, with the 
President, Mr. J. Langdon, in the chair. To the 
right of the chairman were seated the President of 
the Royal College of Physicians, the Principal of 
the University of London, the President of the Clin- 
ical Society, the Dean of the Faculty of Medicine of 
the University of London, the President of the Har- 
veian Society, the President of the Gynecological 
Society, the President of the West London Medico- 
Chirurgical Society, and to the left of the chairman 
the President of the Royal College of Surgeons, the 
Director-General of the Army Medical Service, the 
President of the Royal Medical and Chirurgical So- 
ciety, the President of the Neurological Society, the 
President of the Huntcrian Society, the President 
of the Obstetrical Society, the President of the Lar- 
yngological Society, and the President of the So- 
ciety of Anesthetists. After the usual loyal toasts 
had been duly honored. Sir William S. Church pro- 
posed the toast of "The Medical Society of Lon- 
don." He observed that there was in the air much 



April i, 1905] 



ECHOES AND NEWS; GENERAL. 



611 



talk of a scheme whereby the various medical societies 
in this metropolis would be more or less confed- 
erated together. He trusted that the individual so- 
cieties would still retain their individuality. In any 
such movement, the Medical Society w-as. bound to 
take a leading part. Mr. Langton, in responding to 
this toast, referred to the Lettsomian Lectures given 
by Dr. Savage, and to the address on the Growth 
of Cancer by Dr. Bashford. Sir A. W. Riicker, in 
replying to the toast of "The Guests." proposed 
by Dr. F. de Haviland Hall, said that the number 
of students of medicine in the metropolis, instead 
of increasing, had been for some years falling off, 
owing to the fact the new provincial schools pro- 
vided excellent classes for preliminary medical sub- 
jects. London must certainly put itself on an equal- 
ity with the provinces. London had so many great 
medical schools and such an extraordinary wealth 
of teaching material that instruction in preliminary 
medical subjects in the metropolis must be put on 
a higher footing. These subjects did not require to 
be taught in the immediate neighborhood of the 
sick bed, and it was a matter of the greatest im- 
portance that there should be established a central 
medical institution where physics and chemistry, 
and probably also anatomy and physiology, could be 
taught. That would do something to put the teach- 
ing of these subjects in the metropolis on an equal- 
ity with the provincial centers, and with the greatest 
medical institutions in the capitals of the world. 
He concluded by reminding his hearers that that 
could only be done with the help of the medical 
profession. Mr. Tweedy also responded to this 
toast, and said he was glad to have the opportunity 
•of acknowledging the benefits he had derived from 
the e-xcellent library of the Medical Society. Sir 
Constantine Holman proposed the health of " The 
President," and that gentleman, in acknowledging 
the toast, paid a high compliment to the efforts of 
the two honorary sescretaries of the Medical So- 
ciety, Mr. Waring and Dr. Risien Russell, to whom 
he attributed the great success of the evening. 

Physician (Female) for Government Hospital for 
the Insane. — The United States Civil Service Com- 
mission announces an examination on April 26 to 27, 
1905, to secure cligiblcs from which to make cer- 
tification to fill a vacancy in the position of phy- 
cian (female) in the Government Hospital for the 
Insane, Washington, D. C., at $1,500 per annum and 
quarters, and vacancies as they may occur in any 
branch of the service requiring similar qualifications. 
Only unmarried women will be admitted to this ex- 
amination. The examination will consist of the sub- 
jects mentioned, valued as indicated: I. Letter-writ- 
ing (a letter of not less than 150 words on one or 
two subjects given), 5; 2. Anatomy and physiology, 
5; 3. Chemistry, materia medica, and therapeutics. 
id; 4. Bacteriology and hygiene, 10; 5. Surgery and 
surgical pathology, 15; 6. Obsetrics and gynecology. 
is; 7. Mental diseases, 20; 8. Experience (rated on 
application), 20. Applications will be received from 
graduates of recognized medical schools. Credit 
w-ill be given for experience obtained in a profes- 
sional capacity in institutions for the care of mental 
diseases, in genera! hospitals, and in the actual per- 
formance of surgical operations and the care of 
operative cases. Two days will be required for this 
examination. Age limit twenty-five to forty years 
on the date of the examination. This examination 
is open to all citizens of the United States who com- 
ply with the requirements. .\pplicants should at 



once apply either to the United States Civil Service 
Commission, Washington, D. C, or to the secretary 
of the board of examiners at any place mentioned 
in the accompanying list for application Form 1312. 
No application will be accepted unless properly exe- 
cuted and filed with the Commission at Washington. 
In applying for this examination the exact title as 
given at the head of this anouncement should be 
used in the application. -A.s examination papers are 
shipped direct from the Commission to the places 
of examination, it is necessary that applications be 
received in ample time to arrange for the examina- 
tion desired at the place indicated by the applicant. 
The Commission will, therefore, arrange to examine 
any applicant whose application is received in time 
to permit the shipment of the necessary papers. 

Florida Medical Association. — The thirty-second 
annual meeting will he held at Jacksonville, Fla., 
.•\pril 19, 20 and 21, 1905. The following papers will 
be read: " Double Tubal Pregnancy, a Unique Case," 
witl'^ specimens, by Dr. Edward N. Liell, of Jacksonville; 
" Medical Legislation," by Dr. J. Harris Pierpont, 
of Pensacola; "Personal Experiences with Asiatic 
Cholera," by Dr. A. D. Williams, of Jacksonville; 
" Typhoid Fever in Small Towns and Rural Com- 
munities — Treatment," by Dr. Albert H. Freeman, 
of Starke: "Typhoid Fever," by Dr. H. R. Drew, of 
Jacksonville : " Feeding in Typhoid Fever," by Dr. 
W. L. Hughlett, of Cocoa; " Sulpho-Carbolates in 
the Treatment of Typhoid Fever," by Dr. P. J. Stol- 
lenwerck, of Jacksonville; "Southern Fevers," by 
Dr. Wallace, of Ormond, Fla.; "Intestinal Parasites, 
Blood Findings, Diagnosis and Treatment," by Dr. 
Charles E. Terry, of Jacksonville ; " Malarial Hemo- 
globinuria," by Dr. L. A. Greene, of Greeneville, 
Fla.; "The Etiology of Choroiditis," by Dr. Colum- 
bus Drew, of Jacksonville; exhibit of a large pul- 
monary calculus, a lime concretion, coughed up by a 
patient, with remarks and history of case, by Dr. W. 
L. Hughlett. of Cocoa; "The Causation and Result 
of Enucleation of the Eye; " " Effect of the Galvano- 
Cautery in a case of Deaf-Mutism," by Dr. F. P. 
Hoover, of Jacksonville; "Eye Strain, a Frequent 
Cause of Headaches and Nervous Derangements," 
by Dr. J. Harrison Hodges, of Gainesville: "The 
Mosquitoes of Florida," by Dr. Hiram Byrd, of Kis- 
simmee; "Antiseptics and Disinfectants, Facts Sub- 
stantiating and Disproving Claims Made by l\Ianu- 
facturing Chemists," by Dr. H. S. Holloway, of 
Jacksonville; "Landry's Paralysis," (acute ascending 
paralysis) by Dr.- John R. Ham, of Malabar; "The 
X-ray in Malignant Growths, and in other Patho- 
logical Conditions," by Dr. C. M. Greiner. of Jack- 
sonville; "Surgical Obsetrics," unusual high tem- 
peratures, with report of cases, by Dr. Frederick 
Meagley, of Daytona; " Medicine, the Pioneer of 
Surgery," bj^ Dr. F. D. Miller, of Jacksonville; 
" Radical Treatment of Hydrocele," with report of 
cases, by Dr. John McDiarmid, of Deland; "A 
Case of Filaria Sanguinis Hominis;" "Metastatic 
Gonorrheal Ophthalmia," by Dr. E. Andrade, of 
Jacksonville ; " Changes Necessary to Bring Sur- 
gery Up to Date in Florida," by Dr. C. P. Rogers, of 
Jacksonville; "Peri-Urethra! Abscess," by Dr. Fred 
Bowen, of Jacksonville; "Fractures of Lower End 
of Humerus, with Treatment," by Dr. N. A. Up- 
church, of Jacksonville; paper by Dr. DeWitt Webb, 
St. Augustine, subject to be anounced. 

An American Medical Poet. — In Medicine for 
March there is an interesting account of an Ameri- 
can medical poet whose name, writes the British 



6l2 



ECHOES AND NEWS: GENERAL. 



[Medical News 



Medical Journal, we imagine, will be as new to most 
of our readers as we confess it was to us. James 
Gates Percival was born in 1795, and after taking 
an arts degree at Yale was for some time engaged 
in teaching. He then studied medicine, and after 
graduating at Philadelphia entered the United States 
army as assistant-surgeon. He was for some time 
Professor of Chemistry at the famous military acad- 
emy at West Point. Apparently he left the service to 
devote himself to scientific research, for he made a geo- 
logical survey of Connecticut, in the course of which 
he walked over every hill, plain and morass in the 
State. In this work he was engaged for five years 
at an annual salary never exceeding i6o. In addition 
to his scientific knowledge, he was a linguist, read- 
ing with ease Latin, Greek, French, Spanish, Ger- 
man, Italian, and the Slavonic languages. But he 
was utterly wanting in the power of self-assertion; 
hence his great gifts were hidden from the world. His 
first efforts in verse were damned by the American 
press as brutally as were those of Keats by the 
Quarterly Review. If he was not, like the aruthor 
of Endymion, killed off by one critic, the reviewers 
wounded his sensitive spirit so deeply that he tried 
to kill himself. Yet the workmanship of his verse 
was so fine that it earned praise from so severe a 
judge as Edgar Allan Poe. In addition to metrical 
translations of German and Slavonic lyrics, Percival 
published several small volumes of original poems 
between 1821 and 1843, and a complete edition ap- 
peared in 1859. Throughout his life he was a prey 
to the poverty which used to be the proverbial lot 
of poets. Hunger forced him to play the part of 
literary " ghost." He is said to have been the sole 
author, compiler, and editor of the first edition of 
the Unabridged Dictionary published in the name of 
Noah Webster, in which he gave not only the defi- 
nition but the root and the history of some 16,000 words 
derived from thirty-nine languages, of all of which 
he had some critical knowledge. Webster's first 
dictionary was merely a compilation from standard 
authorities, the only original part consisting in 
American slang. It is to Percival that Webster 
owes his fame as a lexicographer. At last, in the 
decline of his life, fortune seemed disposed to sinile 
on the doctor-poet. In 1854. through the influence 
of some friends who knew his worth, Percival was 
appointed Geologist to the State of Wisconsin. His 
first report was published in 1855, and he was en- 
gaged on the second at the time of his death. If it 
be asked what caused the failure of a man so bril- 
liantly endowed, so versatile in accomplishment, 
and so strenuous in work, we think the answer may 
be given in two words — diffidence and instability. 
Samuel Johnson said: "Slow rises worth by poverty 
deprest." But many have fulfilled their destiny and 
uttered the message that was in them, in spite of 
poverty. There is a wise old saw, " Primum vivere 
deinde philosophari." James Gates Percival, we 
take it, was one of those who find it more easy to 
jiliilosophize than to live. 

Special Trains to Portland, Ore. — Arrangements 
have been completed under which the Northern Pacific 
Railway will run three .solid special trains through to 
the Pacific coast for physicians who will go West early 
in July to attend the coming sessions of the American 
Medical Association, the national organization of doc- 
tors. The first special will run through from Chicago, 
leaving June .•jO and reaching St. Paul July l, proceed- 
ing West and stopping at Gardiner. Mont., for a five 
and one-half day tour of the Yellowstone National 



Park. A second solid special train will leave Chicaga 
July I, reaching St. Paul July 2, and proceeding West 
to Gardiner for a similar tour of the Yellowstone. A 
third special train will leave Chicago July 6, running 
through to Portland with stops at several important 
points. The Northern Pacific has been designated the 
official route for the handling of the physicians, and 
the national otKcers will go West on one of the first 
two specials, in both of which accommodations are very 
nearly exhausted. Arrangements are now being made 
by numerous small parties for space in the third special, 
and it is possible that additional trains will be ar- 
ranged for, if the demand for reservations continues 
heavy. Each special will be made up of standard Pull- 
man equiptuent, with through dining cars and ample 
baggage accommodations. Every facility which adds 
to luxurious comfort en route is being arranged for 
and the train schedules have been worked out with 
especial reference to the convenience of the doctors. 
The third special will arrive in Portland the morning 
before the convention opens. Especial attention is 
called to the fact that berth reservations should be 
made immediately through C. A. Matthews,. General 
Agent Passenger Department, N. P. R., Chicago. The 
best service can be afforded if the phj'sicians will co- 
operate in this matter, arranging their plans accord- 
ingly. 

Dr. Matas Honored. — An event of interest and 
no small note was quietly celebrated at the residence 
of Dr. Rudolph Matas, in New Orleans, last week, 
when a body of physicians, professors and students and 
intimate friends called at the Matas home and pre- 
sented him with a beautiful silver service, consisting 
of some 125 pieces, and a handsome solid silver loving 
cup. These tokens of honor and esteeiu were presented 
to Dr. Matas on the twenty-fifth anniversary of his 
graduation from Tulane Medical School and his en- 
tering upon the active practice of medicine. The whole 
thing was a complete surprise. Dr. Stanford E. Chaille, 
Dean of the Medical College, made the presentation 
in one of his best and neatest efforts. Dr. I. L. Leucht, 
Rabbi of Touro Synagogue, seconded the presentation 
of Dr. Chaille, and then Dr. Matas responded in words 
of tenderest appreciation. He was so overcome by this 
loving remembrance of the day that he spoke with 
difficulty at the beginning of his remarks. These pleas- 
ing ceremonies accupied a half hour or more. Then 
Mrs. Matas took charge of the welcome guests and a 
dainty repast was served. "To-day." said one of the 
Faculty of Tulane, who assisted in the affair, " marked 
the twenty-fifth anniversary of Dr. Matas' graduation. 
His service to the medical profession since his leaving 
Tulane have been of such lasting value to science and 
the medical world that we, as meiribers of the Faculty, 
students, professional luen, and. above all. as personal 
friends, look this simple means of showing soiue mark 
of our love and appreciation." The large chest of silver 
rested on a table under the folding doors of the parlor 
while the presentation was being made. It is one of 
the most beautiful, and at the same time the most useful, 
ever presented on any occasion in this city. The loving 
cup was also of a most beautiful design and creation. 

The Medical Department of the United States 
Army.- -The \cw Vnrk Sun has the fallowing ex- 
cellent cnmnientary on the situation: 

" The Medical Department of the army is yet without 
relief. The Jnurnal of the American Medical Associa- 
tion says: 'The responsibility for the failure of the 
liill introduced last session to increase the efficiency of 
this hrancli of the public service rests with the Speaker 
iif the House, who at the last moment refused to per- 



April i, 1905] 



ECHOES AND NEWS: GENERAL. 



613 



mit the measure to come to a vote.' The petition of 
the American Medical Association, one of the most in- 
fluential bodies in the United States, branch societies 
of which are organized in every Congress district in the 
Union, as well as the personal solicitation of the 
Secretary of War and the still further formal declara- 
tion of the President that ' if the Medical Department 
of the army is left as it is, no amount of wisdom or 
efficienc)- in its administration will prevent a complete 
breakdown in the event of a .serious war,' were of no 
avail against the views of the practical politician. 
Nothing but the ruling of teh Speaker stood in the 
way of this vitally important bill. It had passed the 
Senate, the President was heartily in its favor and a 
majority of the House were ready to vote for it. Now 
it will have to bide its time and await the convenience 
•of the Speaker and the party in power. We do not 
e.xpect a war, but it is the unexpected that happens ; and 
should war come we shall be no more prepared for it 
than at the time of the rupture with Spain. We are 
too apt to forget the disasters for which our short- 
comings were then responsible and to remember only 
the triumph in arms in that short conflict. The recent 
report of the Typhoid Fever Board, appointed to in- 
vestigate the sanitary conditions of the United States 
Army in that period, showed that 90 per cent, of the 
volunteer regiments developed typhoid fever within 
eight weeks after going into camp. There were 20,7,^0 
cases of this single disease, with a death rate of 7.61 
per cent., and this mortality ratio takes no account of 
the loss from all other diseases. Where strict discipline 
prevails and where efficient medical organization is in 
authority, there would be no typhoid epidemics ; in 
fact, no epidemics of any kind. The death rate from 
disease would be reduced to the minimum and the 
efficiency of the fighting line would be practically in- 
tact except for injuries received in battle. Such are 
the results obtained in the army of Japan, in which the 
organization of the Medical Department has reached 
a degree of perfection never before attained by any 
nation. That Medical Staff is in touch with the com- 
manders of the various armies in camp and in the field, 
it is thoroughly equipped, and in all things pertaining to 
sanitation the surgeon's word is supreme. Some idea 
of the value of the service to humanity which the 
Army Medical Staff may perform may be gained by 
reference to the work of the late Walter Reed, Major 
and Surgeon, U. S. A., who died in 1902. The inves- 
tigations of this remarkable man, assisted by Surgeon 
W. C. Gorgas, who is now in charge of the Medical 
Department of the Canal Zone, not only removed yellow 
fever from the city of Havana, where it had had an 
uninterrupted habitat of a century, but wiped it from 
the list of epidemics which had often carried death 
to our seacoast cities and paralyzed for months at a 
time the commerce of the Atlantic coast. These same 
results will follow in the Canal Zone if Major Gorgas 
has proper authority and is furnished with the facilities 
for carrying out the plan with which he became so 
familiar during his experience in Cuba. It is a dis- 
grace of our nation that year after year the Medical 
Department of the .Army should appeal in vain to 
Congress ■ for permission to make itself equal to the 
protection of our soldiers. The Congressmen who fail 
to provide this relief should he held to strict account- 
ability." 

President to Naval M.D.'s. — President Roosevelt 
last Saturday attended the graduation exercises of the 
United States Naval Medical School, held at the Naval 
Museum of Hygiene. Twenty-three assistant surgeons 
were graduated. The President delivered the diplomas 



and made an address. He said : " Ladies and gentle- 
men, and especially the inembers of the graduating 
class : I am glad to have the chance of saying a word 
of greeting to you this morning. You represent two 
professions — for you are members of the great medical 
body, and you are also officers of the navy of the 
United States, and, therefore, you have a double stand- 
ard of honor up to which to live. I think that all of 
us laymen, men and women, have a peculiar apprecia- 
tion of what a doctor means ; for I do not suppose there 
is one of us who does not feel that the family doctor 
stands in a position of close intimacy, in a position of 
obligation under which one is happy to rest to an extent 
that hardly any one else can stand, and those of us 
who, I think most of us, are fortunate enough to have 
a family doctor who is a beloved and intimate friend, 
realize that there can be few closer ties of intimacy and 
affection in the world. And while, of course, even the 
greatest and best doctors cannot assume that very inti- 
mate relation with more than a certain number of 
people, it is to be said, I think, that more than any 
other man, except a few clergymen, the doctor does 
commonly assume that relation to many people. While, 
nevertheless, it is impossible that that relation shall 
obtain between a doctor and more than a certain num- 
ber of people, still with every patient with whom the 
doctor is thrown at all intimately he has that relation 
to a greater or less extent. Just as the great doctor, 
the man who stands high in his profession in any city, 
counts as one of the most valuable assets in that city's 
civic work, so in the navy or the army the effect of 
having thoroughly well trained men with a high and 
sensitive standard of professional honor and profes- 
sional duty is well nigh incalculable upon the service 
itself. I want you now as you graduate to feel that 
on your shoulders rests a great weight of responsibility, 
that your position is one of high honor and that it is 
impossible to hold a position of high honor and not 
hold it under penalty of incurring the severest re- 
probation if you fail to live up to its requirements. 
I am not competent to speak save in the most general 
terms of your professional duties. I do want, how- 
ever, to call your attention to one or two features con- 
nected with them. In the first place, in connection 
with the work you do for the service you have certain 
peculiar advantages in doing work that will be felt 
for the whole profession. For instance, it will come 
to your lot to deal peculiarly with certain types of 
tropical diseases. You will have to deal with them 
as no ordinary American doctor, no matter how great 
his experience, will have to deal with them, and you 
should fit yourselves by most careful study and prep- 
aration, so that you shall not only be able to grapple 
with cases as they come up, but in grappling with them 
to make and record observations upon them that will 
be of permanent value to your fellows in civil life. 
You can do what no civilian doctor can possibly do. 
There probably is not a branch of the profession into 
which, during your career, you will not have to go; 
no type of disease that you will not have to treat. 
But there are certain diseases that you will have to 
treat that the ordinary man who stays at home of 
course does not, and it is of consequence to the entire 
medical profession that you should so fit yourself by 
study, by preparation, that you shall not only be able 
to deal with those cases, but to deal with them in a 
way that will be of advantage to your stay-at-home 
brethren. There is one other point. Every effort 
should, of course, be made to provide you with ample 
means to do your work. Every effort ought to be made 
to persuade the National legislature to take that view 



6i4 



CORRESPONDENCE: CORRECTION. 



[MuucAL News 



of the situation ; to remember that in case of war it 
is out of the question to improvise a great medical ser- 
vice for the army and navy. The needed increase is 
more keenly feh in the army than in the navy, because 
it is always the army that undergoes the greatest ex- 
pansion. But it is felt in both services. If a war 
come for which we have no greater preparation than 
at present we have made, if, as is perfectly certain to 
be the case, there be fever in the camps ; if there be 
trouble among the volunteer forces, it is foolish to 
the greatest degree for the public men, and especially 
for the public press, to complain and shriek over the 
people who happen to be in power at that time. Let 
them shriek — or, rather, do not let them shriek at all, 
for shrieking is a sign of hysteria — but let them solemnly 
tliink over and repent of the fact that they have not 
made their representatives provide adequately in ad- 
vance for the medical system in its personnel, its 
material, its organization and physical instruments 
necessary to make that organization effective, which 
alone, if prepared in advance, will obviate the trouble 
which otherwise is certain to come if we have a war. 
Let them remember not to blame the people in power 
when the breakdown comes, but blame themselves^ 
the people of the United States — because they have not 
had the forethought to take the steps in advance 
which will prevent that breakdown occurring. Means 
ought to be provided. That is part of our duty. If 
we fail in it, then it is our responsibility, not yours. 
But, and this I want to impress with all the strength 
that in me lies upon every medical man in either the 
army or the navy, remember always that in any time 
of crisis the chances are that you will have to work 
with imperfect implements. And you can form a pretty 
good test of your worth. If you sit down and say you 
could have done good work if only you had had the 
right implements to work with you will show your 
unfitness for your position. Your business, then, will 
be to do the very best you can do if you have got 
nothing in the world but a jackknife to do it with. 
Keep before your minds all the time that when the 
crisis occurs it is almost sure to be the case that you 
will have to do no small part of your work with 
makeshifts; to do it, as I myself saw at Santiago the 
army physicians, roughly and hastily and with but one- 
fourth or one-fifth of the appliances that he would 
expect normally to have, and then, as I say, make up 
your mind that while you have done all you can to 
get the best material together in advance, that you 
will not put forward the lack of that material as an 
excuse for not doing all the work you have to do upon 
the imperfect tools. Make it a matter of pride to get 
the best possible use out of them. I greet you on your 
entrance into the service. I welcome you as servants 
of the nation, and I wish you every success in the great 
and honorable calling which you have chosen as yours." 

OBITUARY. 

Dr. F. B. Whiting, Surgeon-General of the Grand 
Army of the Republic, died March 27. 

Dr. John P. Lombard died last week at his home in 
Boston from heart disease. He was born at Medford, 
Nova Scotia, February 14, 1861, and was graduated 
from the New York University Medical School in 1887. 

Dr. Richard H. Sullivan died last Monday at his 
home in Brooklyn. He was fifty-one years old, and 
had practised his profession in that borough for more 
than twenty years. He was a member of the Union 
League Club and the Kings County Medical Society. 

Dr. William C. Detweiler, a well known citizen 
of Easton, Pa., died suddenly on Wednesday night 



last. He was talking with his wife about the sudden 
death of the Rev. David Harbisch in the morning, when 
he became ill of paralysis of the heart, expiring in a few 
minutes. He was seventy-four years old. 

Dr. Frederic Danne, a retired physician, died last 
Monday at his home in New York. He was sixty- 
eight years old. He was a member of the New York, 
New York Yacht, and Union League Clubs, and also 
a member of the New England Society, New York 
Zoological Society, and Brown University Alumni Asso- 
ciation. 

Dr. Frank H. Rice, one of the oldest and best-known 
physicians in Passaic County, N. J., died at hi^fc»me 
in Passaic, March 27. He went to the General Hos- 
pital to perform an operation, and while doing his work 
he fell in a faint on the floor. He was picked up by 
the physicians in the room and removed in a carriage 
to his home. He continued to grow weaker and expired 
that night. Dr. Rice was seventy-five years of age. 
He was born in Massachusetts, was graduated from 
Woodstock College, Vermont, in 1854, and came to 
this city thirty-five years ago. 

Dr. .'Vmos Harrison Brundage, who died a week 
ago Sunday at his home in Brooklyn, in his seventy- 
seventh year, was one of the founders of the New York 
State Medical Society. He was born at Benton, Pa., 
and after being graduated from the Central College 
at McGrawville, N. Y.. he taught school for several 
years in Pennsylvania, at the same time being postmas- 
ter at Fleetville and conducting a drug store. He 
studied medicine, and in 1855 was graduated from the 
medical college of the New York University. When 
the Civil War broke out he joined the 179th Regiment, 
New York Volunteers, and later was acting surgeon 
of the Sixth New York Regiment of calvary under 
Gen. Sheridan, and was present at the surrender of 
Gen. Lee at Appomattox. At the close of the war 
he removed to Cohoes, N. Y., and in 1881 he settled 
in Brooklyn. He was a member of the Brooklyn Medi- 
cal Society. 

CORRESPONDENCE. 



A CORRECTION. 

To the Editor of the Medical News; 

Dear Sir: In your issue of March 11, in your ab- 
stract of the proceedings of the Johns Hopkins 
Medical Society for December 19, 1904, you report 
a paper of mine on Ovariotomy at Extremes of Life. 
In your report you say that I found only three cases 
of carcinoma in children, besides my own case, in 
the literature. As the statement is incorrect and 
was not made in my paper, I should like to give the 
proper version, which is that only three other cases 
of carcinoma in children under ten years of age were 
found in the literature as operated upon. There are 
many cases, relatively speaking, recorded as having 
occurred, found mostly at autopsy. 
Yours truly, 

Harry T. Wiel. 

naltimorc. March 27. 1905. 



THE LYING-IN HOSPITAL. 

To the Editor of the Medical News : 

Dear Sir: Noting your comment on the Lying-in 
Hospital I am tempted to give you a sample of the 
style of treatment I once received there: 

Some time ago I went to this hospital to see Dr. 
X., my cousin, a member of the resident staff. I 
presented my card lo the clerk at the door. 



April i, 1905] 



PHILADELPHIA COUNTY MEDICAL SOCIETY. 



615 



He asked, "' Have you an appointment with Dr. 
X.? " 

"No," I said, "but I think he will see me." 

" Then I won't send your card to him," said 
the clerk. 

"Why?" 

" Because I don't want to, and the doctors don't 
want to be bothered." 

" But this doctor is my cousin, and I know he will 
be glad to see me," I answered. 

" I can't help that," said the clerk; " I am not 
going to send your card up, and you might as well 
go away." 

Then I asked, "Can I see the house physician?" 

(This official happened to be passing through the 
office at the moment), and the clerk snapped out, 
" Yes, there he goes." 

I have been in a good many public institutions in 
the United States and in Europe, but I never remem- 
ber being in one anywhere in which a physician 
was met with as little civility as I happened to me«t 
with in the New York Lying-in Hospital. I sup- 
pose I should have reported the matter to the proper 
authorities at the time, but I hardly liked to do it 
because I felt sure it would make trouble for the 
clerk. 

I might add more but refrain. 

Very cordially, 

X. Y. Z. 

SOCIETY PROCEEDINGS. 



PHILADELPHIA COUNTY MEDICAL SOCIETY. 

Stated Meeting, held January 11, 1905. 

First Vice-President, Franklin B. Stahl, M.D., in the 
Chair. 

The Practice of Medicine in India. — Dr. Anna M. 
Fullerton (by invitation) read this paper. She said 
that the practice of medicine in India is attended with 
great difficulties in consequence of social and religious 
customs. These, with the dense ignorance and grind- 
ing poverty of the mass of the people, are responsible 
for the widespread epidemics which prevail and which 
have baffled all the efforts of the English Government 
for their suppression. There is no scientific system 
of native medicine. Herb doctors, known as "hakims," 
combine with their medical practice the use of charms 
and incantations, with offerings to the gods. Omens 
and astrology are believed in and much practised. Sur- 
gery is consigned to the barber. The condition of 
women is especially deplorable. High caste women can 
never see a male physician, but must be treated through 
the medium of ignorant midwives. Child marriage is 
an unfailing source of evil. Multitudes of girls of ten 
to twelve or even less, are thus given over to outrage. 
Girls of even twelve years are known to become mothers 
in that land, few attain the age of eighteen without 
bearing children. An increasing population under these 
physical conditions cannot be a healthy or a vigorous 
one. On the part of the mother shocking mutilations 
are often met with, for which repair of any kind is 
impossible. The hospitals established by the English 
Government, and especially mission hospitals and dis- 
pensaries are creating a sentiment in favor of Western 
medicine. 

The Antitoxin Treatment of Diphtheria with a 
Plea for Rational Dosage in Treatment and in Im- 
munizing. — Dr. B. Franklin Royer, of the Municipal 
Hospital, in this paper, by a series of tables from the 
statistics of the Board of Health in Chicago, New York 



City, Brooklyn and Philadelphia, proved an actual de- 
crease in the loss of life in each city respectively as 
5,400, 8,204, 951. and 1,853, a total for these four cities, 
without allowing for increased population, of 16,408 
lives. By means of a preliminary table from the 12 
census a reduction of varying numbers per 100,000 pop- 
ulation was shown in 30 large American cities. <i 

By a table including 67,748 patients treated in the 
Metropolitan Asylums Board Hospital a decrease in 
death rate of 15.24 per cent, was shown. By a table 
from the South Department in Boston, reporting 16,544 
cases, a decrease of 29.26 per cent, was shown. In the 
Municipal Hospital, reporting 10,219 cases, a decrease 
of 10 per cent, was proven. Dr. Royer ended his paper 
with a plea for a dose of antitoxin in proportion to 
the amount of exudate and location of exudate. Large 
doses were recommended in nasal, nasopharyngeal and 
laryngeal diphtheria. A plea was made for a more 
general use of antitoxin as an immunizing agent, and 
its use earlier in the disease without waiting for cul- 
ture returns. The dose in use at the Municipal Hos- 
pital is, for tonsillar exudate (single) 2,500 units; 
purely tonsillar (double) 5.000 units; tonsillar exudate 
with pillars and uvula or pharynx involved, 7,500 to 
10,000 units ; nasal and any other part involved or for 
laryngeal diphtheria, 7,500 to 10,000 units. Repeat the 
dose in each type of disease in from twelve to twenty- 
four hours, depending upon the sign of improvement, 
and every twenty-four hours thereafter; when a large 
amount of exudate persists, a dose of S.ooo to 7>S0O 
units is given until a good part of the exudate has dis- 
appeared. 

Dr. H. M. Fussell said he had always felt, as ex- 
pressed by Dr. Royer, that the cause of the high mortal- 
ity of diphtheria in the Municipal Hospital was their 
receiving very bad cases. He also agreed with the 
writer that the conservatism of the practising physician 
was responsible in part. A comparison of the treatment 
of diphtheria twenty years ago and now showed the 
value of antitoxin, for it is now possible to cure every 
case of diphtheria in which antitoxin is given in suffi- 
cient doses in the early part of the disease. 

Dr. A. A. Eshner referred to the intravenous em- 
ployment of antitoxin in malignant cases of diphtheria, 
and to its employment by the mouth. 

Dr. Royer, in closing, said that they had used the 
intravenous administration of antitoxin at the Municipal 
Hospital for about sixteen months in cases that seemed 
hopeless and had been gratified to see a few get well. 
He thought the method was well worth trying in malig- 
nant cases seen late. He had ' not mentioned the 
method, because he thought the practising physician 
would see the cases early and give antitoxin. 

An Unusually Severe Case of Acute Chorea 
Treated Successfully with Apomorphine. — Dr. Mont- 
rose Graham TuU reported a case of acute chorea com- 
ing on gradually in a girl, fifteen years of age, with- 
menstruation not fully established, presenting symp- 
toms of acute mania, thickened tongue, gutteral and 
unintelligible articulations, covered with a confluent, 
morbilliform, rash, and with incessant choreic move- 
ments. After all the accepted forms of treatment had 
been tried for two weeks, with absolutely no effect, the 
services of Dr. Charles S. Potts were obtained. He 
endorsed the diagnosis and treatment pronouncing it 
the severest case that he had ever seen. Everything 
else having failed. Dr. Tull concluded to try apomor- 
phine in tentative doses. One-fortieth grain was con- 
sequently administered hypodermically with remark- 
able result. The choreic movements ceased in about 
three minutes and the child slept peacefully and quietly. 



^i6 



PHILADELPHIA COUNTY MEDICAL SOCIETY. 



[Medical News 



One-twentieth grain of apomorpliine every three hours 
ty the mouth was continued for three or four days in 
addition to the arsenic which she had taken from the 
beginning, with a perfectly uninterrupted recovery. 
Within two weeks the patient went to the seashore for 
the summer and soon became perfectly well. The case 
seemeJ of value as the diagnosis and earlier treatment 
were Doth reviewed and endorsed by a specialist of 
standing and from the fact that practically all known 
means had been exhausted before apomorphine was 
used. The good results following so promptly the ad- 
ministration of apomorphine renders it of especial im- 
portance. 

Stated Meeting, held January .?_5, igo}. 

The President, James M. Anders, M.D., in the Chair. 

Specimens Illustrating the Need of Early Opera- 
tion in Surgical Diseases of the Abdotnen, — Dr. John 
B. Roberts exhibited these specimens, the first of which 
was stricture of the sigmoid flexure due to ulceration 
of the mucous membrane. A diagnosis of obstruction 
of the gastro-intestina! canal in the neighborhood of 
the pylorus and duodenum was made. The condition 
of the patient was so bad that a jejunostomy alone 
seemed possible. This was done for the purpose of 
feeding the patient prior to a more extensive examina- 
tion of the abdomen and operative relief of the condi- 
tion found. Death occurred after a few days from ex- 
haustion. It was then found that the obstruction was 
in the sigmoid flexure. Early operative relief would 
almost certainly have been accomplished by excision of 
gut or intestinal anastomosis. The second specimen 
showed a perforated duodenal ulcer close to the pylorus. 
A time for operation was appointed, but before opera- 
tion was done perforation occurred. Immediate opera- 
tion was then advised as a last resort, but the patient 
and his friends would not consent. Dr. Roberts believed 
there was little doubt that a gastrojejunostomy done a 
day or two prior to the time of perforation would have 
saved this patient's life. The third specimen was a 
perforated appendix removed from a case which had 
come under Dr. Roberts' care about forty hours after 
an attack of abdominal pain. When he saw the man 
his pulse was i6o and very feeble. His hands were 
cold, his face was covered with a clammy sweat and 
the abdomen distended and painful. Believing that 
operation would almost certainly result in death Dr. 
Roberts abstained from even opening the abdomen. 
Autop.sy showed the lower abdomen full of pus with 
a gangrenous opening in the appendix big enough to 
admit a lead pencil. ']"he fourth specimen was a large 
gall-stone measuring an inch and a half by three-quar- 
ters of an inch from the gall-bladder of a woman who 
had suffered for a number of years repeated attacks 
of pain in the region of the gall-bladder. Operation 
showed the stomach, gall-bladder, liver and omentum 
to be bound together by old and firm adhesions. The 
gall-bladder was dragged backward until its fimdus 
pointed toward the spinal column. It was entirely filled 
by this large stone. The patient had in addition a bent 
and adherent appendix from former attacks of appen- 
dicitis. . The gall-bladder was opened, the calculus re- 
moved only with great difficuhy : and the appendix 
excised. Drainage through the lumbar region was 
employed and a large drainage tube introduced through 
the abdominal incision. The patient did moderately 
•well for about two days and then died from asthenia. 
The case illustrated the importance of cholecystotomy 
in the early stage of all cases of gall-stone disease. 
The fifth specimen was a globular gall-stone about 



three-quarters of an inch in diameter removed from 
the junction of the hepatic, cystic and common gall- 
ducts. The patient had great pain, persistent jaundice, 
which at the time of operation gave her a dark bronze 
color. Choledochotomy was required for extraction of 
the stone and was followed by hepatic and abdominal 
drainage. 

The specimens were shown to call attention to the 
importance of operating upon gall-bladder disease, in- 
flammations of the appendix, and obscure lesions of the 
stomach and intestines early. Dr. Roberts believes that 
the best results will undoubtedly be obtained in such 
cases by early exploratory incision, followed by opera- 
tions for relief, even if such surgical methods are em- 
ployed before definite diagnosis can be made. He stated 
that the profession and the public should realize that 
this is the teaching of modern surgery. 

Dr. L. J. Hammond attributes the delay in operation 
not always to the surgeon or physician, but very fre- 
quently to the patient who goes from surgeon to sur- 
geon and from hospital to hospital with fatal results. 

A New Saw Especially Adapted for Cranial Sur- 
gery. — Dr. H. C. Masland exhibited a saw w-hich 
seems to solve the problem of being able to enter the 
skull with safety, celerity and the most promising likeli- 
hood of prompt recovery with replacement of the bone 
flap in a vital condition. The instrument consists in 
a heavy handle to overcome vibration, a circular saw 
attached to a short shaft connecting with the flexible 
shaft of an electric motor or dental engine and a guard 
accurately regulating the depth of cut. Using either 
a detachable inner guard or a separate curved guard 
held by the left hand all irregularities in the thickness 
of the bone are divided with impunity. The saw makes 
a cut but one millimeter wide, guaranteeing a minimum 
waste of bone and replacement without sinking. The 
original opening can be enlarged by making additional 
bone flaps. 

Dr. John B. Roberts said the saw seemed to him to 
be a very efiicient instrument. He agreed with Dr. 
Masland that it did not need the guard, since in cutting 
through bone it is easy to tell by the feel when you get 
through. The rapidity with which the skull had been 
cut through showed, he thought, how much the in- 
strument would lessen the time of operation and reduce 
the time the patient would be under ether. 

Dr. T. H. Weisenburg did not agree with Dr. Mas- 
land that it was not necessary to have the saw set to 
cut thicker than a quarter of an inch, since he had seen 
some .skulls in which a deeper cut was required. 
Neither did he agree that it was not necessary to have 
a circular incision. The circular flap in his opinion is 
more easily replaced and is better for cosmetic reasons. 
He further disagreed with Dr. Masland in regard to the 
question of time and referred to Dr. Frazier's opera- 
tions in the University Hospital in which he opened the 
skull in two minutes and seldom exceeded three or 
four minutes, which he scarcely thought could be im- 
proved upon. 

Dr. Masland. in closing, referred to tlie instrument 
used by Dr. Frazier at the University of Pennsylvania. 
The width of incision made by that instrument he un- 
derstood to be an eightli of an inch at least, which he 
did not think offered as great probability of union 
through the line of incision as a cut one millimeter in 
width made by the saw which he exhibited. This 
guaranteed a minimum waste of bone, and replacement 
witliout sinking. 

The Limitations and Possibilities of Electricity 
in the Treatment of Diseases of Women. 1 )r. Bar- 
t(jn Cooke Hirst presented this paper. He has found 



April i, 1905] 



NEW YORK ACADEMY OF MEDICINE. 



617 



of late years an advantage in the use of galvanism and 
faradism in a limited number of conditions among the 
diseases of women. As a hemostatic agent in uncom- 
plicated small fibroid tumors with no other symptoms 
than metrorrhagia, he regards it as one of the most 
efficient possessed by the medical profession. Tie finds 
it peculiarly useful in the treatment of amenorrhea and 
sterility the result of imperfect development, or atrophy 
of the uterus. Two illustrative cases were reported in 
which normal menstruation was restored and conception 
occurred by means of this treatment. In one woman 
there had been amenorrhea for a year. In the other 
the menstruation had been reduced to a scanty discharge 
lasting less than a day as a result of lactation atrophy. 
The third indication was to restore tone to a paretic 
sphincter ani muscle after its restoration by surgical 
means, in cases in which repeated attempts had been 
made to restore the muscle, with failure, and in which 
there had been no contractile power exercised for a 
number of years. A fourth indication for the use of 
electric currents was found in certain types of dys- 
menorrhea associated with ill-developed uterus. Local 
treatment, however, he believes is very rarely practicable 
in such cases. This limited number of conditions Dr. 
Hirst said comprise all in which t can be hoped to ac- 
complish much by electricity. At the outset of the 
paper he disclaimed any intention to discuss the newer 
developments of electric treatment, such as the use 
of the X-rays, the ultraviolet rays and high frequency 
currents. 

The Toxic Changes in Brain and Spinal Cord due 
to Carcinoma. — Dr. T. H. Weisenburg said that the 
influence of carcinoma of parts other than the brain 
and spinal cord upon the nervous system is becoming 
better recognized. Metastasis may occur in the brain, 
where it may be either in the form of a tumor or an 
infiltration of cancer cells with the pia of the cortex 
or of the base of the brain. A case is recorded where 
basal syphilis was diagnosed, but at the autopsy a metas- 
tatic cancer was found. This teaches that whenever 
cerebral symptoms occur in the course of carcinoma, no 
matter in what form they appear, metastatis should be 
thought of in the diagnosis. In the spinal cord, metas- 
tasis generally involves the spinal vertebrx, causing 
a pressure myelitis. Cases are recorded where during 
the course of the disease such symptoms as mental 
apathy, dementia, hemiplegia and aphasia occur. These 
are undoubtedly of toxic origin. Instances have been 
recorded by the writer of bulbar symptoms and de- 
mentia. In these cases a careful microscopical ex- 
amination of the brain and spinal cord demonstrated 
alterations in the nerve cells of the medulla oblongata 
and pons. In another case where there were no cere- 
bral symptoms, changes were also found in the nerve 
cells of the cortex. Such findings have not been pre- 
viously recorded. 



NEW YORK ACADEMY OF MEDICINE. 

Stated Meeting, held January I2, igos. 

The President, Charles L. Dana, M.D., in the Chair. 

Portrait of Dr. Detweiler. — The first business of 
the evening was the presentation by Dr. S. A. Knopf 
of a portrait of Dr. Detweiler, the distinguished Ger- 
man tuberculosis expert, who died just a year ago. 
Detweiler had been an army surgeon in his younger 
days and contracted tuberculosis in the discharge of 
his duty, for which he was treated successfully by 
Brehmer at Gerbersdorf. Here he stayed for six years, 
eventually becoming Brehmer's assistant. Then he 



founded a sanitorium of his own at Falkenstein. This 
situation was only 1,200 feet in altitude, and Detweiler 
successfully impugned the teaching that altitude was 
necessary in the successful treatment of tuberculosis. 
His experience at Falkenstein showed that climate is 
entirely of secondary importance in the treatment of 
tuberculosis. He was the first who insisted that out- 
door air, even in cold weather, the patients resting 
quietly in chairs, is the most important element in the 
therapeutics of tuberculosis. This principle has now 
come to be adopted by all sanatoria. Detweiler was. 
tlie first to establish sanatoria for poor patients suffer- 
ing from tuberculosis. His most wonderful quality was 
his influence over his patients. As he frequently said,, 
the physician of the tuberculosis patient must be more 
than a friend, he must be a father confessor. Dr. Det- 
weiler came to occupy a very special place in the affec- 
tions of his patients. His birthdays were celebrated 
as special feast days, and cured patients, remembering 
his goodness, helped him to accomplish many things 
for the tuberculous poor. He was a man who had saved 
more lives than many distinguished generals have de- 
stroyed. He was a greater hero than a talker, and it 
is but fitting that his good deeds should be remembered 
at least by his brother practitioners. 

Methyl Alcohol and Neuritis.— Dr. Smith Ely 
Jelliffe said that the recent sensational reports, so 
many of which were unfortunately true, with regard to 
blindness and death from the use of methyl alcohol, had' 
called special attention to this substance. There is 
no doubt that it causes severe optic neuritis even to 
complete destruction of the physiological function of 
the nerve in many cases. It seeins to have a selective 
action for the optic nerve, however, since other forms 
of neuritis are not reported as the consequences of its. 
use. In this it differs very decidedly from ethyl alco- 
hol, which has a tendency to produce multiple neuritis 
as first pointed out by the .'\merican observer, Dr. Jack- 
son, of Boston, in 1822. The question of multiple or 
peripheral neuritis consequent upon the use of methyl 
alcohol is of special interest at the present moment, 
hence the advisability of reporting all personal observa- 
tions that may round out our knowledge of the effects. 

Illustrative Cases. — Altogether three cases have 
been under observation in which peripheral neuritis 
seemed to be due to the consumption of methyl alcohol. 
The first case was that of a man thirty-four years of 
age, who came under the heading of a constant drinker. 
He did not go on " sprees," but every night he took a 
considerable quantity of whisky between dinner and 
bedtime. He took what he considered a very special 
brand, for which he used to pay a neighboring druggist 
twenty-five cents a quart. The druggist assured him 
that the reason why it could be sold so cheaply was 
that it was tax free. His customer thought it was 
moonshine whisky and was very proud of his oppor- 
tunity to get it. It proved, however, to be nothing 
more than Columbian Spirits, the well-known form of 
deodorized methyl alcohol combined with flavoring 
extracts and ethers so as to give it a pleasant taste. 
The symptoms complained of in this case were those 
of ordinary typical alcoholic neuritis. There was the 
characteristic drop-wrist with partial ptosis in the upper 
lids and a loss in vision which, after careful investiga- 
tion, proved to be due to optic neuritis. 

Etiology of the Condition. — There seems to be no 
doubt of the etiology of the symptoms that developed 
in this case. The man was not a beer drinker, so that 
arsenic would practically be excluded. He had nothing 
at all to do with lead or with any form of metallic 
poisoning. He had not recently had any of the in- 



6i8 



NEW YORK ACADEMY OF MEDICINE. 



[Medical News 



fectious diseases, nor was he a sufferer from any of 
the toxic dyscrasise that sometimes cause such neuritic 
symptoms. The history seemed very clear. He very 
seldom drank outside the house, and whenever he drank 
at home, it was always of this mixture of Columbian 
Spirits, and though never to excess, he took it regu- 
lary every day. The most interesting feature of the 
case is the fact that the neuritis which developed did 
not differ from that due to the taking of ordinary 
whisky, and this may serve to throw some light on 
other obscure cases. 

Painters and Shellac. — The two other cases oc- 
curred in painters who were working in an atmosphere 
of methyl alcohol, but with regard to one of whom at 
least there was a suspicion of the consumption of methyl 
alcohol by the mouth also. These men were varnishers 
who were employed in finishing desks. They worked 
in close rooms and were exposed constantly to the 
fumes of the methyl alcohol for many hours each day. 
Neither of them suffered from very severe symptoms, 
and probably their sj'mptoms would have been neglected 
for some time only for the fact that they developed 
simultaneously, and this led them to suspect their origin 
sooner than would otherwise have been the case, and 
brought them to a physician. Both of them suffered 
from hyperesthesia of the hands, though there was 
some numbing also and a parathesia, prickling sensa- 
tions. Pain was caused by pressure over the nerve 
trunks, though there was no pain in the joints. They 
did not mind their sensations until they began to lose 
power in their hands, when the motor weakness scared 
them into consultation with a physician. It seems that 
peripheral neuritis from methyl alcohol is caused by the 
breathing in of the fumes. De Schweinitz has reported 
some cases of optic neuritis due to this cause. 

Comparative Toxicity of Alcohols. — All the alco- 
hols of this series are toxic, but in an ascending scale 
from methyl alcohol to amyl. Methyl alcohol, or wood 
alcohol, as it is called, is cumulative in its effect and the 
others are not. This seems to be due to the fact that one 
of the most important effects of methyl alcohol is a great 
retardation of oxidation. Methyl alcohol remains more 
or less unchanged when in contact with the tissues, and 
as a consequence continues to e.xert its influence. There 
is usually associated with it some formaldehyde and 
formic acid which adds to its toxicity. In recent years, 
owing to the making of odorless wood alcohol, so-called 
Columbian Spirits, there has been much more abuse of 
it than has come to light. The Board of Pharmacy in 
New York City have reported its use in tinctures. It is 
surprising that more peripheral neuritis has not been 
reported from its use. It seems probable, however, 
that deaths from its use come so soon that peripheral 
neuritis has no time to develop. It acts upon the 
ganglion cells of the retina particularly, but also on 
the other important cells of the central nervous sys- 
tem. 

Experience at Bellevue.^Dr. Alexander Lambert 
said that in spite of the rumors of the use of methyl 
alcohol for the adulteration of cheap whisky, the ex- 
perience of methylic poisoning at Rellevue is not large. 
In the last ten years some 50,000 to 60,000 alcoholics 
have been treated in the wards at Bellevue. Of these 
nearly 15,000 have been in Dr. Lambert's service. Per- 
sonally he has not seen any one suffering from what 
he considered wood-alcohol poLsoning, and he has seen 
no blindness. Bellevue is the place to study the effect 
of bad whisky. Avenue A whisky frequently produces 
symptoms of acute poisoning with symptoms of rapidly 
increasing collapse. This often proves fatal. At times 
a variation of the symptoms consists of furious delirium. 



Some of these patients when asked how much liquor 
they had taken, say " a drink or two." '1 hey will con- 
fess to taking this much before breakfast. Further in- 
vestigation, however, shows that by a drink over on 
Avenue A is meant ten cents worth, and ten cents 
worth is, as a rule, a pint of whisky. A quart of whisky 
before breakfast will knock out most men. As a con- 
sequence of this excess in drinking, the pathological 
symptoms found post mortem are very intense, affect- 
ing particularly the stomach and duodenum. 

Seaside Sanatoria for Surgical Tuberculosis. — 
Dr. Linsly R. Williams read this interesting paper. 
There are now many sanatoria for children along the 
seashore in various countries for the treatment of tu- 
berculosis. Contrary to the experience with adults, 
salt air and sea-bathing seem to be the best possible 
treatment for scrofulous conditions in children. The 
application of this principle to surgical tuberculosis, 
however, is as yet very incomplete. An English surgeon 
said not long since that the surgical treatment of tu- 
berculosis is scarcely justified in large city hospitals. 
In orthopedic hospitals, the necessity for fresh air and 
sunshine is well understood, and children are- sent to 
country homes during the summer and come back won- 
derfully improved. The French have demonstrated 
that surgical tuberculosis patients do extremely well in 
seaside sanatoria. 

Experiment in this Country. — Accordingly it was 
resolved to try the affect of life near the sea on pa- 
tients suffering from surgical tuberculosis here in New 
York. In June, 1904, tents were erected on Coney Island 
and the patients were instructed to live as patients suf- 
fering from pulmonary tuberculosis. The cribs were put 
outside in the summer on a piazza and the fullest ad- 
mission allowed to the wards. As the fall came on 
and the days grew quite cool, the children were kept 
warm by means of hoods and gloves, though there was 
practically no complaint of the cold. The effect upon 
the children has been most marked. All of them are 
in much better condition, and the average gain is nearly 
ten pounds in weight. The children were instructed, 
as were also the nurses, with regard to the care of the 
mouth and the teeth of the patients. In children suf- 
fering from tuberculosis in tissues outside the lungs, 
this seems an especially important matter, since the 
avenue of entrance for the tubercle bacilli may some- 
times be carious teeth, and then poor teeth always dis- 
turb the eating and thus hinder the improvement of 
the children's health. No special medication was 
given, though in some cases arsenic and iron were con- 
sidered to be indicated and were used. When this 
group of children who had been all summer in tents, 
and during the colder weather in a frame building on 
Coney Island, is compared with a corresponding group 
of hospital children, the contrast is very striking. Any 
one who sees them will not want to take the responsi- 
bility for treating surgical cases in the city. 

The Fresh-Air Element.— Dr. J. W. Brannan, in 
discussing Dr. Williams' paper, said that the results have 
been excellent almost beyond expectation. Evidently 
the most important factor has been the air. While the 
French were the first to introduce this method of treat- 
ment, they seem to fear the night air. The fact that 
many of Dr. Trudeau's patients live outside all the time 
contradicts any idea of special liarm in the night air. 
The most interesting thing at the present time among 
these children is to find that though playing outside 
nearly all the day, their hands are as warm as toast. 
Of course the children must be kept for a considerable 
period in such favorable condition. In France they do 
not expect a cure of joint tuberculosis under two years. 



i 



April i, 1905] 



NEW YORK ACADEMY OF MEDICINE. 



619 



The French think the sea air is better than mountain 
air, and one thing is certain, that the amusements sup- 
plied for children on the seashore constitute a running 
series of temptations for them to be outside most of 
the time, and this is the important element in their 
treatment. 

Children Comfortable. — Dr. Virgil P. Gibney said 
that in his visit to the wards, while he himself found 
it at time so cold as to be almost uncomfortable, the 
children not only did not complain of it, but they 
had become used to it and did not mind it. He con- 
siders that the sea air is an important consideration in 
the matter and feels that it would be a mistake not to 
give children such opportunities as are afforded by this 
seaside work. The cases sent were not selected and 
the results are enough to convince any one who might 
be dubious of the benefits that accrue from this outdoor 
air treatment, of cases of surgical tuberculosis. 

Absence of Symptoms. — Dr. Charlton Lewis said 
that one of the most striking features of the sanatorium 
was the absence of all the usual symptoms of discomfort 
in the children. In order to convince himself, he spent 
one night down there and found there were no night 
cries and no starlings in the sleep, though such symp- 
toms are not unusual in children suffering from tu- 
berculous joiiits, even after considerable improvement 
has come. The temperature at night in the room was 
32° to 44° F., but the children did not complain, and 
their heads and ears were kept warm by means of 
hoods. The experience undoubtedly shows the -value of 
fresh air for these patients. 

Drugs for Tuberculosis. — Dr. .Abraham Jacobi said 
that while he appreciates thoroughly the helpfulness of 
fresh-air treatment for tuberculosis, he does not con- 
sider, in children particularly, that the affection could 
ever be left entirely untreated. There are certain drugs 
that always do good, and to neglect their use at the time 
when patients are especially susceptible to their good in- 
fluence is a sad mistake. Wagner pointed out years ago 
that when phosphorus is fed to dogs suffering from 
fractures of bones, the good effect of it could plainly be 
perceived. Dr. Jacobi has found phosphorus of ex- 
cellent service in subacute or chronic osteitis and in 
other forms of bone tuberculosis. The phosphates 
should not be employed for this purpose, because they 
are inert. Dr. Jacobi has also found that guaiacol, the 
active principle of creosote is a much better drug to use 
where there are pulmonary symptoms than creosote 
itself, and it saves considerable disturbance of the stom- 
ach, besides being more directly therapeutic. Phos- 
phorus of course is also of service in rachitis, and es- 
pecially in bone lesions. 

Injections for Syphilis. — Dr. H. G. Klotz read a 
paper on Intramuscular Injection of Insoluble Prepara- 
tions of Mercury in Syphilis. He said that this method 
of treatment is undoubtedly the best, though unfor- 
tunately it is somewhat suspected by ordinary medical 
practitioners. Personally he has given some 2,500 in- 
jections and has had no bad results of any kind. He 
has given in various cases from one to forty-two in- 
jections, usually suspended in oil or liquid vaseline, and 
his custom is to give four to six series of six or eight 
injections at a week's interval and then consider that his 
patient has all that is necessary. The most interesting 
and important feature of this method of treatment 
is the small amount of mercury needed for a cure. In 
some cases not more than 10 grains have been employed 
in all. In most cases, the limit has been about 40 
grains. Of late years he has discarded the use of iodide 
and has treated tertiary manifestations by mercury 
alone. He has often seen relapses that took place under 



mixed treatment become better under the injection treat- 
ment almost at once and then remain thoroughly under 
control. His favorite drug has been calomel. This is 
so prompt in its manifestation that he inclines to agree 
with the specialist in syphilis, who said that one injec- 
tion of calomel is sufficient to differentiate malignant 
disease from syphilis. The promptness of relief is one 
of the most prominent traits, and even the severest 
manifestations come under its influence at once. 

Some Contraindications. — His custom has been 
to give the calomel injections deep into the muscles of 
the buttocks, and he has not often seen nodules as the 
result of it. Altogether there has been four abscesses in 
2.500 cases. Where the occupation of the patient re- 
quires the going up and dowji stairs much, the injec- 
tion treatment is not suitable, and it will be a matter of 
regret if employed. In syphilitic patients who are suf- 
fering from tuberculosis and who are weakened in con- 
stitution the result will not be favorable. Dr. Klotz 
has never seen albuminuria except in one case where 
some albumin had been seen previously in the urine. 
Cases of diabetes were not unfavorably affected by the 
injection treatment, but, on the contrary, seemed to do 
better than those treated by , mercury by the mouth. 
Where albuminuria was present, this was not in- 
creased by the use of injection, and it is evident that 
they have no spiritant effect upon the kidney. 

Fashions in Treatment. — Dr. Edward L. Keyes 
said that there are fashions in the treatment of syphilis 
and that at different times the disease has been treated 
in different manners. Personally he has found the use 
of intermuscular injections of the salicylate of mercury 
of great service. This acts as promptly as fumigation 
and is much less bothersome of administration. Dr. 
Keyes has not seen salivation produced by this means. 
He considers it rather important, however, not to make 
syphilis too light a thing for the patient, as otherwise 
there is a tendency to neglect the general health, which 
may encourage the development of the quaternary symp- 
toms of the disease. As is generally recognized now, 
these are the most important features of the disease, 
and must always be considered in every case. If light 
doses of mercury are continued for at least two years 
after syphilitic infection, patients are prone to take 
better care of their general health, and it is a matter 
of common conviction that it is in patients who neglect 
this feature of the care of their disease that the organic 
nervous diseases develop. Symptoms must be treated 
as they occur, and in case of fulminant symptoms, mer- 
curial injections are important. 

Certain Advantages. — Dr. Prince A. Morrow said 
that it is now more than twenty years since he read a 
paper before the Academy on the " Treatment of 
Syphilis by Injection," and the method has come out of 
the tentative stage. It seems better, however, to draw 
out the treatment of syphilis than by intensive mer- 
curialization to prevent symptoms and so lead the pa- 
tient perhaps to neglect the serious condition that still 
remains. On the other hand, it must be remembered 
that while in some cases 10 or 12 injections may be 
sufficient for the treatment of the disease, many more 
may be required. Dr. Morrow himself has used more 
than 100 in a single case. In certain obstinate symptoms 
of syphilis, the injection treatment is more efficacious 
than any other. Dr. Morrow has seen throat symptoms 
that would yield to no other form of treatment get 
better under injections of mercury and stay better. 

Reserve Treatment. — Dr. Morrow considers how- 
ever, that the injection treatment should be a reserve 
method and not the routine treatment for syphilis. He 
has seen no abscesses or other disagreeable results from 



620 



NEW YORK PATHOLOGICAL SOCIETY. 



[Medical News 



its use, but considers that the patients will take better 
care of themselves if treatment is more prolonged. In 
certain late cases of syphilis there is an idiosyn- 
crasy against potassiutn iodide, which may be best 
replaced then by injections of mercurials. On the 
other hand, when early cases of syphilis have run 
a very mild course, but the symptoms have re- 
curred severely, perhaps because of lack of care on 
the part of the patient, then hypodermics are very use- 
ful. Syphilitc neuralgias and neuritises get better more 
rapidly under this treatment than any other. Dr. Mor- 
row considers the salicylates the best form in which 
to give these injections, though in some cases of late 
lesions of the nose and throat, calomel has seemed to be 
more effective. 

Dr. Fuller said that the salicylates may be irritant, 
but they are efficacious. He uses the injection method 
more and more, and for quick results considers it in- 
dispensable. On the other hand, some patients seem 
to absorb so little mercury from the intestinal tract 
that this method is necessary. 

Rhinoscleroma. — Dr. Toeplitz presented a patient 
suffering from this rare affection. Altogether some 
six hundred cases have been reported. The disease is 
epidemic in Central Europe, but some cases of it are 
seen here in New York in emigrants. There is a spe- 
cific bacteria that causes the disease, but it is a very 
low-grade virulence, and seems only to be able to pro- 
duce its effect in persons who have been long associated 
with those suffering from the disease. The disease is of 
long duration but incurable and the slower the course 
of the symptoms the more favorable is the prognosis. 
It has been known to disappear spontaneously after 
long continued severe fevers. 



NEW YORK PATHOLOGICAL SOCIETY. 

Stated Meeting, held December 14, 1904. 
The President, Otto H. Schultze, M.D., in the Chair. 
Sarcoma of the Small Intestine with Extensive 
Metastases in the Heart Muscle. — Dr. E. Libman 
presented this case. The patient was a male, thirty- 
five years of age, who entered Mt. Sinai Hospital 
under the care of Dr. Gerster. Four years before 
admission the patient had an attack of pain in the 
hypogastrium. Six months later he had a second 
similar attack, and eighteen months later a third at- 
tack lasting five weeks. Since that time he had been 
well until four months ago, when the hypogastric 
pains returned and he developed pains in the left 
loin. These pains did not radiate downward, tho\igh 
the patient had pain at the end of the penis during 
urination. The stream was never interrupted. He 
had to get up once every night to urinate for the 
past three weeks. Three weeks before admission he 
vomited all food. He had not been jaundiced. The 
patient thought he had lost fifteen pounds. When 
examined on admission the heart dulness was found 
to extend from the right border of the sternum to 
the nipple line. The apex beat could not be felt. 
The sounds were weak and the first sound of the 
apex was short with very little muscular quality. 
The liver was enlarged and could be felt 2 cm. below 
the border of the ribs. The spleen was not palpa- 
ble. The abdomen wall was rigid. The abdomen 
was generally tympanitic, and there was marked 
tenderness just above Poupart's ligament on the left 
side. Rectal examination showed that about 4 cm. 
above the prostate there was a large mass, the size 
of an orange, which extended up beyond the reach 
of the examining finger. This tumor extended some- 



what more to the left than to the right, was move- 
able and nodular, the mass bulging into the anterior 
wall of the rectum. The patient was operated upon 
by Dr. Gerster. The appendix was found to be ad- 
herent to a large mass filling the pelvis. The niass 
was found to be a tumor involving the intestines 
so that it could not be removed. The further course 
of the patient was uneventful. The temperature was 
slightly raised. .A fecal fistula developed through the 
operation scar. 

At autopsy the thymus was not evident. There 
was left hydrothorax with hemorrhagic infarcts in 
both lungs and areas of new growth. The bronchial 
nodes w-ere enlarged, pigmented, and infiltrated. The 
posterior mediastinal nodes were also infiltrated. 
The heart weighed 510 grams. On the surface of 
the right ventricle there were several rounded hemi- 
spherical prominences, white in color and 2 cm. to 
3 cm. in diameter. All the chambers were dilated. 
The foramen ovale was slightly open. The wall of 
the right ventricle was thickened. The color was 
grajfish red, particularly near the center. The left 
ventricle was dilated and the wall was gray .in color. 
The muscle was rather friable. Evidently it was 
diffusely infiltrated by the new growth. The spleen^ 
contained a few anemic infarcts. The gall-bladder 
was diffusely infiltrated by the new growth. The 
kidneys contained several anemic infarcts, and' 
areas of new growths which shaded gradually 
into the kidney tissue proper. The posterior 
wall of the bladder was infiltrated with the 
new growth throughout all coats except the mucosa. 
There were several blackish areas on the posterior 
walls and the vessels of the trigone were injected. 
The duodenum was infiltrated over a length of 
10 cm., at which point the intestine was dilated. Be- 
low this infiltration there were several places at 
which the intestine was infiltrated for short distances 
and dilated. At a distance of 120 cm. from the be- 
ginning of the jejunum there was a very large dila- 
tation of the intestine, due to infiltration of its wall' 
by the new growth. The tumor was whitish in color 
and soft; the greatest thickness of the wall of the gut 
was V/i cm. The inner surface of the gut was ne- 
crotic and ulcerated. This portion of the jejunum' 
was adherent to the bladder, which was infiltrated 
by contiguity and was also adherent to the sigmoid 
flexure. The mesenteric nodes were greatly enlarged 
and infiltrated. There was a partial thrombosis of 
the superior mesenteric artery. 

Microscopical examination showed that the pri- 
mary tumor of the intestines was Ij'mphosarcoma. 
The heart, lungs, kidneys, spleen, mesenteric nodes, 
liver, gall-bladder, and urinary bladder showed me- 
tastases. The pancreas and the adrenals showed no- 
metastases. In the wall of the left ventricle and in 
the septum there was found to be a very extensive 
infiltration by the new growth, the individual muscle 
fibers being crowded apart by the cells of the tumor. 
The fibers were markedly degenerated. The growth 
was found to begin in the intestinal submucosa and 
to infiltrate between the muscle bundles. Special 
points of interest about the case were the dilatation 
of the intestine, which often occurs in lymphosar- 
coma of that viscus. There was, also, no ascites 
and no enlargement of the external lymph nodes. 
The growth of the tumor in the pelvis and the inva- 
sion of the bladder is a characteristic of some of 
these tumors which deserves more attention from a 
clinical standpoint than has heretofore been given. 
The duration of the disease was longer than that of 
any other case seen by the speaker. This would lead 



Al'RIL I. HJ05] 



NEW YORK PATHOLOGICAL SOCIETY. 



(321 



one to suspect a non-malignant tumor or a tubercu- 
losis of the intestine. Most cases died within nine 
months, though Rutherford had described one case 
with a duration of two and one-half years. The in- 
volvement of the heart was the most striking feature 
of this case. Although a note was made on admis- 
sion to the hospital that the first sound had very 
little muscular quality, there was no suspicion that 
the heart itself was involved by the new growth. 

Dr. Harlow Brooks said that he had studied si.x 
cases of lymphosarcoma invojving the stomach and 
small intestine. Three of these presented metas- 
tases in the heart. Some years ago he had looked 
up the literature and had found that by far the 
larger percentage of cases where cardiac metastases 
occurrred were of this kind. There was evidently a 
tendency on the part of the heart to accept these 
metastases of lymphosarcoma. 

A Case of " Splenomegalie Primitif " with Involve- 
ment of the Hemopoietic Organs. — Dr. N. E. Brill 
spoke on this subject, reviewing the literature and 
giving the clinical historj' of his case.* Under the 
caption of primitive or primary splenomegaly, he 
^aid, there had been heaped together a large variet}' 
"t non-malignant enlargements of the spleen. Osier, 
in an attempt to establish order out of choas, had 
suggested that those cases of splenic hypertrophj- 
with or without anema and associated with hemor- 
rhagic tendencies should be classed under the name 
<if splenic anemia. Osier considered that the eiilarge- 
nient of the liver in the group of cases to which 
I'.anti called attention was but a terminal feature 
't the disease called splenic anemia. Attention was 
lirst called to the group to which Dr. Brill's case 
belonged by Gaucher, Picou and Raymond, and Col- 
lier. More recently two cases have been described 
by Dr. Bovaird. This class of cases, called by 
Gaucher epithelioma of the spleen, should be taken 
from among the group of splenic anemia, because 
its clinical histor}- and pathology were distinct. The 
clinical history of Gaucher's type is so distinct that 
lir. Brill had been able to state that his cases, pub- 
lished about five years ago, did not belong to the 
category of splenic anemia, but belonged to this 
type. The subject of the present demonstration was 
one of these cases. The patient died in March, 1904, 
after having been under observation since 1885. The 
heredity of this young man showed nothing of this 
type of disease. His history had been traced as far 
as the great-grandfather on the maternal side and 
to the grandparents on the paternal side. In none 
of these ancestors was there any suggestion of this 
disease. The disease has appeared only in the one 
generation. The parents of the patient had six chil- 
dren. Tlie oldest died at the age of three of maras- 
mus. The second one is now a woman of forty-five 
j'cars and is in good health. The third child was 
one of the patients described in 1901. The fourth 
was the subject of this demonstration. The fifth 
had shown in the past two years evidences of the 
disease. The sixth had died at the age of nine, 
having shown from his third year a splenic enlarge- 
ment, from exhaustion after tremendous increase in 
the size pf the spleen and liver. Thus four out of 
six children have had the disease. This patient had 
the usual infectious diseases of childhood, measles, 
scarlet fever, etc. He never had malaria nor tubercu- 
losis nor syphilis. From his third to his ninth year 
lie was not very strong, but afterward grew into a 
strong chap and had no complaints whatever except 
occasional bronchitis. At the age of fourteen he 



began to notice that he perspired rather freely; 
otherwise he was in perfect health. In 1888, when 
his sister was married, there having been no occa- 
sion for a previous examination, she herself called 
attention to a mass on the left side of her abdomen. 
On e.xamination a tremendous enlargement of the 
spleen was made out. The brother was also exam- 
ined and there was at that time no enlargement 
whatever. The next year the spleen could be felt 
111 the patient who was under consideration, the 
upper portion extending to the seventh rib. His dis- 
ease thus manifested itself first in 1889, fifteen years 
before his death. At this time he began to have 
attacks of epistaxis. These were the only manifes- 
tations of hemorrhage for some years. They would 
occur four to si.x times a year, were rather profuse, 
and lasted for a short time. During this period there 
were no signs of anemia. About four years after- 
ward, the enlargement of the spleen going on very 
slowly, a beginning thickening of the conjunctiva 
on the nasal side appeared. This was yellow white 
in color, and was much firmer and denser than a 
piiiguicula. This symptom was also noticed in the 
sister, and has since appeared in the other sister. 

During this time the blood showed no changes. 
There was a normal number of red cells, varying 
from 4,500.000 to 5,600,000. There was no increase 
in the white cells, and no disturbance of the norma! 
relations of the leucocytes. The spleen continued to 
increase in size, and nine years afterward the liver 
began to show enlargement. In 1900, the patient had 
an attack of acute collitis, preceded by a chill and 
followed by a temperature of 106.5° F- This was 
accompanied by numerous watery movements, and 
after two days by some blood and mucus. From this 
time the disease progressed very rapidly. During 
convalescence from this attack, a number of hemor- 
rhagic furuncles appeared on the body, the largest 
on the extremities. When these discharged their 
contents they left a permanent pigmented spot. A 
change in the appearance of the parts of the body 
which were exposed to the light and air also mani- 
fested itself. The skin of the face and hands became 
yellowish brown in color. There was no icterus at 
any time. There was no further pigmentation ex- 
cept that left from the furuncles. In 1902, the first 
sign of pain manifested itself in the region of the 
spleen. The spleen extended down to the crest of 
the ilium by this time. Over the bridge of the nose 
was a persistent erythema, which had made its ap- 
pearance when the patient was fourteen years old 
and which lasted until his death. In 1902, for the 
first -time, pain was noticed at the extremities of the 
tibia and femur. Up to this time there had been no 
bone pain. In June, 1902, the patient contracted ma- 
laria and the Plasmodia were found in his blood. 
.\fter this attack the first tendency to hemorrhage 
manifested itself. There now appeared permanent 
petechia scattered over the hands, legs, and trunk. 
During 190.3, he had a fairly favorable year, notwith- 
standing the treinendous increase in the size of the 
spleen and liver. He complained of no discomfort 
whatever. After 1895 the first sign of anemia ap- 
peared. The hemoglobin was about 80. From 1895 
it gradually diminished, losing perhaps one or two 
points a year until 1900, when after the attack of 
colitis it suddenly fell to 65. From this time on 
to the end of his life on March 30, 1904. the hemo- 
globin diminished until it reached 45. In March he 
complained of dyspnea. On examination the signs 
of pericarditis were manifest. The area of cardiac 



622 



NEW YORK PATHOLOGICAL SOCIETY. 



[Medical News 



(liilness increased rapidly, establishing a diagnosis 
of pericardial effusion, which Dr. Brill assumed to 
be hemoirhagic. Death occurred on March 31, 1904. 
The autopsy was made by Dr. E. Libman at mid- 
night. Dr. Libman was asked to present the results 
of the autopsy and Dr. F. S. Mandelbaum the patho- 
logical histology of the affected organs. 

Dr. E. Libman showed the liver and spleen from 
the case described by Dr. Brill, and also presented 
those from the second case which Dr. Brill had 
mentioned. The spleen in the first case weighed 
II pounds, the liver 10 pounds. In the second case, 
the spleen weighed 14 pounds, the liver over eight 
pounds. The organs in both cases presented the 
same findings, except that atheroma of the splenic 
vein was absent in the first case. The spleen was 
very firm. It was chocolate in color, with lighter 
grayish-red areas. The pulp was swollen. There 
were numerous infarcts present, some recent, some 
old. ]\Iany of these were in the periphery of the 
organ. There was no evidence of marked fibrosis 
to be seen, except where the pulp was less swollen. 
The measurements were 40 x20 x14 cm. The liver 
measured 35 cm. in width, cither lobe, 27 cm.; -the 
organ was 13 cm. thick. There was marked old and 
recent perihepatitis. On section, the organ was 
chocolate colored, of firm consistency; it appeared 
rather granular. Throughout the viscus there were 
irregular white markings varying in diameter from 
0.5 to 2 or 3 cm. They did not seem to bear any 
definite relation to the lobular markings. The peri- 
cardium was distended by two liters of very bloody 
fluid. The lymph-nodes in the thorax and abdomen 
were enlarged. The largest were about the size of 
a large bean. They were fairly soft, and were of a 
peculiar ochre color, some showing hemorrhagic 
areas. The bone marrow in the first case was quite 
firm, dark red in color. In the second case it was 
partly red and partly ochre-colored. 

Dr. F. S. Mandelbaum described briefly the histo- 
logical picture of the case. The characteristic fea- 
ture of the disease was a very marked endothelial 
hyperplasia. This was found in the spleen, liver, 
lymph-nodes, and bone marrow. The picture found 
in the case followed very closely, with a few excep- 
tions, the case described by the French writers and 
Dr. Bovaird, as mentioned previously by Dr. Brill. 
In the spleen the endothelial hyperplasia occurred 
in round or oval alveolar spaces. These spaces were 
the pulp spaces or venous sinuses, and were lined 
with endothelium which was normal in some areas 
and slightly swollen in others. The endothelial 
cells as a rule filled these spaces completely, though 
some of the alveoli contained a few normal pulp 
cells, while others were more or less filled with 
red blood cells. The endothelial cells varied in size 
and shape, depending on the number in an alveolus. 
For the most part they were round, oval, or polyg- 
onal. The boundaries of the cells were fairly well 
distinguished, as a rule, but in some places the cells 
were fused together and the cell outlines then were 
not clearly seen. The cytoplasm of the cells was 
slightly granular, or streaked with fine wavy lines, 
arranged in a more or less concentric fashion, giving 
a wrinkled appearance to the cells. The nuclei were 
relatively of small size. The cell body measured 
anywhere from 17 by 21 micra to .34 by 47 micra, 
while the nuclei varied from S to 8 micra in size. 
Tn some of the cells several nuclei were found, as 
many as six or more being present in some cases. 
These were not arranged in any particular form but 



were scattered throughout the cell. No forms pre- 
senting the usual appearance of giant cells were 
found. In other parts of the spleen dense bands of 
connective tissue were seen, also anemic infarcts 
containing small areas of necrosis. The Malpighian 
bodies were for the most part absent, though occa- 
sionally one could be seen showing a slight thick- 
ening of the walls of the central vessel. A large 
amuuiit of pigment was scattered throughout the 
sections. This was seen along the connective tis- 
sue bands and sometimes in the alveolar spaces. 
The sections of the liver presented the ordinary 
picture of a diffuse cirrhosis. There was a marked 
increase in the interlubular connective tissue with- 
out apparent effect on the liver cells. The bile ducts 
were not affected. The endothelial cells described 
in the spleen were also found in the liver. For the 
most part they were seen in the connective tissue 
spaces, but were not so clearly defined as in the 
spleen. They were also found in the lobules proper, 
either near the periphery or in the capillaries, ex- 
tending towiwrd the centei" of the lobule. The cells 
were somewhat smaller in size than those in the 
spleen, but otherwise were identical in thefr general 
appearance and staining reaction. Pigment was also 
found distributed throughout the connective tissue 
of the organ. 

The sections from the lymph-nodes were so 
changed that they appeared simply as one mass 01 
endothelial cells, with a remnant of a follicle re- 
maining here and there. With the low power one 
could sec large masses of pigment in the lymph 
sinuses and also following the reticulum of the 
node. Tne endothelial cells had the same general 
appearances as in the spleen and liver, but then- 
outlines were more definitely preservjed. Some very 
large forms were seen in these sections. The pig- 
ment in the nodes, as well as that found in the 
spleen and liver, gave the usual reaction for iron. 

In the bone marrow these endothelial cells wert 
also found, and Dr. Mandelbaum thought this to b< 
the first case of splenomegaly in which their pres 
ence in the marrow had been noted. They wer. 
found attached to the walls of the capillaries and 
to the reticulum of the bone marrow. In several 
places these cells were seen in the lumen of th( 
capillaries. They had the same features as in tin- 
other organs. As far as the deductions to be drawn 
from these sections were concerned. Dr. Mandel- 
baum did not feel justified at the present moment 
in coming to any conclusions as to the consecutivi' 
involvement of the various organs, or whether tli' 
process occurred simultaneously. A modification < 
.Mallory's connective tissue stain, devised by Dr. 
Buerger, had been used in staining some of the 
sections. This brought out the markings in the 
cytoplasm very distinctly and also differentiated the 
nuclei better than most of the other stains employed. 
Dr. David Bovaird, in the discussion, said that 
these cases were of very great interest from two 
standpoints. First, the clinical; he thought the> 
liroved that there was a definite group characterized 
by this primary enlargement of the spleen which 
^iiould be separated from the other groups of cases. 
.'Shortly after the publication of his own paper, Dr. 
Brill had called his attention to this series of case 
in one family. Dr. Brill had said at that time th:. 
tlic cases reproduced the clinical picture of the caS' 
■ Uscribcd by Dr. Bovaird. In other words. Di 
I'.rill had made a clinical diagnosis of a condition 
exactly that was found in these children, and the 
autopsy findings proved that this diagnosis was cor- 



I 



April i, 1905] 



SOCIETY OF THE ALUMNI OF CITY HOSPITAL. 



623 



rect. From the pathological standpoint the condi- 
tion was of interest in the interpretation put upon 
the findings. Dr. Bovaird thought that the question 
really lay between whether this condition should be 
called a hyperplasia, or whether it should be classed 
as a tumor and called endothelioma. At a recent 
meeting of the American Association of Physicians, 
the opinion had been expressed that these conditions 
belonged in the class of endothelioma. Whether this 
condition was a tumor or an hyperplasia was one 
of those questions which only pathologists could 
discuss to advantage. It seemed that even among 
pathologists the conception of what constitutes a 
tumor was not clear enough to enable one to de- 
termine the exact position of changes such as these. 
The clinical history of these cases seemed to point 
rather clearly to some influence running in a family 
rather than to a new growth. It would, of course, 
take many other observations and much further 
study to determine this point. 

Dr. Libnian said that the absence of disease of 
the splenic vessels in the first case was noteworthy. 
In the condition described by Banti it was usually 
present. The microscopic changes in the bone mar- 
row were of great interest. There were present 
many nucleated erythrocytes, lymphocytes and mono- 
nuclear cells, neutrophilic and eosinophilic myelocy- 
tes and giant-cells in abundance. The occurrence 
of such changes in the marrow with the absence of 
abnormal cells in the blood was a remarkable find- 
ing. Dr. Libman thought that the cases showing 
the same lesions as this one — those of Gaucher, 
Picou and Raymond, Collier and Bovaird — should be 
grouped separately from other forms of spleno- 
megaly, and for the time being be called " spleno- 
megaly of the Gaucher type." Dr. Osier had seen 
the microscopic sections and had noted the resem- 
blance to Gaucher's findings. 

Recent Observations on Parasites of the Mosquito. 
— Dr. W. N. Berkeley reported some recent observa- 
tions on parasites of the mosquito. The first speci- 
men was a minute nematode worm, called by Mr. 
Henry L. Viereck, of the Connecticut Agricultural 
Experiment Station, Agamomcrnis. The speaker 
was indebted to Mr. Viereck for the beautiful prepa- 
rations shown, illustrating the egg, larva, pupa, and 
imago of the mosquito concerned (Grabltamia sol- 
licilans, formerly Ctilex soUicitans), and the para- 
sites. Mr. Viereck wrote that he had found 
Agamomernis only in the female mosquito, usually 
one only, but sometimes as many as five, in one 
body. In parasitized mosquitoes, eggs have been 
found only in one or two individuals out of hundreds 
examined. The same, or certainly a very closely 
allied parasite, had been reported as found in a dish 
of water in which pupje of Anopheles had been 
reared (H. P. Johnson, Bulletin of Neiv Jersey Agri- 
cultural Experiment Station, November 29, 1902). A 
very similar worm was described as having been 
noticed many years ago by Leuckhart (Howard, 
quoting from Stiles, Mosquitoes, New York, 1901). 
The worm was easily recognized as a nematode 
under the lower power of the microscope. The 
speaker had never had the good luck to find a speci- 
men in his own work. The second specimen was a 
red mite, smaller than a small pinhead (1.5 mm.), 
which he had discovered on two occasions, attached 
once to the thorax, once to the abdomen, of one 
of the common Culex species (not worked out care- 
fully, probably Culex impiger or Culex triscriatus) 
in the City of New York. The mite appeared to 



do little or no damage to its host. A specimen had 
been kindly identified for him by Mr. Nathan Banks, 
of the United States Department of Agriculture — 
through Dr. Howard's good offices — as the larva of 
a Hydrachnid belonging to the genus Eytais. Dr. 
Howard had wrillen as follows: "The adults of 
these mites are parasitic upon the water-bugs or 
' water-striders,' usually of the family Nepidce. Their 
presence upon the mosquito is probably accidental, 
they being probably in no sense specific parasites of 
the Culicidw." Dr. Berkeley feared that both speci- 
mens were mainly of academic interest, but thought 
that, in view of the vast hygienic and economic im- 
portance of mosquitos, their parasitology was worthy 
of systematic study. 

Studies on the Etiology of Measles. — Dr. Cyrus W. 
Field said that these studies of measles were begun 
in connection with some observations of Dr. Duval's 
during the summer. Dr. Duval devised a method of 
obtaining blister fluid in scarlet fever cases to see 
if he could obtain the parasites described by Dr. 
Mallory. He used the 'Wright stain, and therefore 
in a great majority of the slides there was absolutely 
no sign of chromatin stain. These bodies stain a 
pale blue, with a little darker blue granules through- 
out. After seeing these specimens Dr. Field had 
made some blisters on scarlet fever patients and also 
on measles and diphtheria patients. In scarlet fever, 
out of eighteen cases these bodies were found in 
fourteen. Thirteen cases of measles were studied. 
In the first six days of the rash the bodies were 
found in eight cases. After the fifth day to the tenth 
day they were not found. They were not found in 
three cases of diphtheria antito.xin rash, in erysipe- 
las, in hereditary syphilis, in an urticaria rash, in 
normal skin, or in irritated normal skin. The bodies 
found were very definite and characteristic. The 
ones considered as being of interest were those 
which stained bkie with a chromatin staining sub- 
stance in them in the form of granules or solid dots. 
The specimens were all stained with Hastings' or 
the Giemsa stain, the latter being much stronger. 
Some hanging drops and spreads had been made 
which showed some very suspicious occurrences. 
For instance, there were a number of leucocytes in 
the different fields which gave oflf pseudopodia which 
would work ofif very rapidly and in a short time as- 
sume a definite round appearance, with two, three, 
or five granules dancing rapidly and giving a much 
more striking appearance than many malarial para- 
sites. They were very numerous in freshly drawn 
serum, and when stained showed that these small 
granules were chromatin-like in their reactions. 



SOCIETY OF THE ALUMNI OF CITY HOSPITAL. 

iiSth Stated Meeting, held January 11, igoj. 
Joseph F. Terriberry, M.D., in the Chair. 

Sporadic Cretinism — Observations Based on Four- 
teen Personal Cases. — Dr. E. Mather Sill read this 
paper. The author related the history and treatment 
of 12 cases of infantile cretinism. This paper will be 
found in full in a subsequent issue of the Medical 
News. 

Dr. William P. Northrup opened the discussion of 
Dr. Sill's paper. He said that very great credit was 
dut to Horsley for the successful experiments on mon- 
keys which led directly to an understanding of the 
then obscure etiolog}' of myxedema. It rendered in- 
telligent and successful treatment possible. He then 



624 



BOOK REVIEWS. 



[Medical News 



described at great length the history of an attack of 
pneumonia which occurred in a cretin under his ob- 
servation. Except for the temperature, which rose but 
slightly above the normal, this attack ran the usual 
course, which is expected of the disease in the healthy 
individual. He said that the color of cretins was usually 
characteristic and likened it to that of tallow. He com- 
pared cretinism with a case of myxedema in an adult 
and showed that although apparently diflferent, the 
symptoms exhibited by the two types were in reality 
identical. 

Dr. Charles G. Kerley briefly reported a case of cre- 
tinism occurring in a patient three years old. He 
showed photographs taken at intervals of three or four 
days, during which time 34 grains of thyroid extract 
had been taken. Tlie change in the individual was 
so marked as to render it impossible to recoginze the 
two photographs as having been made of the same pa- 
tient. The speaker considered the diagnosis to be as 
a rule relatively easy. He usually begins treatment by 
giving one-half grain of thyroid the first day and one 
grain the second day, the dose being then kept at this 
point and improvement awaited. The signs of this im- 
provement were in his opinion first that the skin loses 
its dryness and that occasional perspiration is noticed. 
Later the mental condition shows improvement. The 
dulness and apathy are the first to give away. Then the 
weight gradually diminishes and the hair thins out. 
A constantly clammy skin is a certain indication for 
a smaller dose of thyroid. He instanced a case of cre- 
tinism occurring in a girl six years of age. She is at 
present in good health. Her treatment was temporarily 
.stopped at the second year. This was followed imme- 
diately by a return of symptoms. The hair of cretins, 
even under the most judicious treatment, will never 
become normal. 

Dr. William L. Stowell mentioned four cases of 
cretinism which he at present had under treatment. 
The first patient is a male, twenty-one years of age. 
He is three feet tall and weighs 44 pounds. He has 
gained rapidly under treatment, appears happy and is 
much pleased with toys. The second case was that 
of a female, nineteen years old. Her weight had de- 
creased by treatment, but her disposition was still un- 
improved, for she continued to be extremely quarrel- 
some. The third case was that of a boy. In many 
respects this history is remarkable. The girth of the 
trunk had diminished and the individual had actually 
gained three inches in height. In this case it was 
further noteworthy from the fact that a plaster cast 
applied for the treatment of a fractured leg liad caused 
an erosion ulcer. Under thyroid this ulcer healed very 
rapidly, thus demonstrating the profound effect of the 
secretion on metabolism. Dr. Stowell said that as to 
treatment by transplantation by thyroid glands into 
the abdominal cavity or other regions of the patient's 
body, it had been noticed that such transplantation was 
invariably followed by atrophy of the transplanted 
gland. Benefit has usually resulted for from five to 
six months only. 

Intravenous injection had been used, but was now 
virtually given up. The best treatment is probably 
the continued giving of the gland by mouth. 

Dr. Terriberry mentioned a case of cretinism which 
was particularly interesting because of the hereditary 
deductions to be drawn from it. The mother had given 
birth to two cretin children. She was then treated by 
thyroid and gave birth to a third child, which was en- 
tirely normal. 



BOOK REVIEWS. 

A Dictionary of New Medical Terms, including up- 
ward of 38,000 words and many useful tables, being 
a supplement to " an illustrated dictionary of Medi- 
cine, Biology and Allied Sciences." By George M. 
Gould, A.M., M.D., author of " The Student's Med- 
ical Dictionary," 30,000 medical words pronounced 
and defined, " The Meaning and Method of Life," 
" Borderland Studies," editor of American Medicine, 
etc. Based upon recent scientific literature. P. 
Blakiston's Son & Co., Philadelphia. 
As Dr. Gould himself says, nothing so well illus- 
trates the astonishing vitality and progress of present 
day medical science as its unparalleled multiplication 
of words ; that in a decade over 30,000 new terms 
should have been devised is almost incredible. It is 
doubtful if any other science or object of study has 
ever shown such a phenomenon. That the work of col- 
lecting the new words is well done goes almost with- 
out saying. That it is complete, its surprising size 
under the circumstances is the best evidence. Un- 
doubtedly a great many words have been admitted to 
it which have as yet scarcely vindicated -for them- 
selves a place in the language, but then the book is 
not meant so much as a language treasury as a help 
to the busy medical reader. 

Under these circumstances, however, we consider it 
unfortunate that there should be so many compulsory 
references to Dr. Gould's larger dictionary. There are 
a large number of words for which no direct definition 
is given, though phrases in which the words are used 
and compound terms of w'hich they form a part are 
freely defined. Not infrequently the consultant of the 
dictionary will have to turn to the larger dictionary for 
the essential significance which might, it seems to us, 
have readily been given in a few words without adding 
materially to the bulk of the book. This will, we fear, 
detract from the usefulness for the busy doctor, who 
unist read as he runs, of a very valuable work, 
PRiNcirLEs OF Physiological Psychology. By Wil- 
helm Wundt, Professor of Philosophy in the Uni- 
versity of Leipzig. Translated from tlie Fifth Ger- 
man Edition (1902). By Edward Bradford Titch- 
ener, Sage Professor of Psychology in the Cornell 
University. The Macmillian Co., New York. 
Twenty-eight years is a long life for a book, yet 
such is the age of the fifth edition of Professor Wundt's 
work, a translation of which is before us. 

Of the book itself it is unnecessary to speak. Work- 
ers in psychology have recognized it as the leader in its 
subject for a number of years. We congratulate our- 
selves that we have it in such a commendable form and 
felicitate Dr. Titchener on the final success of his hopes 
and ambitions. 

We feel that the present work will give a renewed 
impetus to the awakening sense of the needs of a psy- 
chological substratum for correct interpretation of mor- 
bid mental phenomena, and that the book will meet 
the requirements of the alienist more particularly, while 
also contributing largely to the culture of the progres- 
sive general practitioner. 



BOOKS RECEIVED. 

Essentials of Nervous Diseases and Insanity. By 
Dr. J. C. Shaw. Edited by Dr. S. E. JelliflFe. Fourth 
Edition. i2mo, 196 pages. Illustrated. W. B. Saun- 
ders & Co.. New York, Philadelphia and London. 



THE MEDICAL NEWS. 

A WEEKLY JOURNAL OF MEDICAL SCIENCE. 



Vol. 86. 



New York, Saturday, April 8, 1905. 



No. 14. 



ORIGINAL ARTICLES. 

FURTHER NOTES ON THE FUNCTION OF THE 

PARATHYROID GLANDS. 

BY W. G. MACCALLUM^ M.D., 

NSSOCIATE PROFESSOR OF PATHOLOGY, THE JOHNS HOPKINS UNIVER- 
SITY, BALTIMORE, 
AND 

C. F. DAVIDSON, 

STUDENT OF MEDICINE. 
OF BALTIMORE. 

In a previous paper' one of us reviewed some 
of the recent work on the physiology of the para- 
thyroid glands and recorded a number of experi- 
ments carried out with the aim of defining in 
some way those functions. Since there still re- 
mains much obscurity about this subject we ven- 
ture to make known the result of a few more 
experiments along similar lines. 

In the paper cited, experiments were described 
which tended to show that the tetany resulting 
from extirpation of the parathyroids is probably 
not an affection of the muscles themselves nor 
of the peripheral nerves, but rather of the higher 
centers of the nervous system, for section of the 
spinal cord practically abolishes tetany on the 
portion of the body thus paralyzed. After the 
publication of these results the paper of Lanz- 
first came to our notice in which he describes 
similar experiments and further the elimination 
by extirpation of the motor areas of the cere- 
bral cortex in which even an increased tetany of 
the paralyzed side was observed. We have pro- 
duced this condition once after several attempts, 
•extirpating the motor area on one side only and 
after the wound had healed, or nearly healed, 
extirpating the parathyroid glands. The dog 
succumbed to the typical tetany in which there 
was no especial inequality of the convulsive 
movements to be noted on the two sides. We 
ean therefore agree with Lanz, or at least say, 
that this is an affection of those cells which con- 
tinue the function of the muscles which are cut 
off from their original direct cortical connections. 
Exactly where these cells are it is difficult to 
say. 

In that paper there were also notes of some 
experiments which showed clearly, as the papers 
of Albertoni and Tizzoni. Fano and Zanda and 
others had previously shown, that the tetany 
coiild be temporarily relieved by bleeding and 
injection of salt solution into the veins. This 
apparently demonstrated the presence of a circu- 
lating toxin which was the cause of the nervous 
disturbance. At that time it was not found pos- 
sible to confirm this idea by producing tetany by 
the transfusion of the blood of a dog in tetany 

1 W. G. MacCallum, Medical News. Oct. 31, 1903. 

2 O. Lanz. Volkmann's klinische Vortrage, 1894. 



into the veins of another dog, either normal or 
parathyroidectoniized. Two cases were described 
there, in neither of which any symptoms ap- 
peared. Several Italian writers have, however, 
described positive results in such an experiment, 
and on that account it was again attempted. The 
experiments hardly lend themselves to tabula- 
tion so that they will be recorded briefly, in order 
as copied from my notes : 

Dog 119. — One parathyroid removed from 
each side; dog remained well. On May 3 at 
4.30 P.M., the dog was etherized and the blood 
of dog 121 transfused directly from the aorta 
into the jugular vein while dog 121 was in vio- 
lent tetany. At 5.30 p.m., on recovery from 
ether, the dog is trembling, but not in tetany ; 
7 P.M., and no definite twitching; 12 midnight, 
dog seems normal, no twitching ; May 4, dog is 
quite well. 

Dog 127. — Small puppy — May 9, 5 p.m-, right 
thyroid with parathyroids removed ; two para- 
thyroids removed from left side. Dog bled 100 
c.c. from jugular vein. Canula from aorta of 
dog 124, then in tetany, introduced into proxi- 
mal end and blood allowed to run until dog 124 
died of anemia. Animals etherized. 8 p.m., dog 
recovered from ether and no tetany — seems well ; 
1.30 A.M., dog asleep, no twitching. 

Dog 135. — Partial parathyroidectomy; dog 
bled 80 c.c. and 90 c.c. of serum of blood from 
dog in tetany run into jugular vein. No evi- 
dence of tetany. Dog died of pneumonia. 

Dog 145. — Two parathyroids removed from 
right side, thyroids with parathyroids from 
left, January 14. (From the further history it 
seems that some parathyroid tissue must have 
remained.) On February i dog seemed quite 
well. Etherized, bled 50 c.c. and 200 c.c. of 
blood from dog 147, then in tetany, allowed to 
run into the jugular vein from a funnel after 
straining through four-ply gauze. On recovery 
from ether the dog had violent spasmodic twitch- 
ings, trismus, etc., which were confused by the 
incoordination and shivering due to ether. We 
thought at the time that the dog was in tetany, 
but in the course of an hour this wore off and 
it could then only be said that the dog was 
shivering. Ne.xt day (February 2) he received, 
without anesthetic,' 80 c.c. of the same blood 
which had stood overnight. Some twitching 
appeared but soon passed off. Dog was well 
next day and remained well until March 10, 
when, almost two months after the first opera- 
tion, he had an attack of tetany with respiratory- 
distress, which however soon passed off. Dog 

I The operation of introducing the Wood is very slight and 
the animals make no objection to it; ' therefore, on account of 
the disturbing effects of the anesthetic, which are obvious in 
the decriptions given by other writers, the subsequent trans- 
fusions were done without anesthetic. 



626 



MacCALLUM and DAVIDSON: PARATHYROID GLANDS. 



[Medical News 



was then well until March 26, when he was 
found in another attack of tetany with violent 
respiratory distress, rigidity of the legs, etc. 
Two days later (March 28) dog seemed quite 
well; was bled from jugular 100 c.c. and received 
at I P.M. 150 c.c. of blood from dog 157, then 
in violent tetany. At 2 p.m., slight shivering. 
At 3 P.M., distinct shivering; dog lies quietly, 
with scattered slight twitchings ; nothing more 
definite. At 6 p.m., dog has very slight twitch- 
ing, which is declared by the bystanding dog 
fanciers to be merely shivering. No fibrillary 
tremor of tongue; dog lies quiet. Next day 
(March 29) he seemed normal enough; dog 
died April 6 much emaciated. No lesion found 
to account for death. 

Dog 151. — February 21, four parathyroids 
removed ; there was probably not a complete 
parathyroidectomy. March 6, dog seems quite 
well ; wound healed. At 5.30 p.m., bled 100 c.c. 
from the jugular vein and received 300 c.c of 
blood from dog 153 bled during tetany- The 
blood was defibrinated and introduced . into the 
proximal part of the jugular vein, a little at a 
time, during about forty-five minutes. Some 
slight tremor of limbs and head appeared during 
operation, readily felt over the legs. 6.30 p.m., 
after dog was released, nothing definite could be 
made out; tremor, if present, was remark- 
ably slight and easily confused with shiver- 
ing. 8.30 P.M., dog observed with care imdcr 
strong light. There is. while he walks about, no 
evidence of any disturbance unless it be a gen- 
eral lassitude and tendency to lie down. When 
allowed to be still the hind legs and pectoral 
muscle do twitch distinctly, even when he is 
lying on a warm wooden surface. 11 p.m., same 
conditions ; nothing observed when walking, 
slightest tremor on remaining quiet. Next day 
the dog seemed quite normal. Alarch 8, dog has, 
at 9.30 A.M., slight definite tetany. Next day 
(March 9) dog was quite normal, and from 
then to April 17 the condition remained the 
same. On April 17, at 12.30 p.m., dog was bled 
100 c.c. from jugular vein and received 150 c.c. 
of blood from dog 152 killed in tetany. Dog 
runs about after operation ; slight shivering, no 
other disturbance; no definite tetany; 1.30 
P.M., dog shivering quite violently, but no defi- 
nite tetany; 3.45 p.m., laid in sun on a warm 
table for a while. It is so warm there that he 
can hardly be shivering. Dog lies perfectly 
quiet, while slight but distinct twitchings can 
be both seen and felt. The hair over the twitch- 
ing area makes definite excursions. This is 
most marked over shoulders and thighs and 
respiration not aflfected. .^t 10.30 p.m., twitch- 
ing had stopped ; April 18, normal. 

Dog 186. — December 23. complete parathy- 
roidectomy ; December 24, dog in violent tetany 
at 4 P.M., with rigidity of limbs, dyspnea, tachy- 
pnea, etc.; 4.30 p.m., bled about 100 c.c. or a 
little more from jugular vein. By this time the 
tetany had liecomc reduced to a play of muscu- 



lar twitchings over the body, and a distinctly 
rapid but not violently labored respiration. 100 
c.c. salt solution introduced into the jugular vein. 
Within four or five minutes the respiration be- 
came normal and the tetany was reduced to a 
scarcely perceptible twitching of a few muscle- 
bundles, the upper eyelids, which had been much 
retracted, became normal, and dog was allowed 
to run about. At 5.20 p.m., or about half an 
hour after the previous bleeding and infusion 
had been completed, the blood which had been 
defibrinated was returned to the veins. No in- 
crease in the very slight twitchings. 6.30 p.m.. 
dog in same condition. Observed again at 7.30 
p.m. and at 12.30 .\.m., but no return to the vio- 
lent tetany could be observed. December 25, 
dog shows no tetany and seems to be in good 
condition. December 28, dog still without evi- 
dent tetany, runs about. Tetany did not reap- 
pear, and by January 10 the wound had healed 
and the dog seemed pretty well. The thyroids 
were then removed and two bits of parathyroid 
tissue were discovered embedded in them. This 
dog had, therefore, developed tetany upon thi 
incomplete removal of the parathyroids. 

It is apparent from these cases that no very 
intense tetany can be produced by the intra- 
venous injection of blood taken from a dog dur- 
ing tetany, even when the subject of the experi- 
ment is an animal deprived of most of its para- 
thyroid tissue and subject to occasional attacks 
of tetany, as in dog 145. In the last experi- 
ment (dog 186) the dog was subjected to this 
test practically during the attack of tetany, but 
the introduction of the salt solution to produce 
the non-tetanic condition makes it no longer 
possible to expect the pure eflfects of the intn- 
<luction of such toxic blood in a dog known tc 
l)e disposed to tetany, for the experiment finally 
amounts to the simple introduction of 100 c.c. of 
salt solution into the veins of a dog in tetany 
which would doubtless stop the t-tai!\. Two 
attempts were made to cause the disappearance 
of tetany by the mere removal of blood and its 
reappearance by the reintroduction of the blood, 
but unsucessfully. 

Dog 179. — Medium-sized female. Thyroids 
and parathyroids extirpated Januarv 16; dog 
found in violent tetany January 19 with marked 
respiratory disturbances, and from one period 
of a])nea was restored only by vigorous arti- 
ficial respiration. Bled about 150 c.c. from the 
carotid, after which the respiration remained 
irregular, being rapid for perhaps twenty sec- 
onds, returning then to the normal rate. The 
rigidity and twitchings were somewhat im- 
proved but the dog was still pretty stiflf. In the 
course of further bleeding, in the attempt to 
cause the disappearance of the tetany, the trem- 
ors did seem to disappear but the dog was mori- 
bund and died. 

Dog 192. — Young dog- Parathyroids re- 
moved February 13 ; violent tetany February 
14: bled 175 c.c. anrl 150 c.c. salt solution intro- 



April 8, 1905] 



MacCALLUM and DAVIDSON: PARATHYROID GLANDS. 



627 



duced into veins. Rigidity and tremors dis- 
appeared within twenty minutes. Half an hour 
later the defibrinated blood was reintroduced 
into the veins, causing marked congestion. The 
dog continued to lie quietly on the floor, appa- 
rently quite comfortable. From February 14 to 
February 21 he seemed fairly well, although 
rather apathetic — no tetany. On February 21 
the dog again developed violent tetany with 
respiratory distress. Attempted to bleed and 
reintroduce the blood without salt solution, but 
the animal succumbed after the removal of about 
125 c.c. of blood, while still showing definift 
tetany. 

It is doubtful whether one could place any 
reliance upon observations made upon an animal 
bled to such an extent, at any rate, for the 
characteristic respiratory symptoms are at once 
modified by the anemia, and the great weakness 
resulting from the anemia of the muscles has 
also its effect upon the tetany. The disappear- 
ance of tetany on the introduction of a small 
quantity of salt solution and, especially the 
length of time during which the dog will re- 
main apparently well after such treatment be- 
fore the tetany reappears, offers some difficulties 
for explanation. 

Apparently the quantity of toxin in the circu- 
latory blood is, if one may judge from these 
experiments, extremely small and is probably 
rapidly bound up with the cells of the nervous 
system when the parathyroids are not present to 
neutralize it, so that the continued influx of a 
minute quantity serves to bring about finally the 
violent symptoms. It was thought that this 
might be warded off even after tetany had be- 
gun by the use of emulsions of fresh dog's brain 
substance which, on being injected into the peri- 
toneum, would afford an excess of suitable mate- 
rial for the linking of the toxic groups in the 
blood. This was, in fact, carried out in three 
cases, as follows : 

Dog 148. — Two parathyroids (right) one large 
parathyroid and whole thyroid lobe (left) re- 
moved on February 2. On February 4, at 9.20 
A.M., dog showed slight twitching, which gradu- 
ally increased until 4.30 p.m. The emulsified 
brain of a normal dog mixed with salt solution 
injected into the peritoneum. At 8 p.m., tetany 
was milder, but at 10 p.m. very violent. Next 
day. (February 5) dog seemed quite well all day 
— no twitching whatever, but somewhat somno- 
lent. The third day, February 6, tetany reap- 
peared and continued all day, being very violent 
in the afternoon. At 2.30 p.m., the brain of 
another dog was emulsified and injected into the 
peritoneum. The fourth day (February 7) 
there was moderate tetany and for six days fol- 
lowing the dog apparently was in fairly good 
condition, becoming, however, gradually emaci- 
ated. Death on February 13. 

Dog 150. — Complete parathyroidectomy: after 
four days violent tetany. Brain emulsion in- 
jected into peritoneum. Dog seemed to recover 



and stood up and walked about. Found dead 
next day, however. 

Dog 154. — March 5, complete parathyroidec- 
tomy ; March 8, beginning tetany — rather vio- 
lent toward noon. Emulsion of brain injected 
into peritoneum. Dog recovered from tetany 
but sank into an apathetic condition, which 
lasted five days and ended in death. 

Whether the action of the brain emulsion was 
such as is suggested above, or merely such as 
the injection of so much salt solution, or, still 
more probable, of so much emulsion of any 
other organ from a normal dog or of blood, it 
is hard to say. It is, indeed, curious to observe 
how slight a thing may suffice to stop the 
tetany. A whiff of ether will cause a complete- 
cessation of tetany, usually also with cessation 
of the respiration, while the heart goes on for a 
time. The animal may be restored by artificial 
respiration, but unless this is prompt he dies. 
The tetany may reappear at once or it may re- 
main absent for some time; particularly is this 
true as it seems, if any operation is performed 
on a dog while in tetany. When, however, the 
tetany is very severe these things affect it but 
little. Various sedatives, such as morphine, when 
given in rather large doses, will cut short the 
spasms, and when somnolent from the effects 
of such a drug the dog shows spasmodic move- 
ments only when frightened or on exertion. 

Mention was made in the previous paper ofT 
the work of Verstraeten and Van der ;Linden,. 
in which they attempted to show that, when fed 
on milk alone or on bread and water, [iarathy- 
roidectomized dogs were less liable to , violent 
attacks of tetany. They thought that t in this- 
way they had in some degree explained t;he sup- 
posed immunity of the herbivora from this coip- 
dition of tetany. Although a case was there 
quoted which seemed to support their statement 
— a dog parathyroidectomized and fed on bread 
and water, which lived for twenty days without 
tetany — it seems, from more recent experiments. 
that the nature of the food has but little influ- 
ence upon the course of the tetany. 

Dog 144. — January 12. Complete parathy- 
roidectomy; exclusively milk diet; January 14, 
distinct tetany, rigidity of legs, etc. Used after 
this for other experiments. 

Dog 146.— Fed for two days on milk alone 
and this diet continued throughout. January 16, 
complete parathyroidectomy, one thyroid lobe 
being also removed. January 20, dog in violent 
tetany; given morphine and became somnolent. 
Tetany ceased; January 21, no tetany. January 
22, violent tetany and death. 

Dog 150.— February 9, given no food at all; 
February 10, given no food. Epsom salts pro- 
duced purgation; intestines apparently cleaned 
out; February 11, complete parathyroidectomy; 
still given no food; February 12, dog seems 
well, no tetany; February 13. dog found in vio- 
lent tetany this morning. Since February 9 has 
had nothing whatever to eat. 



628 



MacCALLUM and DAVIDSON: PARATHYROID GLANDS. 



[Medical News 



From these cases it appears that even when 
the intestinal tract is quite empty before and 
after the operation, tetany will develop with the 
maximum intensity ; and the suspicion enters 
one's mind that possibly the explantion of the 
freedom from tetany in Verstraeten and Van 
der Linden's cases was, as it is in so many 
other negative results in connection with the 
tetany of parathyroidectomy, due to incomplete 
extirpation of the parathyroids. 

Many writers on the subject of the symptoms 
resulting from extirpation of the parathyroids 
state that the animals may die either of the well- 
known tetany, or they may sink into an apathetic 
condition, becoming daily more and more emaci- 
ated, and perish after a number of days in an 
extraordinary cachectic condition. The ques- 
tion enters one's mind as to whether this is the 
direct result of the complete extirpation of the 
parathyroid, or possibly due to infection of the 
wound, or to modification of the usual tetany 
by the leaving behind of some minute portion 
of parathyroid tissue. It is to be noted that this 
condition of protracted poisoning may ensue 



The cases of this sort which occurred in our 
series are noted below. 

Further, there were at least two cases, such 
as 1 20 and 186, in which the repeated bleeding 
and infusion of salt solution warded off or re- 
lieved the tetany, which would otherwise have 
been quickly fatal, and allowed of the develop- 
ment of the slower process of poisoning. In 
some of these cases, such as 144, 171, and pos- 
sibly also 169, the infection of the wound and 
the development of abscesses may have played 
an important part in the production of the 
Symptoms ; in others, however, such infections 
as are evidenced by an intense coryza, conjunc- 
tivitis and scattered skin pustules seem to be the 
result of the lowered resistance rather than the 
cause of the condition. The stupor and 
cachexia seem not to depend upon the coinci- 
dent removal of the thyroid which was carried 
out in some cases, for it was quite as marked 
in the cases of simple parathyroidectomy. It is 
interesting that in at least one case (169) the 
parathyroidectomy was certainly incomplete, 
and there seems to be a good deal in favor of 



Dog. 



125 
132 

144 

160 
167 

169 
171 



Duration of Exp. 



9 days 

20 days 
16 days 

II days 

7 days 

5 days 

6 days 
10 davs 



Organ extirpated. 



Results. 



Thyroid and parathyroids 

Parathyroids 

Parathyroids and one lobe of 

thyroid 
Parathyroids 

Parathyroids and thyroids 
Parathyroids 

Partial parathyroidectomy 
Parathyroids 



Slight tetany, conjunctivitis, gradual emaciation and 

weakening. 
No tetany, emaciation (bread and water diet). 
No tetany, gradual emaciation. 

Tetany repeatedly relieved by morphine, multiple ab- 
scesses, emaciation, apathy. 

Conjunctivitis and coryza, emaciation, cachexia. 

Tetany, thyroidectomy ; tetany continued, cachexia and 
death. 

Gradual cachexia, tetany, slight infection, died at night. 

Gradually developing stupor, tetany on sixth and sev- 
enth days, extensive infection of wound, etc. 



when, after tetany is once well developed, its 
course is interfered with by washing out of the 
blood, etc. Often, too, when the symptoms of 
tetany are particularly mild and consist only in 
slight twitching, the progressive emaciation may 
be associated and in time lead to the death of 
the animal. This atypical course of the symp- 
toms of parathyroidectomy is, however, not 
especially common, and in the majority of cases 
in which the parathyroidectomy is performed 
tetany appears frankly. Thus of our 39 cases, 
which were not known to be partial extirpation 
only of the parathyroids, tetany developed a 
well-marked form in 35. In all but two cases 
there was at some time twitching of the mus- 
cles, and possibly this was true also of those 
two and would have been recorded had they 
been more minutely watched. The fact remains, 
however, that in a certain small number of cases 
the tetany does not develop with its usual rap- 
idly fatal result, but is overshadowed by the 
gradually increasing stuporous and cachectic 
condition, appearing in the course of this only 
as a moderate twitching of the muscles. 



the idea that the absence of a tetany sufficiently 
violent to produce death at once, thus allowing 
the development of symptoms from the more 
general poisoning of the tissues, is due to the 
existence after the operation of some trace of 
parathyroid tissue — just sufficient to ward oflf 
the violent tetany, while not sufficient to main- 
tain health.' The same explanation will apply 
perfectly to the results of washing out the blood 
at tlic beginning of the violent tetany. 

We have made several attempts to control 
llu' course of the tetany following parathyroid- 
ectomy by injection of parathyroid material. In 
the literature this has been attempted with vary- 
ing results. Edmunds- fed a large quantity of 
parathyroid material to an animal in tetany with- 
out result. Vassale" obtained good results from 
the emulsion of thyroids in which the parathy- 
roids were included, and Gley* confirined these. 

1 Since this w.ns written further cxnmination of the tissues 
of doR 186. removed at a second operation, showed that while 
the tetany had been nnitc intense there were still two portions 
of pnrathyroid tissue left imbedded in the thyroid. 

2 F.dmunds. Brit. Medical .Tournal, 1901. 
.1 Vassale. Rev. Sper. de Ffematria, 1800. 
iClcy. r. R. d. la Soc. dc Hiol., 1891. 



April 8, 1905] 



MacCALLUM and DAVIDSON; PARATHYROID GLANDS. 



629 



Lusena' describes several cases in which he pro- 
longed life by transplanting parathyroids or by 
injecting parathyroid material subcutaneonsly.. 
His results are astonishingly good as compared 
with ours, for, by the subcutaneous injection of 
parathyroid emulsion for eight days and then the 
subcutaneous transplantation of one parathyroid 
every fifteen days, the dog was kept alive for 
more than four months. Others were kept alive 
for over two months by the implantation of para- 
thyroids. Lusena says nothing of the anatomi- 
cal condition of these implanted parathyroids 
after the death of the animal, but on account of 
their usual rapid degeneration it seems remark- 
able that they should have been so effective in 
preventing tetany. 

For our experiments see table on this page : 
Of these dogs the last two were most inter- 
esting, and the clinical history of one at least 
may be given in greater detail. 

Dog 170. — November 5. Parathyroidectomy 
attempted ; only two of the parathyroids found ; 
dog showed no symptoms after this ; November 
23, wound quite healed. Again operated upon 



ing: respiration quiet; runs about and eats. 
December i, condition still good. December 2 
and 3, slight twitching about temple. Decem- 
l)or 3, emulsion of parathyroid from twenty-two 
dogs injected into peritoneum. December 4, 
5 and 6, dog well enough. December 7, sHght 
twitching about head ; 1 1 a.m., parathyroids of 
eighteen dogs emulsified and injected into peri- 
toneum ; 3 P.M., dyspnea and general tetany ; 
respiration very stridulent. December 8, 8 to 
10 A.M., dog in violent tetany, lying on floor 
rigid ; inspiration difficult and squeaky ; vomit- 
ing. Emulsion of parathyroid of cow in sterile 
water injected into inferior hypogastric vein. It 
is difficult to estimate the amount (8 c.c. of a 
cloudy emulsion made from about .25 grm. of 
dried parathyroid, probably fifteen dried parathy- 
roids of cow). December 9, remarkable im- 
provement ; runs about and is playful : December 
10. twitchings in muscles of neck: given emul- 
sion of fresh dog's parathyroids (about fifteen 
dogs) intravenously; December 11. dog seems 
well, no tetany; December 12, dog seems quite 
well ; occasional slight twitching about temples. 



Dog. 


Operation. 


Tetany. 


Treatment. 


Result, 


113 


April 10 


;\pril 15 


April IS, three parathyroids of cow 
intraperitonally. 


Twitching continued. Emaciation, 
apathy ; lived five days. 


u<> 


Jan. 16. 


Jan. 20 


January 20, subcutaneous injection of 
emulsion of beef parathyroid, also 
of morphine. 


January 21, recovered from tetany. 
January 22, violent tetany and 
death. 


170 


Nov. 25 
Thyropara- 
tliyroid- 
ectoniv. 


Nov. 28 


Various injections intravenously of 
emulsion of paratiiyroids. 


Temporary relief with each injection. 


178 


Nov. 22 


Nov. 26 


One intravenous injection of parathy- 
roid emulsion. 


Recovery from attack of tetany ; death 
five days later from infection. 



and both thyroid lobes removed. On November 
28, dog was found in violent tetany, with the 
usual respiratory disturbances, etc. The right 
jugular vein was opened and an emulsion of 
parathyroid of dogs (parathyroids from twenty 
dogs ground up in 2;^ c.c. of sterile bouillon 
and strained through gauze) injected into the 
vein at 11 a.m. At 5 p.m., respiration was quiet 
and there are only slight twitchings observed. 
He walks stiffly, however, lifting his hind feet 
far too high in entering the cage. November 28. 
8 a.m., no tetany; runs about well; slightlv 
apathetic and stupid. At 1.45 p.m.. tetanv has 
begun again; 5.45 p.m., dog in violent dyspnea, 
very rigid, tetany very marked. Emulsion of 
parathyroid from thirty-seven dogs injected into 
jugular vein (the parathyroid material was 
obtained from the slaughter-house, where stray 
dogs are killed in great numbers) ; 7.30 p.m., 
dog still having severe dyspnea of Cheyne- 
Stokes character, lies on floor ; tetany is fairly 
violent. November 30. 8 a.m., dog seems greatly 
improved and is able to walk about; no twitch- 



I Lusena. Fisiopatologna 
Firenze, 1899. 



deir .\pparecchio tiro-paratiroideo. 



December 13, 8.30 a.m., well-marked tetany and 
dysjjnca, not, however, of maximum violence ; 
no parathyroid material was obtainable and the 
dog died at 3 P.M. Autopsy revealed no infec- 
tion of wounds ; organs in general, normal. Sev- 
eral accessory thyroids of small size in tracheal 
region and aortic arch. 

Evidently after complete parathyroidectomy 
the life of the animal can be maintained only 
with the greatest difficulty by the injection intra- 
venously of relatively large quantities of para- 
thyroid material. Even this, as shown in the 
case just related, was insufficient to prevent the 
repeated reappearance of the tetany, so that it 
seems probable that the cases in which the 
symptoms are relieved for a long time by insig- 
nificant doses given subcutaneously, are in- 
stances in which the extirpation of the para- 
thvroids was incomplete. From this it follows 
that the treatment of the tetany which has been 
seen to follow extirpation of the thyroid 
(with the parathyroids) in human beings, by 
the used of parathyroid extracts, would prob- 
ably be almost impracticable, although the use 
of such material might perhaps be beneficial in 



630 



MacCallum and davidsox: parathyroid glands. 



[Medical News 



those cases in which symptoms are due to a less 
intense parathyroid insufficiency. The condition 
is different from that found after extirpation of 
the thyroid alone, in that the symptoms appear 
so rapidly and are so quickly fatal that there is 
no time to apply the usual methods of adminis- 
tration of the organ extracts, which are so ef- 
fective in the case of myxedema and in which 
possibly a cumulative or continuous action is 
produced. The emulsion or extract of parathy- 
roid, to produce its maximum effect, must be 
introduced into the veins in considerable quan- 
tity.' After this process the result may be 
astonishing', as illustrated bv our notes on dog 
178: 

Dog 178. — November 26, 4.30 p.m.. dog rigid 
and tetanic : respiration 60. labored : emulsion 
nf parathyroids from sixteen dogs injected into 



authors, however, hold that there is a func- 
tional relation between thyroid and parathyroid. 
Aloussu. basing his results on changes in the 
parathyroids after extirpation of the thyroids 
in rabbits, put forward this idea and disagreed 
with Gley's theory. He found that after extir- 
pation of the thyroids the parathyroids enlarged 
and became more vascidar. This, as we now 
see, was probably an attempt at compensatory 
hypertrophy, on account of the removal of the 
other two parathyroids, which lie in or upon the 
thyroids, and not more directly related to the 
removal of the thyroid. Gley showed that there 
is iodine in the parathyroids, and concluded that 
this established a functional relation between 
them. Vassale and General!, and. later. Lusena. 
determined that the effects of parathvroidectom\ 
came on more suddenlv and were more violent 







s-s? 




oi 






IJog. 


Date of operation. 


11: 


Date of first 
tetany. 


•oi? 

.OB 

7i >, 

Si 

6 


Date of death. 


Nature of symptoms. 


no 


April 2, 


2 


.\pril 4, 


April 10, 


slight tetany. 




' April 25, one lobe. 












I2C 


•( April 29 remaining 
lobe. 
February 27, 3 para- 
thyroids removed. 
March 18. one thyroid 


2 


May I, 


8 


May 9, 


violent tetany, cured temporarily by 
bleeding and infusion. 


152 


removed. 














April 9, second thy- 


8 


April 17. 




April 17, 


violent tetany 




1, roid removed. 












160 


Oct. 20, 








October 27, 


emaciation and cachexia. 


162 


Oct. 21, 
f November 5, 3 para- 
1 thyroids removed. 
1 November 25, thy- 


8 


October 29, 


6 


November 4, 


slight tetany. 


170 


.? 


November 28, 


IS 


December 13, 


violent tetany, parathyroid treatment. 




1. roids removed. 












166 


January 10, 








January 22, 


abortion, emaciation, no tetany. 


^73 


January 10. * 








January 12, 


110 symptoms observed. 


179 


January 16. 


3 


January 19, 




January 19, 


violent tetany. 


18S 


January 17, 






II 


January 28, 


slight tetany : apathy. 


186 


January 10, 








February i, 


emaciation, apathy, no tetany except 
on one day. tlien slight. 


'^7 _ 


January 14. 








January 23 


slight tetany ; apathy. 



jugular vein. Dog stopped breathing several 
times, but was resu.scitated : secmefi practically 
moribimd. 5.50 v.m.. dog lying stretched on 
lloor, limbs very stiff: Cheync-.'^tokes respira- 
tion; 8.30 P.M.. still lying stihly on side; tetanic 
spasms in muscles; breathing regular. Xovcm- 
l)er 27. 9.30 A.M., (log is able to stand and walk 
about ; respiration pcrfcctlv (piiet. No signs of 
rigiditv or tetanic spasm. 

For a time Gley and others held the belief tlial 
the parathyroids arc merely undeveloped bits of 
thyroid tissue which, if the thyroids be de- 
stroyed, can develop into thyroid tissue. This 
idea, however, has lieen disproved by anatomical, 
cmbryological and experimental work, and the 
glands recognized as distinct organs. Certain 

I In order tr> avctici tlie confusing effect of the injection of 
larKe quantities of HniH which of it.self miubt temporarily relieve 
the tetany, the parathyroid emulsion was made in a minimal 
luantity of salt solution, usually 2 to 3 c.c. only. 



than tlio.se of tliyroparathyroidectom\-, which 
began slowlv and usually allowed the animal a 
longer lease of life, liifleed, Lu.scna claimed to 
have stopped the ])rogress of the tetany of para- 
thyroidectomy by excising the thyroid during 
the convulsion. 

\'assale and Generali explain this as follows ; 
The parathyroids ordinarily neutralize poisons 
producerl in the course of metabolism. Meta- 
liolism is decreased by thyroidectomy, and there- 
fore the task of the parathyroids will be less and 
the disturbances in a paralhyrtiidcctomized ani- 
mal less. Lusena. on the other hand, regards 
the thyroid as a gland in which toxic substances 
arc collected from the blood, and. under the 
necessary influence of the parathyroid glands, 
convertcfl into the innocuous colloid material. 
On removing the parathyroid glands this con- 
x'ersion ceases, and after a few days the poison 



April 8, 1905I 



MacCALLUM and DAVIDSON: PARATHYROID GLANDS. 



631 



may be returned to the blood and the tetany thus 
come on suddenly. On the other hand, if the 
thyroid and parathyroid are removed altogether, 
the poison begins at once to be present in the 
blood and the symptoms therefore appear gradu- 
ally, but from the beginning. The beneficial ef- 
fects of the removal of the thyroid during the 
tetany arc evidentl\ to be explained on the 
ground that stored-ui> unchangetl toxic material, 
which might be returned to the blood, are there- 
bv removed. That such an accumulation of toxic 



produce tetany by the complete extirpation of 
the thyroid as long as the parathyroids are left, 
and it seems that to refer this to the action of 
the infinitesimal and inconstant accessory thy- 
roids, and to the hypophysis of which we know 
nothing, is an evasion. The tetany is at once 
cured by the introduction of pure parathyroid 
emulsion or extract into the vessel, even when 
the th\'roids have been extirpated. 

It seems more probable, therefore, that these 
glands are much more independent in function 







Interval after operation 






.■\uthor. 


Case. 


before beginning of 
syniptt>ms. 


Duration of symptoms. 


Severity and nature of syniiitnnis. 


Ughetti and de 


10 dogs 


2 to 3 days 


4 days — I case 


cachexia, dyspnea and tetany. 


Mattel 






6 days — 3 cases 
12 days — ^3 cases 
IS days — 3 cases 




.\lbertoni and 


I dog 


3 days 


4 days (killed) 


severe tetany. 


1 izzoni 


2 dogs 


2 days 


several days (killed) 


severe tetany. 




3 dogs 


3 days 


IS days 


cachexia dyspnea and tetany. 


Gley 


I dog 


43 hours 


II days 






I dog 


41 hours 


6 days 






I dog 


22 hours 


2 days 






I dog 


42 hours. 


3 days 






I dog 


64 hours 


(killed) 






I dog 


61 hours 


74 hours 


' 




I dorr 


66 hours 


86 hours 






. I dog 


23 hours 


9 days 






I dog 


30 hours 


SO hours 






I dog 


41 hours 


7 days 




Masoin 


I dog 


18 hours 


4 days 






I dog 


24 hours 


II days 




Verstraeten and 


I dog 


I day 


S days 




Vanderlindeii 


I dog 


2 days 


9 days 






I dog 


3 days 


3 months 




R e g n i e r and 


I dog 


I day 


I day (killed) 




Patile.sco 


I dog 


I day 


3 months 




Jnlltv 


I dog 


2 days 


S days 


violent tetany. 




I dog 


6 days 


7 days 


violent tetany. 




I dog 


3 days 


I day 


violent tetany. 




I dog 


2 days 


I day 


violent tetany. 


Liisena 


I dog 


4 days 


II days 


tremors and shaking; coma. 




I dog 


3 days 


10 days 






I dog 


3 days 


5 days 






I dog 


4 days 


12 days 






I dog 


4 days 


7 days 






I dog 


S days 


19 days 






I dog 


3 days 


7 days 






I dog 


4 days 


16 days 






I dog 


S days 


17 days 






I dog 


3 days 


II days 






I dog 


2 days 


12 days 






I dog 


2 days 


13 days 






I dog 


4 days 


14 davs 






I dog 


4 days 


14 days 


tetany at second day, acces- 




I dog 


2 davs 


254 days 


sory thyroid. 



materials in the blood does not occur in thvroid- 
ectomy when the parathyroids are left, is ex- 
plained by the presence of accessory thvroids 
;md of the glandular part of the hvpophysis 
which is assumed to have a similar function. 

There are many weak points in this theory, 
which is based on several assumptions which are 
liardly justified by the facts at our disposal. For 
example, we have no proof whatever that the 
thyroid has any such antitoxic or neutralizing 
action in the production of colloid. We cannot 



than L.usena would have us believe. ( )ur series 
of cases of extirpation of the thyroid together 
with the parathyroids is small, and the results 
complicated by further exjjeriments upon the 
same dogs. .Sec preceding page. 

The course of events in dogs 120, 152, 
I/O and 179 could not have been distinguished 
from that in the pure parathyroidectomy, the 
longer duration of life in some after the 
beginning of tetany being entirely due to the 
treatment. In the other cases tetany was slight 



632 



MacCALLUM and DAVIDSON: PARATHYROID GLANDS. 



[Medical News 



or absent and the course of the ilhiess somewhat 
prolonged. For comparison with these, I may 
quote from the hteratnre such cases as have 
been observed after this operation of thyropara- 
thyroidectomy. See table on preceding page. 

From this list of cases it is seen that 
symptoms, sometimes those of violent or moder- 
ate tetany, sometimes rather those of gradual 
emaciation, predisposition to infection, etc., 
usually with slight tetany or tremors, appear 
after a period of eighteen hours to eight days 
after the operation, usually after two or three 
days. The course of the affection, to judge from 



the parathyroids alone are extirpated seem to 
enter a violent tetany, leading more rapidly to 
death and with less tendency to the development 
of the symptoms of emaciation, cachexia, etc., 
than in the cases of thyroparathyroidectomy. 
Nevertheless, a considerable proportion of those 
cases do develop violent tetany — tetany which 
quickly leads to the death of the animal — and 
in practically all the cases the symptoms began 
quite as soon as in the other cases. With regard 
to Lusena's statement that the removal of the 
thyroid after the tetany of parathyroidectomy 
has begfun will cut short the tetanv, I have 





Parathyroidectomy 








Dog. 


Interval before 

appearance of 

tetany. 


Duration 
of tetany. 


Its character. 


Result. 


104 


2 days 


2 days 


violent 


died. 


109 


3 days 


— 


violent 


died. 


113 


5 days 


5 days 


moderate 


died. 


"S 


2 days 


I day 


violent 


killed during tetany. 


116 


8 days 


— 


violent 


killed during tetany. 


117 


7 days 


— 


slight 


still alive. 


121 


3 days 


— 


violent 


killed in tetany. 


124 


3 days 


— 


violent 


killed in tetany. 


126 


2 days 


— 


violent 


died. 


133 


27 days 


— 


moderate 


killed. 


138 


2 days 


— 


violent 


died. 


139 


10 days 




violent 


killed. 


141 


7 days 


— 


violent 


killed. 


144 


2 days 


9 days 


slight 


given morphine, etc. 


146 


4 days 


2 days 


violent 


given morphine, etc. 


147 


3 days 


— 


violent 


killed. 


148 


2 days 


9 days 


violent 


Iirain emulsion injected. 


150 


2 days 


I day 


violent 


died. 


153 


5 days 


— 


violent 


killed 


154 


3 days 


6 days 


violent 


lirain emulsion injected. 


157 


I day 


3 days 


violent 


salt infusion. 


167 


2 days 


3 days 


slight 


died, secondary thyroidectomy. 


172 


7 days 




violent 


died, secondary thyroidectomy. 


I7S 


2 days 


— 


violent 


died, secondary thyroidectomy. 


im 


I day 




moderate 


infused. 



this table, is by no means so violent and rapidly 
fatal as in the case of simple parathyroidectomy, 
although sometimes, as in at least four of twelve 
of our cases and in all of Jouty's four cases, the 
tetany is recorded as severe. The uniformity of 
the fatal tetany resulting from parathyroidec- 
tomy alone may be illustrated bv the above 
table: 

Unfortunately of the twenty-five cases nine 
were killed during the first violent attack of 
tetany, so that one cannot be absolutely certain 
that they would have died on the day when the 
tetany developed (as represented by the dash 
in the column headed "Duration of Tetany"). 
Nine cases died in the first attack of tetany, 
others underwent a protracted' affection as a 
result of treatment of one sort or another. 
Lusena gives a table of nineteen cases of para- 
thyroidectomy in which death occurred with 
tetany always within five days after the opera- 
tion and within thirty-six hours of the on.set of 
tetany. 

On the whole then, although neither from our 
own cases nor from the others recorded in the 
literature can we arrive at results so uniform 
and satisfactor)' as Luse«a's, tlie cases in which 



already made some remarks. Since the publica- 
tion of that paper several experiments have been 
made along these lines. They are as follows : 





>, 




Tin- 


?f 


CS ^ >x 


Tetany. 


roidec- 


a 


ells 




tomy. 



Results. 



1 28 I Oct. 2; 



iS 1 Nov. 23 



1^5 I 

■"I 

I 



Oct. 24 
Oct. 27 

Nov. T 4 
Nov, ig 



Oct. J 5 

10 A.M. 

Nov. J 5 
9 A.M. 

Oct. .'() 

3 P.M. 

Oct. 2g 
12 NOON 



Xmv. .'I 
9.30 A.M 

Nov. *' I 

2 P.M. 



Oct. 35 

10 A.M. 



Nov. 25 

9.30 A.M. 



Oct. J 6 
5 PM. 

Oct. jf) 

7.30 P.M. 



Nov. J I 

II A.M. 



Nov. 21 

3 P.M- 



Tetnny Himinishcd for a few 
lioiirs. Regan aRain at 3 p.m. 
Dog died in tetany, 8 p.m., 
Oct. 25. 

Tetany increased and dog died 
at 3.20 P.M. Tetany was ex- 
tremclv violent and dog was 
bled for another experiment. 

Tetany disappeared. Kxtcnsire 
secondary hemorrhage oc- 
cnrrcd. Dog died Oct. 30. 

Tetany of varying intensity 
througliout Oct. 30. Very 
slight tetany Oct. 31. Tetany 
disappeared. Dog apathetic and 
weak Nov. i. Death Nov. 2. 

Died in violent tetany at 12.45 
P.M. Tetany reappeared at 
once on recovery from ether. 

Tetany reappeared and became 
progressively more violent un- 
til dog's death at 6.15 p.m. 



Of tlicse six experiments four showed abso- 
hitely no effect upon the course of the tetany 
produced by the thyroidectomy. In one (165) 
the tetany was very sli^it before the thyroidec- 



April 8, 1905] 



MEYER: PERNICIOUS ANEMIA. 



63? 



tomy and disappeared entirely after it. In 167 
the tetany, also slight, continued, but became 
progressively milder until it disappeared just 
before death, which occurred four days later. 

Lusena describes thirteen cases in which he 
either extirpated the thyroids or ligated their 
vessels, after having practised parathyroid- 
ectomy and allowed the tetany to appear, and 
without exception in these cases the tetany di- 
minished or disappeared and the dogs continued 
to live for from four to twelve days after their 
second operation. In five cases in which in- 
stead of complete extirpation of the two thyroid 
lobes only one was extirpated or tied off, no 
effect upon the tetany was produced. 

Our cases, except for the two in which the 
tetany was slight, and in which the dogs under 
ordinary circumstances might have been ex- 
pected to show remissions and to live some days, 
showed absolutely no effect from the extirpa- 
tion of the thyroids after tetany had commenced. 
These experiments one after another were so 
striking that, despite their relatively small num- 
ber, we felt quite convinced of the contrary to Lu- 
sena's statement. The theory which Lusena has 
constructed is difficult to disprove, because it 
deals for the most part with hypothetical sub- 
stances and with organs variable in number and 
position. 

It is difficult to understand his position with 
regard to the action of the thyroid after para- 
thyroidectomy, for, while in one place he states 
that the removal of the influence of the para- 
thyroid allows poisonous substances to accumu- 
late in the thyroid whence they are then sud- 
denly returned to the blood, producing tetany, 
he does not explain how. after this has occurred, 
the removal of the remaining empty thyroid can 
ameliorate this tetany. He thinks that the ac- 
cessorv thyroids and hypophysis must be con- 
sidered as rendering impossible any complete 
extirpation of the thyroid, but does not find that 
they accumulate and empty out sufficient toxin 
to appreciably alter the clinical picture resulting 
from the thyroparathyroidectomy. Presumably 
Lusena would explain the curative effects of 
parathyroid therapy as a stimulation to the thy- 
roid to continue to neutralize poison. The re- 
sult, however, is the same when the thyroid has 
been extirpated and then it would be necessary 
to refer the stimulation to the accessory thyroids 
and hypophysis, a theory which does not seem 
probable, but which we cannot absolutely dis- 
prove. The injection of fresh thyroid secretion, 
according to this theory, should, however, be 
quite as efficacious, if not more so, than the in- 
jection of parathyroid to stop the tetany, but 
even in Lusena's hands this is not so. 

On the whole, although the cases reported by 
Lusena and others in the literature have shown 
a milder course after thyroparathyroidectomy 
than after parathyroidectomy, we cannot sup- 
port this as a general rule, for in half of our 
cases the symptoms were of the maximum se- 



verity. Nor can we support Lusena's statement 
that subsequent thyroidectomy stops the tetany, 
for in four out of six of our cases it had abso- 
lutely no effect and the dogs proceeded to a 
more and more violent tetany and died. We 
therefore regard the tetany not as the result of 
a disturbance of the thyroid from the loss of the 
influence of the parathyroids, but as the direct 
result of the loss of parathyroid function, espe- 
cially since it may be directly cured by injection 
of parathyroid emulsion in the absence of the 
thyroid. 

TWO CASES OF PERNICIOUS ANEMIA DUE TO THE 
DIBOTHRIOCEPHALUS LATUS. 

BY ALFRED .MEVEK, M.D.^ 

OF NEW YORK. 

There is perhaps no pathological state so 
commonly met with in private or in hospital 
practice, whether by the general practitioner or 
the specialist, as that of secondars^ anemia. In- 
many cases the cause is readily ascertained : a 
hemorrhage, convalescence from a long febrile 
disease, a carcinoma, a chronic nephritis, a ma- 
larial toxemia, a tuberculosis, a leucemia ; and the 
success of the treatment instituted depends more 
or less upon the success with which we can 
reach the etiological factor. Other secondary 
anemias — as for instance those accompanying 
chronic cystic degeneration of the kidneys — are in 
most cases not even diagnosed and their causative 
treatment therefore not even discussed. But 
there is a type of severe secondary anemia due 
to the presence of certain parasites in the in- 
testines, notably the Anchylostomum dnodenalc 
and the Dibothriocephalus latus which, when rec- 
ognized, are not only amenable to treatment by 
anthelmintics, but so prompt and striking is the 
cure at times that almost the whole field of 
medicine may be searched in vain for similar 
illustrations of its beneficent power. It ought 
to be both a warning and a stimulus to medical 
men not to be satisfied with the routine ad- 
ministration of iron and arsenic, especially in 
progressive anemia of obscure origin or long 
duration, but to examine the stools for links and 
ova, for upon their discovery may depend ab- 
solutely the issue of the case. The temptation 
to use iron is particularly great, for have we not 
a very large list of iron preparations to choose 
from ? Alid is not the enterprise of chemists 
and pharmaceutical houses continually adding to 
the number? And may we not. varying the poet's 
language a bit, say with perfect truth that the 
medical profession is " Dragging a lengthening 
chain of iron behind it ? " 

It has often been observed and commented 
upon by medical men having large hospital ser- 
vices that if a rare disease occurs in the service, 
or a rare complication of a common disease, the 
same is not infrequently met with again after a 
short interval. Within the present year I have 
had confirmation of this " law of chances," if 



634 



MEYER: PERNICIOUS ANEMIA. 



[Medical News 



you choose, in the wards of Mt. Sinai Hospital. 
For many years tht- stools of every patient suffer- 
ing from a high graile of anemia, for which 
no cause coukl be fouiul. have been systematic- 
ally searched for intestinal parasites and their 
ova; never, so far as 1 know, was there found 
a single case of Dibothriocephaliis latus anemia, 
and then, curiously enough, two cases followed 
each other within about a year — both of them 
anemias of the severest kind, clinically and micro- 
scopically. 1 shall only give extracts from the 
complete histories of the cases as taken by the 
house staff'. 

Case I. — Edith H., twenty-two years old, do- 
mestic, born in Finland ; admitted November 6. 
1903; marked tuberculous history on mother's 
side, but no subjective tuberculous history. Ill 
one year with weakness and increasing pallor 
with occasional vomiting. On admission the 
pallor was marked and of a yellowish hue. the 
conjunctiva? fatty looking, loud systolic murmurs 
at the apex and in the aortic area. Slight edema 
of extremities. No petechia. 

Blood. — Red blood corpuscles, 780,000; while 
blood corpuscles, 5,000; hemoglobin, 15 per cent. ; 
poikilocytosis, microcytes, macrocytes, cells show- 
ing polychromatophilic degeneration, some nor- 
moblasts. 

Diff'erential count 100 cells: Polynuclears, 37 
per cent. ; mononuclears, 8 per cent. ; lympho- 
cytes, large and small. 54 per cent.; mastzellen. 
I per cent. 

Numerous ecchymoses upon arms and about 
ankles and trochanter. Large retinal hemor- 
rhages, especially in the right eye. Temperature 
TOO to 102° F. for first twenty days in the 
hospital. The first few days no ova were found 
in the stools. On the eighth day after admission 
ova were found, but not recognized as those of 
any known parasite. A few days later 30 grains 
of thymol were given in two doses and four 
hours later a tapeworm was passed which proved 
to be a Dibothriocephalus latus. measuring 8 feet 
and 8 inches in length. Ova were still found in 
the stools from time to time, until nine days after 
the expulsion of the worm, when they disap- 
peared for a period of three weeks and then 
were found again on one day only. For fear 
that there might be a second Dibothriocephalus 
latus, thymol and male fern were given suc- 
cessively without the expulsion of another para- 
site, and after that no ova were found during 
the remaining five weeks of the patient's stay 
in the hospital. The improvement of the patient 
was immediate and truly marvelous. The mu- 
cous membranes steadily and rapidly improved 
in color, she gained thirteen pounds in weight. 
the hemoglobin rose from 15 to 63 per cent, 
and the red blood cells from 780,000 to 3,460,000. 

Case JI. — The history of this patient was as 
follows : Is still in the Mt. Sinai Hospital. Jennie 
L., twenty-five years old, married, born in Rus- 
sian Poland ; admitted December 7, 1904. First 
child born four months ago. Her illness began 



about two months before birth of baby with 
swelling of feet and legs. Pallor began about 
the same lime and progressively increased. Says 
that she saw segments oi worm in stools about 
one year before. Marked pallor of body and 
mucous mebranes with an icteric tinge ; edema 
of lids and of extremities ; systolic blowing mur- 
mur at apex and pulmonic area. Temperature, 
101.2° F. 

Blood. — Red blood corpuscles, 660,000 ; white 
blood corpuscles, 5,400; hemoglobin. 10 per cent. 

Differential count, 200 cells ; jjolynuclears, 533^ 
per cent. ; eosinophiles, y^ per cent. ; large mono- 
luiclears, 15 per cent.; large lymphocytes, 6 per 
cent. ; small lymphocytes, 25 per cent. Marked 
poikilocytosis and basophile degeneration ; one 
normoblast, 6 megaloblasts. 

Dr. Griining, who made the fundus examina- 
tion, reported numerous hemorrhages along the 
veins, also hemorrhages where there are no'veins. 
When I first saw this patient and before the 
report of the stool examination was handed in. 
I was inclined to regard the case as one of 
progressive pernicious anemia of the pregnant, 
of which seven fatal cases were originally re- 
ported by (Jusserow of Zurich, Switzerland, in 
1871, and of which type I have reported one case 
without autopsy in the Mt. Sinai Hospital reports 
of 1898. I might very reasonably omit this 
reference to my first erroneous impression of the 
case, because it was not a final diagnosis and 
necessarily was subject to revision after the stool 
examination which I immediately ordered, and 
which examination had actually been begun by 
the house staff before the order was given. But 
I mention it deliberately in order to show the 
very grave condition of the patient that would 
have justified such an opinion — an opinion 
which, if verified, would have meant death 
in a few weeks. The following day a large 
number of ova of the Dibothriocephalus latus 
were found in the stools. Thymol was 
given in half-dram doses with the same pre- 
cautions as in the first case in regard to with- 
holding the food and the administration of castor 
oil the day before and two hours after the remedy, 
but the worm was not expelled. The same 
negative result with 2^> drams of the ethereal 
extract of filix mas. 

December 19: Red Blood corpuscles, 556,000 
( a loss in eleven days of 100,000). 

January 3: Red blood cor])u,scles, 468,000 (an- 
I idler loss nf about 90,000). 

January 7: Some segments of Dibothrio- 
ccphahts talus passed and ova were found for 
the first and only time since the administration 
of anthelmintics was begun. Many and varied 
doses of thymol, filix mas and pelletierine sul- 
l^hate were employed but without expelling the 
parasite (so far as knowti). 

January 16: Red blood corpuscles, 1,176,000 
(nearly trebled in thirteen days) ; white blood 
corpuscles, 5,800; hemoglobin, 21 per cent. 
C doubled in the same period). 



April 8, 1905] 



THOMPSON: DIBOTHRIOCEPHAI.US T.ATUS. 



635 



It is hard to determine why in some cases 
liie Dihothrioccplialiis latiis develops only slight 
gastric or nervous symptoms and in others the 
severest grades of anemia. ISraiin (Thier. Para- 
sitcn (Ics Menschcn, p. 202) Ijelieves the -latter 
dm' til the al)sor])tion In' the hosts of poisonous 
mate-rial excreted hy the parasite. In this con- 
nection it is interesting to note that in the second 
case reported by me the iniprovement in the ane- 
mia followed soon after the use of anthelmintics 
and the disappearance of eggs from the stools. 

The worm has not been discovered in the 
stools up to the present time (February 2), but 
the persistent absence of ova for a period of 
twenty-six days' makes it probable that the same 
has been expelled and escaped the observation 
I if the nurse. 

1 saw the jiatient this afternoon. She is steadily 
improving. The last blood examination shows : 
Red blood corpuscles, 1.648,000 (nearly quad- 
rupled in twenty-four days) : hemoglobin, 36 per 
cent (nearly quadrupled in twenty- four days). 
Only a faint systolic murnuu' is still present in 
pulmonic area. 

In view of the claim that has been made in 
some quarters " that healing may occur without 
removal of the worm or before the worm has 
passed and that possibly the improvement is only 
a temporary improvement of a pernicious an- 
emia," I have determined to keep the patient 
under observation for some months at the hos- 
])ital in order to continue the search for ova, anil, 
after her discharge from the institution, to watch 
for a relapse of the anemia. 1 shall take plea- 
sure in reporting upon her case again at some 
future time. 

A CASE OF DIBOTHRIOCEPHALUS LATUS INFEC- 
TION, CAUSING PERNICIOUS ANEMIA; WITH 
COMPLETE RECOVERY.- 

B\- W. OILMAN THOMP.SON, M.I).. 

OF NEW YORK; 

PROFK.SSdR OF MEDICINE IN THE CORNELL UNIVKRSITV MEDIC.M- 
COLLEGE IN NEW YORK CITY. 

Thk symptoms produced bv the presence of 
intestinal worms are peculiar in the facts that 
they vary greatly at different periods in the same 
person and that the s\ niptoms caused by several 
varieties of parasite may be identical. Thus 
Davanie, the French helminthologist, says that 

Tccnia. Bothrioccphalus. Ascaris and Oxxuris 
may all give rise to similar phenomena." The 
nibuthrioccphalus, however, affords an excep- 
tion in that at times it is capable of producing 
a most serious and even fatal anemia, which may 
assume a truly " pernicious " type, with hemor- 
rhages. The sym])toms of parasitic infection of 
the intestine by the larger worms are explainable 
u])on several grounds. For example : ( i ) A 
very large worm or colony of worms may cause 
mechanical obstruction. (2) Active worms mav 
irritate the intestinal wall, giving rise to loss of 

1 Fifty-one days at time of reading proof. 

2 Read before the New York .\cademy of Medicine, February 
2, 1905. 



fimction, and causing remote reflex nervous dis- 
Uirbances. (The consumption of nutritive ma- 
terial by the worm itself is relatively so small as 
to be unworthy of consideration. ) These expla- 
nations, however, prove insufficient, for in the 
most serious cases there are nervous phenomena 
and degrees of anemia which are only to be 
accouiUed fur \\\nm the theory that the worms 
periodically, if not constantl}-, excrete toxic sul)- 
stances which are absorbed from the alimentary 
canal. Such symptoms are convulsions, tremors, 
paralysis, chorea, perversions of special sense, 
great weakness, both mental and physical, and 
extreme anemia with hemorrhages. (3) The 
theory of special toxemias produced by the 
worms would satisfactorily account for all of 
these symptoms, ami is reinforced by the fad 
that reactionary changes, such as cosinophilia. 
may be produced in the blood. The absence of 
symptoms or their internwttency may be ac- 
counted for, as such phenomena are explained 
with other parasites, as for exam])le the Plasino- 
ditmi inalaruc, i.e., the parasites themselves, 
ma\ i)iisscss varying degrees of activity, depend- 
ing upon food or other conditions ; the human 
system may present varying degrees of resist- 
;mce, or the blood may possibly supply varying 
quantities of antitoxins. 

In further confirmation of the special toxemia 
thcor\' is an exceedingly interesting series of ex- 
jjeriments reported in 1904 by S. Isaac and von 
den V'elden' -who discovered that when an ex- 
tract of the fresh proglottides of the Dibothrio- 
ccphalus lafiis was added to blood serum from a 
Ijatient harboring the parasite, an albuminous 
precipitin was obtained. This precipitin reaction 
was not obtainable from the blood serum of 
iminfected persons, and the reaction is therefore 
specific. 

Tallqvist and Schaumann have also lately 
shown that serious anemia mav be produced in 
dogs by inoculating them witli an extract de- 
rived from the fresh ])arasile 

It is an interesting fact that in the pernicious 
anemia caused by the Dibothriocephalus latii.': 
eosinophilia appears to be absent, as it is from 
idiopathic ])ernicious anemia, although it is a 
common enough phenomenon in connection with 
other forms of intestinal parasites. In three 
cases of such parasitic infection the presence of 
an unusually high degree of eosinophilia has led 
me to have the patients' stools searched for 
worms or ova, which thus for the first time were 
discovered. 

The Dibothridccphalns latiis was so named b\- 
Linnreus in 1758. although it was known to exist 
at a much earlier date. It is also called Tccnia 
lata in the tenth edition of Linnasus' Systema Na- 
tural. It is often erroneous!)- called " Bothrio- 
cephalus." and was classed by Bremser in 1819 in 
the germs bearing that name. Dr. C. W. Stiles 
informs me, however, that " for some years it 
has been known to zoologists that the species 
latn.'; could not remain in the genus Bothrio- 



636 



THOMPSON: DIBOTHRIOCEPHALUS LATUS. 



[Medical News 



ccphalus; and Luehe, in 1899, made it the type 
of the new genus Dibothrioccphalus — thereby re- 
storing its original name." 

The Dibothrioccphalus latus, or " broad tape- 
worm." possesses wide, flattened segments that 
vary much in size, and may number 3,000 or 
4,000, which makes it the longest human tape- 
womi, its length sometimes eS:ceeding 30 feet. 
The head, which is club-shaped, is unarmed with 
booklets or rostellum, and is depressed at the 
sides, where there are two longitudinal deeply 
grooved suckers. There is a long, thin neck, 
and, unlike many tsnis, the body tapers toward 
both extremities. 

Extending from the neck, the proglottides, 
which have yellowish margins and blue-gray cen- 
ters, are very wide, but short in the anteropos- 
terior diameter. The largest, according to Dock," 
measure 10 to 18 mm. by 5 to 6 mm. The yel- 
lowish, rosette-like uterus is centrally situated, 
and cirrhus and vagina open immediately behind 
it on the median ventral surface. The testicles 
are situated laterally. The elliptical ova are 
brown and granular, with a thin capsule, and 
average .07 mm. in length by .045 mm. in width. 
At one extremity is a curious lid, like a small 
trapdoor. The number of wonns found in the 
same person may be quite numerous. James Ew- 
ing found three in one patient, and Bottcher as 
many as 48 in a woman. The parasite is some- 
times associated with other species in the human 
intestine. 

It was first demonstrated by Max Braun that 
the intermediate hosts of the parasite are cer- 
tain fish, like the pike, carp, salmon and trout, 
in which the PIcrocercus is found, hence the para- 
site abounds in countries in which these fish are 
extensively used as food and sometimes are eaten 
raw, or salted or smoked without cooking, pro- 
cesses which do not destroy the embryos. The 
mode of infection of the fish has not yet been 
satisfactorily explained, but cats and dogs are 
known to harbor the parasite. It is found in 
man in the Baltic provinces of Russia, whence it 
is carried to Finland and Sweden, and some- 
times to Holland, Bavaria and Rumania. It 
is also found in man in parts of Switzerland, in 
Mexico, and is said to be the most frequently 
observed cestode of Japan, where it infests both 
man and the dog. In certain localities a large 
proportion of the community may become in- 
fested, for example, near Lake Geneva 20 per 
cent, and in Moscow 9 per cent, of those ex- 
amined have sliown cither the worm or its ova. 

In the United .States a few cases have been 
reported from time to time among immigrants. 
Dock-' reported two from Galveston. Texas, and 
one from Leadville, Colo. Max Braun refers to 
a case in Philadelphia. Theodore Janeway re- 
ported one case, James Ewing one case (in New 
York), and Horace M. Bellows a ca.se in a girl 
who had been traveling in Egy]it and jiassed 19 
feet of the tapeworm after taking pellctierine. 
\\m. X. Berkeley* reported four cases in 1903, 



all among immigrants. One of these patients 
was a Russian woman, who had passed seg- 
ments of the worm at intervals during eight 
years, in all of which time her only symptom had 
been occasional slight abdominal discomfort. 
After a dose of oleoresin of aspidium the worm 
was expelled complete. Two cases were referred 
recently for diagnosis to Dr. T. W. Hastings, 
at the Clinical Laborator\- of the Cornell Uni- 
versity Medical College. In both cases the pa- 
tients were immigrants recently arrived in New 
York. 

In the Veterinary Magazine'' Dr. C. W. Stiles, 
writing from the Bureau of Animal Industry, 
states that " Of all the 300 or more specimens 
of human tapeworm from patients in various 
parts of this country which have passed through 
my hands during the last three years, three speci- 
mens have been Dibothrioccphalus latus, and the 
rest have been Tccnia saginata." 

Dr. Stiles informs me that " in the United 
States Public Health and Marine Hospital Ser- 
vice collection is a specimen of Dibothrioccphalus 
latus sent in by Assistant Surgeon Claude C. 
Pierce from Mullet Key, Fla., in 1902. This 
specimen came from a dog which was brought 
over by a Norwegian vessel." 

In none of these cases in man does it appear 
that anemia reached a pernicious or even serious 
type. 

In 1886 Gustav Reyher" reported 13 cases of 
pemicious anemia due to this parasite, all of 
which were cured by removal of the worm, and 
in the same year Heinrich Schapiro' reported 
another case, also cured, after the red blood cells 
had been reduced to 837,000 and the hemoglobin 
to 30 per cent. In 1887 J. W. Runeberg^ cited 
seven cases with pernicious anemia, all result- 
ing in cure. 

.\11 of these pernicious cases, iiowever, were 
studied before the day of accurate differential 
blood counts, and the diagnosis of the variety of 
anemia was based upon the red blood cell and 
liemogloiiin estimation alone. 

The case which appears to most closely rcsem- 
l)le the one herein reported in detail is described 
by W'itold Orlowski in the Krako2i.' Medical 
Journal." The article, being Polish, I am nat- 
urally unable to read, but from the Greek 
nomenclature of the blood examinations (which 
api^ears to constitute a sort of medical Volapiik), 
i have gathered the following data: The minimum 
blood count, several having been made, showed : 
Red cells. 295.375: white cells. 3.170: hemoglo- 
I)in. 15 per cent.; color index, 1.93; megalo- 
cytes, 6 (400 counted) ; lymphocytes 52 per cent., 
and eosino])hiles i per cent. There were no 
normoblasts or megaloblasts. The patient ap- 
])e;irs to have recovered, at least to have improved 
greatly under treatment, for the last blood exami- 
nation records: Red cells, 3,125,000; wliite cells. 
3.720; polymorphonuclear cells, 64 per cent.: 
Ivmphocytcs, 32 per cent. ; microcytcs, 6 per cent. 
and eosinophiles, 1.5 per cent. 



Al'KlL^S, 1905] 



THOMPSON: DI BOTHRIQCEPHALUS LATUS. 



The case herewith reported (with specimens 
of ova and stained uteri and proi^lottides, pre- 
pared by Dr. T. W. Hastings, of the Cornell 
Clinical Laboratory) was studied in 1904 in the 
wards of Bellevue Hospital, in the service of 
Dr. C. L, Dana and the writer. 

The patient was a boy, aged seventeen years, a 
native of Finland, employed as a plumbers' ap- 
prentice. He gave no family history of im- 
portance or any personal history until about seven 
months prior to admission to the hospital, when 
he first noticed increasing pallor. A month later 
repeated attacks of epistaxis occurred on succes- 
sive days, one of which lasted half a day. He 
also began to suffer from dyspnea on exertion. 
A month before admission his legs became ede- 
matous, and as his weakness increased, he lost 
some 30 pounds in weight, and having had about 
50 attacks of epistaxis. he applied to the hospital 
for relief. A month before admission he took a 
dose of a decoction made from some seeds which 
had been sent him from Finland to rid him of a 
tapeworm of several years' growth. He said 
that very many of his countrymen were similarly 
afflicted. He passed about four feet of ' the 
worm, as he thought, with the head attached. 



had a transient attack of blindness in the left eye 
the week before the examination. The patient 
iiad several more severe attacks of epistaxis, 
which were controlled with difficulty. The tem- 
perature on admission was 104° F. for three days, 
with a pulse of 120, and for two weeks there- 
after it ranged between 100° and 101° F., becom- 
ing subsequently normal. Soon after admission 
the ova of the Dibothriocephalus latus were o\>- 
served in the feces, with a few red blood cells. 
During a period of eight weeks the patient was 
given five doses of the oleorcsin of aspidium, oj, 
in each dose, and on four occasions thereafter he 
passed several feet of the parasite, — in all about 
25 feet, — but no head was discovered. The ad- 
ministration of male fern was preceded by ,.a 
period of starvation, and followed in twelve 
hours by castor oil. In addition the patient 
received adrenalin chloride. Fowler's solution, 
liasham's mixture and sodium cacodylate. At 
the height of his illness the patient had inconti- 
nence of both urine and feces. After three weeks 
of treatment the hemorrhages ceased and the 
general condition, including the anemia, began to 
show steady improvement, which was maintained 
imti! the patient was discharged, after three 



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Upon admission the boy presented a typical 
clinical picture of pernicipus anemia. He ap- 
l)eared well nourished, but was of a pale lemon- 
yellow color. There was moderate edema of the 
legs and the cervical glands were enlarged upon 
the left side. The pulse was quick and compres- 
sible : the heart appeared normal in size, but pre- 
sented an apical systolic bruit, and another at the 
base transmitted to the muscles of the neck ; the 
])ulmonic second sound was accentuated ; the leg 
reflexes were diminished, but there were no other 
nerve symptoms ; the abdominal viscera appeared 
normal ; the urine was slightly albuminous, with 
a few hyaline casts and uniformly low specific 
gravity, which, on repeated examinations, was 
between 1.007 and i.oio; there was moderate 
dyspnea and a few crepitant rales were heard at 
the base of the right lung. The patient had re- 
jieated epistaxis, but examination of the nasal 
cavities revealed nothing abnormal. Dr. Alex- 
ander Duane, who examined the eyes for me, re- 
ported the optic disks as being very pale, with 
small veins and arteries, secondary atrophy and 
several small hemorrhages in the fundus, but 
none in the maculae or periphery ; niotion of the 
eyes and vision was normal, but the patient had 



months, apparently cured and with normal blood. 
A table of si.x representative blood analyses is 
presented above. 

The features of special interest in the blood 
examinations are as follows : ( i ) The complete 
restitution of the red cells from a count of 608,- 
000 to 5,980,000, and of the hemoglobin from 20 
])er cent, to 98 per cent. ; (2) the early high-color 
index (1.6); (3) the absence of eosinophiles in 
the earliest examinations; (4) the early high per- 
centage of macrocytes ; (5) the early presence 
of nomioblasts and megaloblasts, and (6) the 
early leucopenia. 

These characteristics fairly entitle the case to 
be classed as one of extreme pernicious anemia 
with complete recovery. Doubtless the hemor- 
rhages greatly intensified the anemia, but the dif- 
ferential count showed more than a mere secon- 
dary anemia, i.e., a specific anemia caused by 
some fomi of toxemia produced by the intestinal 
]5arasites. 

This case is of exceptional interest as form- 
ing a type of pernicious anemia with definite 
etiology. The question has latel^? been much dis- 
cussed as to whether there is such a disease as, a 
■' primary idiopathic " anemia, originating de 



638 



ELSNER: CEREBROSPINAL MENINGITIS. 



[Medical News 



novo in tin- lilinHl-fciniiing" slructiircs of the body 
(bone marrow, various glands, etc.), and the 
view has been advanced by certain chnicians that 
there is always a prior cause, making this disease 
a secondary rather than a primary or idiopathic 
anemia. I am about to pubhsh in the First Aledi- 
cal and Surgical Report of Bellevue Hospital 
(now in press) notes on 14 cases of pernicious 
anemia. In only two of these cases, which tenni- 
nated in complete recovery, was it possible to 
determine the etiology. One of them was secon- 
dary to chronic endocarditis and gastritis : the 
other was the parasitic case above described. 
Nine of the 14 cases terminated fatally and in 
six autopsies were obtained. In five of the six 
autopsies a condition of advanced chronic inter- 
stitial or atrophic gastritis was observed. In 
these, as in many similar cases which have been 
reported, it was not easy to determine which 
was the antecedent condition, the gastritis or 
the anemia. Pernicious anemia occurs without 
permanent gastric atrophy, as in the parasitic 
cases, and many types of gastritis are observed 
without any blood changes other than those of 
the ordinary secondary variety. The essential 
matter is that at least one definite toxic cause 
of pernicious anemia being established, there is 
ground for belief that others may be discovered 
to explain the etiology of this obscure disease. 

REFERENCES. 

T Deut. med. Woch., 1904. xx.x. 982. 

2 The Am. Syst. of Medicine, Vol. Ill, p. 328. 

3 Log. cit., p. 329; Medical News, 1903, Vol. LXXXIII. p. 
S"7. 

4 Medical News, 1903, August i. p. 203. 

5 Veterinarv Magazine. Mav, 1895. Vol. II. (q). p. 284. 

6 Deut. Arch. f. klin. Med.", 1886, p. 31. 

7 Deut. Arch. f. klin. Med., 1886, p. 416. 

8 Deut. .'\rch. f. klin. .Med.. 188-, p. 304. 

9 Przogl. Ick., 1903, xliii, 151, 168. 



SYMPTOMS AND DIAGNOSIS OF CEREBROSPINAL 
MENINGITIS. 

BY HENRY L. ELSNER, M.D.. 
OF svracu.se, n. y. ; 

professor of medicine, SYRACUSE UNIVERSITY. 

In considering the symptoms and diagnosis of 
cerebrospinal meningitis as a part of the sym- 
pMDsium in which it is my privilege to participate 
to-day, I shall limit myself mainly to the re- 
hearsal of experiences with this dread disease in 
the central counties of New York State. Two 
facts are noteworthy : ( i ) There is not a single 
year when cerebrospinal fever fails to claim its 
victims in Central New York; (2) The disease 
may be either sporadic or epidemic. A search of 
the vital statistics and hospital reports proves 
the truth of the first statement. We are re- 
minded by these statistics that individual and rare 
experiences are often readily forgotten. In the 
city of Syracuse there have been 175 deaths dur- 
ing the past ele.ven years due to cerebrospinal 
meningitis; 499 have died of meningitis. The 
deaths during tliis period were reported as fol- 
lows : 



Cerebrospinal 
Meningitis. Meningitis. 

1893 II 55 

1894 4 61 

189s 17 61 

1896 18 51 

1897 12 SI 

1898 19 71 

1899 45 43 

1900 13 29 

1901 9 23 

1902 19 32 

1903 8 22 

175 499 

During these years there were no large epi- 
demics of the disease. The majority of cases 
were considered sporadic, either primary or sec- 
ondary. In 1899 there were a few house epi- 
demics; the disease existed also in a limited area 
without attacking many. The records of St. Jo- 
seph's Hospital in the city of Syracuse show that 
there were 24 cases of cerebrospinal meningitis 
admitted from January, 1894, to October, 1904, 
with 16 deaths, a mortality of 66% per cent. It 
is interesting to note that during the year when 
there were 45 deaths in the city of Syracuse, the 
larger number probably epidemic, not a single 
case of cerebrospinal meningitis presented for ad- 
mission to St. Joseph's Hospital and that this 
was the only year during many when our wards 
were free from the disease. Through the kind- 
ness of Drs. Darlington and Guilfoy, of the De- 
partment of Health of the Borough of Man- 
hattan. I am able to show the continuous pres- 
ence of the disease within the city of New York. 
The number of deaths from cerebrospinal menin- 
gitis is as follows : 

Year 1894 213 

1895 204 

" 1896 178 

1897 232 

" 1898 258 

" 1899 287 

" 1900 201 

" 1901 201 

" 1902 210 

" 1903 195 

" 1904 i.oio Jan. I to Nov. i, 1904. 

Total 3,189 

The high mortality during 1904 was due to the 
prevalence of the disease in epidemic form. This 
epidemic did not reach Central New York. 

During years when epidemic cerebrospinal 
fever has spared the central counties, non-epi- 
demic cases have dotted our cities and country 
districts indiscriminately. The disease claims the 
larger number of its victims from the homes 
of the poor; yet it is not infrequently 
found in homes where sanitary conditions are 
good. There have been but few serious epi- 
demics of cerebrospinal meningitis in Central or 
Northern New York. When present, the num- 
ber of cases have been surprisingly small : these 
showed no continuous extension, while the mor- 



April 8, 1905] 



ELSNER: CEREBROSPINAL MENINGITIS. 



639 



talit)- has been discouragingiy high. The dis- 
ease has been held within a narrow precinct of 
the city or a corner of the county township. So 
infrequent have serious and extensive epidemics 
been that there are among the Nestors of the pro- 
fession hving in Onondaga County to-day only 
two or three who recall more than one severe epi- 
demic, and that in 1855 ^"^ 1856, the most fatal 
visitation of the disease ever experienced in Cen- 
tral New York, in which many were attacked. 
The central counties of the State were invaded. 
As a rule, when epidemic cerebrospinal menin- 
gitis has visited this country, the same surprises 
have been in store for us as have been noted by 
foreigners, in the remarkable limitation of its 
ravages, the small number originally attacked, 
always with a high mortality- These facts were 
well illustrated in the epidemic form of the dis- 
ease on board the U. S. Receiving ship Minne- 
apolis, as reported by Surgeon Stokes in the 
Report of the Surgeon-General, U. S. Navy, 
1903. The ship was overcrowded with 1,450 
men on board at the time of the outbreak, yet 
only 23 cases developed ; of these 6 died, an un- 
usually low mortality of 26 per cent. 

Epidemic cerebrospinal meningitis is due to the 
meningococcus of Weichselbaum, a fact which 
was promptly corroborated in this country by 
Councilman and others. It has been demon- 
strated both clinically and experimentally that 
pneumococcus cerebrospinal meningitis and men- 
ingitis are more virulent than are those forms of 
the epidemic disease due to the meningococcus. 
Heubner says, " the benign nature of the men- 
ingococcus as compared with the virulence of 
other meningitis-producing germs, accounts for 
the comparatively few cases during epidemics, 
their ready control with the subjugation of the 
germ." Sporadic or non-epidemic cases are likely 
to run a much shorter and more fatal course 
than do those of meningococcic origin. Netter 
makes the statement that pneumococcus menin- 
gitis is almost uniformly fatal. Of 68 cases, 61 
died during the first days of the disease. Only 
one-third of the meningococcus cases died. The 
majority of these run a protracted, often irregu- 
lar and even an intermittent course- Some con- 
tinue weeks and months. There are exceptions 
to this behavior, as was exemplified by an epi- 
demic of the disease as it raged in a corner of the 
town of Cicero about thirty-three or thirty-four 
years ago. The cases were met in the practice 
of the late Dr. Blynn. There were a number of 
families living near each other; all children in- 
fected attended the same district school. Death 
claimed its victims within the first twentv-fonr 
hours of the disease. There were no sporadic 
cases. With but few exceptions the disease was 
confined to children. The few who lived long 
enough had the classical symptoms of epidemic 
cerebrospinal meningitis and those who recov- 
ered had sequelae which relegated some to a mat- 
tress orave, some were robbed of their hearing 
or si'jfiit. while others recovered with less serious 



damage. This was before the days of bacterio- 
local diagnosis, but the behavior cf the epi- 
demic and its comparison with those of to-day 
justify the conclusion that it was of the menin- 
gococcic variety and that occasionally this is 
found malignant — prompt in claiming its victims. 
Such a " lightning " course has been experienced 
since the days of lumbar puncture and has been 
confirmed by accurate bacteriological diagnosis, 
but is exceptional. The fatality of the disease, 
its sequelae, with final permanent damage to vital 
organs and the special senses in a large number 
of those who live, have led the lay world and the 
profession to fear the infection, whether epidemic 
or sporadic. There are cases so mild, it is true, 
that they may originally escape detection ; some 
of these are recognized only, or suspected, when 
the disease has attacked others more violently in 
the same house or neighborhood. 

Another interesting fact which has been no- 
ticed in Central New York is the presence of 
other infectious diseases of the nervous system 
during the prevalence of even limited epidemics 
of cerebrospinal meningitis. On three occasions 
within the past ten years we have met cases of 
cerebrospinal meningitis, acute poliomyelitis an- 
terior and Landry's paralysis almost side by side, 
in which the diagnosis of each was positive. 

Cases of poliomyelitis anterior, occurring en- 
demically, have, in the middle counties of the 
State, been present with a limited number of un- 
doubted Meningococcus meningitidcs. This has 
not always been the rule. A limited epidemic of 
poliomyelitis anterior was found in Oneida 
County in the practice of Dr. Huntley, in which 
there were no other cases of infectious nervous 
disease. Those found bore no resemblance to 
cerebrospinal meningitis. 

House epidemics of the disease in which from 
tw^o to five members of a household were at- 
tacked, and these without further spread of the 
disease, have been met on five different occasions. 

Cerebrospinal meningitis is rare after the for- 
tieth vear. In sporadic cases occurring in adults, 
mental strain and long-continued worry may 
prove inviting factors. Eichhorst reports two 
epidemic cases hastened, he believed, by mental 
fatigue. Sporadic cases offer no positive sub- 
jective s\nnptoms which differentiate these from 
those of epidemic origin. Bacteriological and 
cultural tests only give information which in- 
sure safetv and give that protection to which we 
are at all times entitled. One attack probably 
gives immunity. Councilman found but five cases 
in which the disease showed itself twice in the 
same individual. 

There are unexplainable factors which modify 
the severity of both forms of the disease during 
different years and materially influence its 
course. With sporadic as with eoidemic cases, 
all degrees of severity are found. In all forms of 
cerebrospinal meningitis, ophistotonos is rarely 
absent : so constant is this symntom that the Ger- 
mans have named the disease " Genickstarre." 



640 



ELSNER: CEREBROSPINAL MENINGITIS. 



[iMedical News 



The headache of cerebrospinal meningitis is 
almost always severe. Its persistence anil ap- 
preciation by the patient as consciousness de- 
parts and while merging into deep coma be- 
comes impressi\^. We cannot easily forget the 
persistent groan and occasional shriek when tlie 
sensorimn to all ap])earances seems thoroughly 
blunted. 

(jeneral hyf^crcsthcsia is the rule. 

Photof'hohia is usual. Pressure ttpon nerve 
trunks is usually jsainful. often causes the pa- 
tient to shriek and may give rise to general con- 
tractures or tremor. 

The fades of the patient and characteristic 
f>osUion in bed with rapid wasting of muscle and 
fat. with legs drawn in anomalous positions, are 
not easily simulated by other diseases of the 
nervous system. 

The knee-jerk is absent in one-sixth of all 
cases. In one-tenth this phenomena is absent to. 
reappear during convalescence. In a number of 
cases the deep reflexes have been exaggerated. 
In some these have been slightly decreased. The 
variation in the behavior of the reflexes in differ- 
ent cases proves that these follow no rule. 

Jnsoumia is almost always present. 

Res])irati(ni may he increased, bronchial ca- 
tarrh becomes a frecjuent complication. Sudden 
temporary cessation of respiration ( Biots' res- 
piration) or Cheyne-Stokes breathing may some- 
times be ]jresent. though less frequent than in 
tuberculous meningitis. 

The pulse and temperature offer nothing char- 
acteristic other tlian the acceleration of the for- 
mer and the elevation of the latter. .As death 
approaches, the pulse becomes exceedingly rapid, 
due to vagus ]5aralysis. 

Hyperpyrexia has characterized .some cases. 
Some of these have been of the foudroyant type, 
ending in a few hours. 

The abdomen is retracted in the uiajoritx of 
cases, constipation is the rule. 

The urine continues to be secreted in good 
quantities, albuminuria is usual, glycosuria oc- 
casional. Pressure aloui; the spine and occiput 
continues cxc|uisitely painful almost to the end of 
the disease. 

The skin su|)plies a nimiber of lesions in herpes. 
crvthenia. roseola and heniorrluij^e. Herpes labi- 
alis is less common as a svm])t(.)m of ej)i(lcniic 
cerebros])inal meningitis than either roseola or 
hemorrhage. I ferpes facialis is more frc(|uent in 
Germanv than in this countrv. Ziemssen sa\s, " in 
no other disease have I observed facial herpes 
which spread so widely." It is present early, there 
are. repeated croi)s, its presence is of no prognostic 
value. Heniorrhas^c which has given to the dis- 
ease the name " spotted fever," a misnotner. is 
not alwavs jiresent, and in some cases seen in 
Central New "N'ork was absent. Large cutaneous 
hemorrhages and bleedintr from mucous mem- 
branes are r)minons. indicating malignancy. The 
cerebral macule has been early and ])ersistent in 
most cases. 



Coin'ulsious are rare in adults. Children, i)ar- 
ticularly the very young, are likely to begin the 
disease with tonic spasm. General epileptiform 
convulsions have occasionally been present. 

Tonic spasm limited, without ftdl convulsions, 
is quite characteristic of the beginning posterior- 
basic meningitis of the English, which Lees and 
Barlow describe in AUbutt's System. The ma- 
jority of these are undoubtedly cases of cerebro- 
spinal meningitis. A thorough study of the 50 
post-mortem reports appended to the article men- 
tioned shows that the spinal membranes were in- 
volved in 26 of these cases: in eight the cord 
and membranes were found normal: in 16 of the 
cases the cord was not examined, or no metition 
is made of such examination, and in two of the 
26 cases in which the spinal membranes were in- 
volved, only the ujiper inch or two of the cord 
was examined. 

fomitins; has characterized the cases in _which 
there has been an unusually long prodromal pe- 
riod. It is less common than in tuberculous men- 
ingitis, although it may be present at any time 
before the final deep coma of the average case. 
Conjunctival redness with edema and. at times, 
chemosis, are common. The lips and tongue are 
dry and cracked, while sordes accumulates on 
the teeth as in ty])hoiil. The eye and ear symp- 
toms will be considered separately in this sym- 
posium. As a rule, the blood shows a marked 
polynuclear leucocytic increase, ranging from 
9,000 to 24,000. Tuberculous meningitis rarely 
gives evidence of marked leucocytosis. A few 
cases have been described in which this has been 
found ( ( )sler, Ridder and Za])pert). 

Metastatic joint inflammation was found in 
three cases of which we have records. When 
this occurs early, its differential diagnosis from 
acute rheumatism and pyemia may ])resent diffi- 
culties. In one of our ca.ses, a woman aged 
twenty-four years, the early symptoms were lim- 
ited to the ankle-joints. There was hyperpy- 
rexia, severe headache, ra])id develo|)ment of 
opisthotonus which cleareil all doubt. This pa- 
tient died in the second week of the disease of 
pundent cerebrospinal meningitis with sui)])ura- 
tive changes in all joints involved. I'rtjuz and 
( )sler have callefl attention to this complication 
in elaborate and valuable articles. Both observ- 
ers found meningococci in the joints. 

.Splenic enlargement is usual, the spleen is not 
as large or easily ])alpated as in some other 
acute infections. 

'The Kernig phenomenou is present in almost 
all cases of cerebrospinal meningitis. If the pa- 
tient is made to sit uj) or nearly so and an at- 
tempt is made to extend the leg, a marked con- 
traction of the flexor tendons is felt in the |)opli- 
teal space with inability to straighten the leg. 
Kernig in his original article makes the follow- 
ing statement : " This phenomenon is so striking, 
the difference between nothing and something, 
between the com])lete absence of the contraction 
while the j)aticnt is King down and its presence 



Arkii. 8, 11J05 I 



ELSNER: CEREBROSPINAL .MENINGITIS. 



641 



when the patient sits up, is so plainly percepti- 
ble that it is well worthy of consideration and 
special attention should be paid to this SNiiiptom, 
its presence looked for in all cases." In 15 cases 
of meningitis Kernig found this phenomenon 
present. In eight of these the diagnosis was con- 
firmed post mortem. Of the 15 cases, 13 were 
epidemic cerebrospinal meningitis. This sign is 
not limited to meningitis, it is occasionally pres- 
ent with other diseases. In six of Kernig's cases, 
not meningitis, but with brain symptoms with 
pial trouble, the phenomenon was more or less 
marked. Kernig believes that it is an early 
manifestation, as early as opisthotonos, and that 
it is late to disappear. 

In considering the importance of this phenom- 
enon in the diagnosis of cerebrospinal meningitis, 
it must be conceded that but few cases have been 
found in which it could not be demonstrated 
early, and in which it did not continue until the 
end of the tlisease. However, as a differential 
sign in grave infections, such as pneumonia and 
typhoid fever, in which all symptoms may be 
masked during the several days because of the 
presence of brain symptoms, its presence and pos- 
sible persistence may become misleading. Thus 
we have found cases of pneumonia in which the 
Kernig phenomenon was present with and 
w'ithout the associated changes in the brain. Our 
experience at St. Joseph's Hospital during the 
past few months strengthens the conclusion that 
the phenomenon is absent, as a rule, in cases in 
which the meninges are not involved but that it 
is not always present with meningitis. Dr. 
Harris kindly examined for me 121 ])atients at 
St. Joseph's Hospital, including 61 medical and 
60 surgical cases. In only one of these did he 
find the Kernig phenomenon, that a case of tu- 
berculous meningitis. In three cases of menin- 
gitis included in this number the Kernig phe- 
nomenon was absent. One of these followed a 
fracture at the base of the brain, the second 
proved to be purulent cerebrospinal meningitis 
with brain abscess, opisthotonos was marked, 
the third followed a fracture at the base of the 
brain with associated apex pneumonia. In 90 
per cent, of the cases of cerebrospinal meningitis 
seen during the past six years we found the Ker- 
nig phenomenon present. Friss, of Copenhagen, 
reports 60 cases of cerebrospinal meningitis, in 
53 of which he found the Kernig symptom, i.ei, 
88 per cent. Netter's experience is of Value. He 
reports 25 cases of meningitis including 12 of 
epidemic cerebrospinal meningitis in which the 
Kernig phenomenon was present in 23, or 92 
per cent. Kernig, Henoch and Netter have 
called attention to the value of this symptom in 
clinching the diagnosis of cerebrospinal menin- 
gitis, even during the period of convalescence in 
cases where the disease was not originallv sus- 
pected and where the diagnosis of the disease in 
other rnembers of a family was aided by its per- 
Ristence. Herrick's experience in 19 cases, in- 
cluding nine of the epidemic form of the disease, 



showed the presence of the Kernig phenomenon 
in 17 cases or 89.4 per cent. In none of these 
cases was it needed to make the diagnosis posi- 
tive. Lewin reports 29 cases of meningitis in 
which the phenomenon was present in 21. Its 
early presence with a few brain symptoms has, 
on several 'occasions, created a strong suspicion 
of cerebrospinal meningitis. Such a case was 
seen with Dr. Joy at Cazcnovia in which the 
Kernig symptom was present early with increas- 
ing headache without opisthotonos, stupor or 
vomiting. Depending upon this symptom with 
headaches, cerebrospinal meningitis was strongly 
suspected and finally developed. In two cases 
seen in private practice with few or no added 
classical symptoms early, the Kernig phenom- 
enon has been of diagnostic value, creating a 
strong suspicion at least approaching cerebro- 
spinal meningitis. We must emphasize the fact 
that the suspicion is only strengthened in these 
cases, for the Kernig phenomenon is by no 
means pathognomonic of cerebral or cerebro- 
spinal meningitis, and that it is often absent in 
meningitis, as our experience at St. Joseph's 
Hospital proves. Taken alone, its value may be 
overestimated : when used as a link it adds great 
strength to the diagnostic chain. 

Lumbar puncture. — The subarachnoid space 
is the only hollow in the body tvhich normally 
contains an appreciable quantity of fluid. Thus, 
the brain and cord are suspended without any- 
where coming in contact with their bony cover- 
ing. This fact makes it possible for the cHn- 
ician, in the majority of cases, to follow the 
maneuver of Quincke and withdraw this fluid, 
by means of a trocar and canula from the lum- 
bar region for close macroscopic and microscopic 
examination, staining and cultural experiments. 
In considering the value of lumbar puncture 
in the diagnosis of cerebrospinal meningitis, I 
would call attention to two underlying facts : { r) 
The normal pressure within the subarachnoid 
space is increased; (2) the fluid is materially 
changed and as a rule holds the specific micro- 
organism responsible for the meningitis. 

Thousands of punctures cautiously made have 
proven the possibility of determining in an over- 
whelming number of cases the nature of the un- 
derlying infection. The macroscopic appear- 
ances of the fluid withdrawn have led some ob- 
servers, whose experiences have been large, to 
conclusions which ought not be accepted by the 
inexperienced without confirmation either by mi- 
croscopical examination or cultural experiment. 
Lichtheim. Frohmann, .Schift', Pfandler and 
Lange believe that flocculi or coagulas which 
prcci]>itate from the fluid are characteristic of 
tuberculous meningitis. On the other hand, 
Stadelman refuses to subscribe to this view. The 
majority of observers have formulated the rule 
that with purulent cerebrospinal meningitis the 
fluid is turbid and contains pus ; that the absence 
of flakes from the fluid (Stadelman. Orgel- 
meister) does not argue against the possibility 



..J««^ 



642 



ELSNER: CEREBROSPINAL MENINGITIS. 



[Medical News 



of a tuberculous process, nor is their presence 
positive evidence of tuberculous meningitis. Se- 
rious errors will be made if we depend upon the 
macroscopic examination of the withdrawn fluid 
alone. Orgelmeister reports an unfortunate ex- 
perience in which the diagnosis of meningitis 
with abscess of the brain, correctly made, was 
changed to tuberculous meningitis because the 
fluid contained fibrinous flakes with increase of 
leucocytes but without micro-organisms or tu- 
bercle bacilli. The post mortem proved the cor- 
rectness of the original diagnosis — cerebrospinal 
meningitis with abscess in the left temporal lobe. 
Polynuclear leucocytes may be taken, when 
found in the lumbar fluid, as pointing strongly to 
the purulent form of cerebrospinal meningitis 
and to non-tuberculous disease. The experiences 
of Wentworth, Pfandler, Widal, Ravout, Monod 
and Sicard strengthen the diagnosis of tubercu- 
lous meningitis when there is mononuclear leuco- 
cytic increase. Lymphocytosis of the withdrawn 
fluid, therefore, argues against ordinary sporadic 
or epidemic cerebrospinal meningitis. Macro- 
scopic and microscopical examinations of the 
withdrawn fluid can ultimately serve only to 
strengthen suspicions. The greater and scien- 
tific value in the differential diagnosis of the va- 
rious forms of meningitis, cerebral and spinal, 
must depend upon the demonstration of the 
specific organism. This, lumbar puncture en- 
ables us to do in a large majority of cases, prov- 
ing its utility, not only as a means of diagnosis, 
but for prognosis and treatment of the disease 
under consideration. 

Prophylactic measures must of necessity fol- 
low accurate bacteriologic diagfnosis in this as 
in other contagious infections. Failure to find, 
on staining, in the withdrawn fluid, tubercle 
bacilli or other meningitis-producing germs with 
positive evidences in symptoms of cerebral or 
cerebrospinal meningitis may occasionally post- 
pone accurate differentiation. Cultures of men- 
ingococci and pneumococci may be grown in 
from twenty-four to forty-eight hours, tubercle 
bacilli in from ten to fourteen days. 

Hansemann in his recent publication (Lehr- 
buch der klin. Untersuchungsmethoden (1904), 
Eulenberg, Kolle und Weintraub) says : " Lum- 
bar puncture has been largely practised during 
recent years. There have been hundreds, yes, 
thousands of these. I do not believe that there 
are many cases in which diagnoses made, after 
painstaking observation, have been materially 
modified by this maneuver or in which the ther- 
apy of the individual case has been directed 
along new lines." " Considering," Hansemann 
says, " still further, the anatomic relations of the 
cerebral and spinal membranes and the compli- 
cation of conditions, a positive find may be of 
value for diagnosis. A negative result justifies no 
conclusions. To depend upon lumbar puncture 
for a hurried differential diagnosis of a purulent 
meningitis may become impossible, for in such a 
condition there mav be no or onlv a few leuco- 



cytes in the lumbar fluid. If we decide the di- 
agnostic worth of lumbar puncture we must re- 
member that with hemorrhagic pachymeningfitis, 
blood may be absent, that at times the fluid may 
be bloody from puncture of a vessel, that tuber- 
culous meningitis may give fluid {occasionally} 
free of cells and even bacilli." Hansemann fur- 
ther says, " In general, I believe that lumbar 
puncture is more a method for the Clinical In- 
stitute than for use in general practice." We dO' 
learn the nature and micro-organic cause of 
cerebrospinal meningitis in the majority of cases 
by such procedure. We acknowledge the fact 
that the knowledge gained by lumbar puncture 
is not needed in all cases of cerebrospinal menin- 
gitis. It becomes important whenever, for the 
protection of the masses, the true cause of the 
disease demands demonstrations, or whenever the 
positive differential diagnosis during the life of 
the patient depends upon the informatiort which 
it alone can give. Negative results will continue 
disappointing. Positive finds, when needed, 
prove exceedingly satisfactory. Netter has gone 
so far as to hold, as a result of his observations, 
that two conditions are necessary for the positive 
diagnosis of epidemic cerebrospinal meningitis: 
(i) The Kernig sign; (2) lumbar puncture and 
the presence of tht disease-producing organism. 

If, as Councilman and Eichhorst claim, so- 
called sporadic cases become foci from which 
epidemic cerebrospinal meningitis may spread, 
the knowledge gained by the thorough bacterio- ■ 
logical study of the individual case may be the I 
means of protecting entire communities against 
the ravages of this disease. Lumbar puncture 
is not a procedure for the novice or the careless. 
It demands skill, cleanliness and judgment, as 
well as infinite patience. The clinician needs the 
aid of the bacteriologist in his practice. Such 
helpmates are being supplied in all parts of our 
State as promptly as they are demanded by the 
intelligence and scientific spirit of the profession. 

With either sporadic or epidemic cerebrospinal 
meningitis mixed infection is not uncommon ; 
occasionally the pneumococcus may be found 
with the Friedlander bacillus and the meningo- 
coccus may have abundant companionship be- 
fore death or recovery. 

1. The pneumococcus as certainly causes cere- 
brospinal meningitis as it does malignant endo- 
carditis, and both of these fatal infections with- 
out puhnonar\ inflammation. The infection is 
malignant, the clinical picture is characteristic ; 
cerebral, spinal and peripheral symptoms are 
abundant. Early death is the rule. These cases 
are less frequent than are those associated with 
pneumonia. 

2. Cases of cerebrospinal meningitis with 
pneumonia in Central New York have been uni- 
formly fatal. It is exceedingly difficult to diagnos- 
ticate this complication in the majority of cases. 
Timely and frequent lumbar punctures offer aid 
which may prove conclusive. Nauwerck reports 
17 cases each with post mortem, and adds 12 



April 8, 1905] 



ELSNER: CEREBROSPINAL MENINGITIS. 



643 



cases from the literature of this subject — 29 in 
all. All of his patients were over twenty years 
of age. He calls attention to the latency of men- 
ingitis in pneumonia, recognized post mortem 
only, as a rule. Netter also mentions this latency, 
and Osier in his splendid Cavendish Lecture on 
cerebrospinal meningitis says, " Of the cases I 
saw in Montreal I remember but one in which 
the diagnosis was made during life." With 
opisthotonus, the Kernig sign, general rigidity 
and advancing pneumonia the mind has remained 
clear in some cases. This behavior, however, 
was exceptional. About one-half of the cases 
seen by the writer have presented no spinal 
symptoms. In other cases wild delirium with 
subsultus, strabismus, opisthotonus and the Ker- 
nig symptom have been followed by coma, high 
fever, rapid, irregular, small pulse and death. 
Repeated lumbar puncture in these cases is nec- 
essary to prove the presence of meningeal infec- 
tion. The respiratory and circulatory symptoms 
may not be materially changed. The original 
leucocytic count may remain unchanged or 
slightly increased as meningitis develops. Pneu- 
monias are repeatedly met in which cerebro- 
spinal involvement is strongly suspected by the 
presence of many of the symptoms mentioned, 
in which no change in brain or cord are found 
post mortem. Especially difificult is the diagnosis 
of sporadic or epidemic cerebrospinal meningitis 
as a complication of alcoholic pneumonia in which 
there may have been pre-existing or accompany- 
ing wet brain with delirium, marked rigidity 
and general hyperesthesia. Meningococcus pneu- 
monia may complicate cerebrospinal meningitis. 
Thus, Councilman, Mallory and Wright in the 
presence of both these conditions found the 
meningococcus present in eight of ten cases. In 
the other two the pneumococcus was found. 

3- Pneumococcus meningitis may follozv distal 
infection. 

During the past ten years we have had three 
cases at St. Joseph's Hospital in which cerebro- 
spinal meningitis of pneumococcus origin have 
followed. The first was after removal of the 
upper teeth, the second after otitis media, the 
third after a transverse fracture at the base of 
the brain. We have notes of two fatal cases of 
cerebrospinal meningitis which followed nasal 
operations, once after the removal of a nasal 
polyp, the second after removal of bony masses. 
Pneumococci were found in the nasal secretion. 
This was before the days of lumbar puncture. 
Besides the pneumococcus, Streptococcus pyo- 
genes. Staphylococcus pyogenes and the influ- 
enza bacillus have been found with the meningo- 
coccus in the lumbar fluid and pus. Heubner re- 
ports 14 cases of tuberculous meningitis, in two 
of which he found with meningococci, tubercle 
bacilli. Fiibringer reports a case of cerebro- 
spinal meningitis dependent upon gonococcic in- 
fection. Pfuhl and Walter have called attention 
to the association of the PfeifTer influenza bacil- 
lus with other meningitis producing germs, while 



ir'eucker, Donath and Wasserman call attention 
to cerebrospinal meningitis dependent upon the 
influenza bacillus alone. Wasserman's case was 
conclusive in proving the presence of the bacillus 
in the lumbar fluid. Saquepee and Peltier 
strengthened by their clinical and bacteriologic 
studies described a grippal form of cerebrospinal 
meningitis. 

Symptoms due to complications are dependent 
upon extension of the primary or mixed infec- 
tions or upon consecutive structural changes. 
These cannot be fully considered at this time. 
So numerous are these, and so far reaching their 
results, that chapters have been written in their 
consideration. 

The consideration of the differential diagnosis 
of conditions resembling cerebrospinal menin- 
gitis is manifestly impossible within the time 
limit of this paper. Few errors will be made by 
the cautious who are willing to associate pains- 
taking bedside examination with the knowledge 
gained from laboratory methods. These errors 
will be limited, if past experiences are repeated, 
to tuberculous meningitis, cerebral typhoid, the 
pneumonias, intestinal infections, rheumatism 
with cerebral symptoms and smallpox. The long 
prodromal period of tuberculous meningitis, the 
absence of leucocytosis in the majority of cases, 
the paralyses in the domain of the third, fourth 
and seventh nerves with other basilar symptoms, 
the absence of other cases and the knowledge 
gained by lumbar puncture will brand the case 
as one of tuberculous meningitis. The greater 
rigidity and opisthotonos will always be found 
associated with cerebrospinal meningitis. The 
differentiation of malignant scarlatina in fou- 
droyant cases will continue speculative. The dif- 
ferentiation of smallpox will not puzzle long. 
Osier reports once such failure. The presence 
in variola of mononuclear lymphocytosis with 
the assistance gained from lumbar puncture, the 
Kernig sign and the characteristic umbilication 
of the vesicle will suffice in most cases. 

An interesting experience which I have re- 
cently had with Dr. Randall, of Liverpool, brings 
to my mind a series of typhoid cases in which 
the symptoms during the first four to seven 
days are those of cerebral or cerebrospinal fever. 
The case to which I refer was that of a young 
man over twenty years who, during the first 
week of typhoid, had with delirium, opisthotonos, 
the Kernig symptom, rigid muscles and violent 
headache, cutaneous and general hyperesthesia 
with cerebral macule, no diarrhea but retracted 
abdomen, temperature 103° F., pulse 120, respira- 
tions 24. On the sixth or seventh day the Widal 
agglutination was positive. With that day ended 
the symptoms of cerebrospinal involvement. An- 
other similar case, that of a child, aged onlv seven 
months, was seen with the late Dr. Winslow, of 
Ithaca, four years ago. During the first week of 
the disease the diagnosis of cerebrospinal menin- 
gitis seemed justified because of the usual symp*- 
toms of that disease. P>y the seventh day the 



644 



DAVIS: CEREBROSPINAL MENINGITIS. 



[Mki 



\n 



spleen became palpable ami enlarged. Abundant 
roseola with a crop of sudamin;e covered the ab- 
domen. The position of the child in bed was that 
of cerebrospinal meningitis. The Widal agglu- 
tination was positive on the tenth day. After this 
all evidences of cerebrospinal meningitis faded, 
the babe merged into the usual typhoid condition 
which was followed by a slow convalescence with- 
out sequel. The child was infected from the 
mother's breast. The latter had a mild ambulatory 
typhoid, unrecognized until a positive Widal re- 
action was found during the child's illness. 

Cases of typhoid fever in which the first week 
simulates cerebrospinal meningitis are extremely 
difficult of recognition. Others have called atten- 
tion to these anomalous forms of typhoid. Thus 
Curschmann, in 1886, reported five similar cases 
from which he concluded. " that it is surprising 
to find a condition scarcely mentioned in medical 
literature in which with a final characteristic 
course of abdominal typhoid the disease begins 
with all of the symptoms of a true cerebrospinal 
irritation which disappears after the first week of 
the disease." A search of medical literature 
shows that Fritz, a French physician, called at- 
tention to these cases in 1864 and proved that 
none of them showed change in the brain or cord 
on post-mortem examination. Staubli reports 
three cases and makes a plea for the classification 
of these as meningismus typhosus or typhoid 
without lesions of spinal or cerebral meningitis 
but with all of these symptoms during the early 
days. Typhoid toxins must be charged with 
producing this mimicry of true meningitis. The 
longer period of prodromal symptoms, the greater 
enlargement of the spleen, the greater likelihood 
of intestinal manifestations, the absence of leuco- 
cytosis, the sterile lumbar fluid, the Widal ag- 
glutination, all strengthen the suspicion of ty- 
phoid. 

That there are occasional cases of cerebrospinal 
meningitis dependent upon typhoid infection can- 
not be safely denied. My own experience offers 
no pathologic data to prove the truth of this state- 
ment. Konig reports two cases with normal 
pressure, demonstrated by lumbar puncture, one 
recovery and one death. In the first he diagnos- 
ticated edema and profound congestion ; in the 
second the post mortem confirmed the association 
of the two diseases. Both pathologists and clin- 
icians are disagreed on the ability of the typhoid 
bacillus to produce su])purative changes. Mor- 
ing's conclusions during tlie Crimean War, in 200 
typhoid autopsies with microscopic sections, in 
which there had been pr()foun<l cerebrospinal 
symptoms, never showed the presence of sup- 
purative changes in exudation or pus corpuscles. 
Holscher in 2.000 tyjihoif) autopsies found 1 1 
cases, i.e., five per cent, with suppurative menin- 
gitis! Murchison denied the possibility of pus 
formation associated with aCute typhoid inflam- 
mation, referring probably to' extra-inte.stinal 
lesions. I miglit cite a large number of authori- 
ties ('r)notcd by Staubli V proving^ 1)0vond jtcrad- 



venture the occasional association of cerebrospinal 
meningitis with typhoid in which the typhoid ba- 
cillus was the only ])athogcnic organism present, 
found in the Umibar fluid and post mortem. The 
last of these comes from the ^lunich clinic and is 
reported by Staubli. His methods included all 
])ossible ante-mortem and post-mortem refine- 
ments of diagnosis and demonstrate the fact that 
the typhoid bacillus may cause purulent cerebro- 
spinal meningitis. The splendid illustration of the 
article adds to its value and makes it convincing. 
There is no time during an active typhoid in 
which symptoms of deep involvement of the cere- 
brospinal system may not develop. To determine 
whether these have a foundation in pathologic 
change in the cerebral or spinal membranes will 
often prove exceedingly puzzling. 



EYE SYMPTOMS OF CEREBROSPINAL MENIN- 
GITIS. 

r.V .\. EDW.ARD DAVIS, A.M.. M.l)., 

OF NEW YORK. 

The eye symptoms of cerebrospinal menin- 
gitis may, for the convenience of consideration, 
he divided into two grou])S — motor and visual. 
Besides these two main groups, there is fre- 
quently present a conjunctivitis, which at times 
is attended with marked swelling and ederha oi 
the lids. ' ! I : ■ . 

As is well known, the eye symptoms in cere- 
brospinal meningitis vary in different epidelnics. 
For instance, one epidemic may be marked 
simply by a conjunctivitis of a more or less se- 
vere character ;' in another the chief eye symp- 
toms ma\- be a plastic or suppurative choroiditis ;- 
in another the cornea ma\- lie the seat of affec- 
tion ;■' while in another the optic nerve and retirta 
may be the chief points of trouble.* NystagmuS 
is frequent in some epidemics.''' 

In my experience as attending ophthalmic sur- 
geon to the liabies' Wards at the l'ost-(iraduate 
Hospital I have examined the eyes in from ten 
to fifteen cases of sporadic cerebrospinal menin- 
gitis every year, and I may say that the eye 
symptoms vary as widely in these cases as in the 
dift'erent epidemics. In some there were no eye 
symptoms whatever, in others only a mild con- 
junctivitis, while in others neuroretinitis, irido- 
choroiditis, keratitis, or various disturbances of 
motility, singly or in Cdinhination, have been ])res- 
ent. Last year — 1904 — late into the winter and 
extending into the spring months, we had an epi- 
demic of cerebros])inal meningitis in New York 
City, and I had the opportunity of examining 
some thirty odd cases during the year. Thirty- 
one cases in all were examined by me, some once 
and some many timesl ^ 

Since all epidemics of "Cerebrospinal meningitis 
have one or more eye symptoms in common, I 
shall first consider any and all of t1ie eye symp- 
toms that mav occur in enidemic menintritis, and 

^ - M ■ I '■' •■ i_, LLLi. i_:^ ^ 

•» Head- Tir-Nnt-- York-State •M«drea^ Society,- Albany, January, 



April 8, 1905] 



DAVIS: CEREBROSPINAL MENINGITIS. 



645 



then give a detailed account of the eye symptoms 
observed bv me in the epidemics of 1904 in Xew 
York City.' 

MOTOR SYMPTOMS. 

These may be paralysis of the third nerve, 
sixth nerve, fourth nerve, ophthalmic division of 
the fifth nerve, seventh nerve, in all of which 
the paralysis may be partial or complete from 
pressure on the nerve trunks. We also have con- 
jugate deviations, nystagmus and ptosis, from 
cortex lesions. 

Paralysis of the Sixth and Third .\ eifc. — Par- 
alysis of the sixth nerve is one of the most com- 
mon of the motor lesions occurring in epidemic 
meningitis. In an ei)ideinic of t\vent\-nine cases 
observed by Leichtenstern, the external rectus 
was affected oftener than the other eye tnuscles. 
And such was the case in the patients observed by 
me in the epidemic of 1904 in Xew York City 
Randolph, on the other hand, in an epidemic of 
forty cases, reported third nerve paralysis in eight 
cases, every strabismus being of the divergent 
variety. 

Pupillar\- s\niptoms, as dilatation, contraction, 
and inequality, are common, and are due to aflFec- 
tions of the third nerve, the sympathetic nerve ; 
or indirectly to inflammation of the iris and 
choroid, the retina and optic nerve and optic 
tracts. In the early stages of the disease we an- 
liable to have contraction or inequality of the ])u- 
liils. at times accomi^anied with a squint. In the 
later stages of the disease we often have dilata- 
tion and sluggishness of the pupils. Where 
iridochoroiditis is a complication the pupil is con- 
tracted and irregular, and the iris may be bal- 
looned forward, the pupillary margin coming al- 
most in contact with the posterior surface of the 
cornea, as in a case I now have under observa- 
tion. " 

Sez'cnth Xcrz'c Paralysis. — From pressun- "ii 
the seventh nerve we may have the condition of 
lagopiithalmns. that is. the eyes remain half open, 
the patient lieing unable to close the eyelids. The 
cornea thus left exposed may, and often does, be- 
come ulcerated. In such cases the cornea should 
be protected l)y frequent applications of vaseline 
and tlie application of a protective bandage 

Paralysis of the Fifth Nerve, Ophthalmic Di- 
vision. — From pressure on the fifth nerve an- 
esthesia of the cornea and a neuroparaKtic kera- 
titis may develop. On the other liand. from irri- 
tation of the fifth nerve, we may have ]iaresthesia, 
or even a hyperesthesia of the eyeball and lids, 
and a headache confined to the temple on the side 
affected. 

Fourth Xervc Paralysis. — This is a verv infre- 
quent symptom, but has been noted in a few cases. 

Ptosis. — Ptosis, unilateral or bilateral, is ob- 
served now and then in these cases. Unilateral 
ptosis, as the only focal symptom, occurs in corti- 
cal lesions alone. Not infrequently ptosis, sin- 
gle or double, occurs temporarily as a secondary 
symptom. 



Conjugate Deviations. — Conjugate deviations 
of the eyes are sometimes met with in epidemic 
meningitis, but it is usually a secomlary symp- 
tom, and is of short duration. It may be due to 
lesion in the cortex or in the pons. If the former, 
the deviation is toward the side with the lesion 
in paralysis, and from it in spasms ; just the re- 
verse of this happens when the deviation is due to 
a lesion in the pons. 

.Xystagmns. — Nystagmus is a frequent symp- 
tom in some epidemics, as in the one observed by 
Leichtenstern, while in others it is a rare occur- 
rence or not present at all. 

VISLTAL SYMPTOMS. 

optic Xeuritis. — Infiannnation of the optic 
nerve occurs comparatively frecjuently in some 
epidemics and very rarely in others. Randolph 
found it in six cases of forty examined by him, 
and ■■ great venous engorgement and tortuosity, 
with more or less congestion of the optic disk," 
in nineteen others, besides one case of hemor- 
rhagic retinitis and thrombus of the central vein 
of the retina. OjJtic neuritis usually occurs late in 
the disease, but has been observed as early as the 
sixth day. When it does occur, and early in the 
disease, it is of vast importance in establishing 
the diagnosis. 

Keuroretinitis and Perineuritis. — The retina as 
\\ ell as the optic nerve may become involve<l, the 
condition being termed neuroretinitis ; or, if the 
retina is the chief seat of trouble, as in cases de- 
scribed by Galezowski, it may be more correctly 
designated as perineuritis. So marked swelling 
I'i the optic nerve as to give rise to choked disk is 
rarely seen in this disease. It is more cominonly 
met with in tuberculous meningitis, and mo.st 
often in brain abscess and tumors of the brain. 

Optic neuritis in meningitis ma\ be caused in- 
directly by pressure from exudation and cell in- 
liltration on the outside of the nerve. However, 
ilie nerve and its sheath maybe directly implicated 
li\ continuity of tissue. The optic disk has a more 
nr less characteristic ajipearance in the.se cases, 
which is a certain " smoky " or " misty " appear- 
ance. In addition to this .smoky condition the 
edges of the disk are indistinct or obscured alto- 
i^ether, there is more or less redness, and, at times, 
hemorrhagic spots on the disk. Main- times there 
i-i only a decided congestion of the disk, while the 
retinal veins are large, tortuous and full of dark 
Iilnod. The condition described and designated 
by Galezowski as perineuritis is characterized bv 
a slight swelling at the periphery of the optic 
disk, a sinking in at its center and a moderate 
amount of redness, the retina presenting a striated 
appearance, or at times an edematous look. T 
have seen two such cases myself, and consider the 
condition to be simplv a neuroretinitis. 

Optic Atrophy. — This mav be secondary, the 
result of optic neuritis ; or it may be of a pri- 
niarv nature and descending. Primary atrophy 
of the optic nerve in cerebrospinal meningitis is 
tmcommon, but T have one such case under oh- 



646 



DAVIS: CEREBROSPINAL MENINGITIS. 



[Medical News 



servation at present. Dr. C. S. Bull reported such 
a case at the New York Ophthalmological Society 
this winter. 

A marked peculiarity in optic atrophy follow- 
ing meningitis is that vision is restored in some 
of these cases although a white atrophy remains. 
Williams' and Randolph* have each reported a 
case where the patient was entirely blind, but sub- 
sequently recovered vision completely ; in Wil- 
liams' case the patient was deaf as well as blind, 
but the hearing was restored also. In neither of 
these cases it is distinctly stated that an optic 
atrophy is present, but we are led to infer this 
from the report of the cases. Dr. H. Knapp re- 
ported such a case at the Section of Ophthalmolo- 
gy, Academy of Medicine, December 10, 1904. 
In this patient, a young adult, there was complete 
white atrophy in each eye following meningitis, 
but, strange to say, vision was perfect in one eye 
and absolutely destroyed in the other. Knapp 
said he could not explain why vision should be 
present in either eye, and told the patient, in look- 
ing into his eyes with the ophthalmoscope, ac- 
cording to all rules, he ought to be blind. 

Plastic and Suppurative Choroiditis. — Suppur- 
ative choroiditis with iritis and occlusion of the 
pupil, accompanied in some cases with pus in the 
anterior chamber, is the chief eye symptom in 
some epidemics. Plastic choroiditis usually ap- 
pears in the second or third week of the disease, 
and, as a rule, causes total destruction of sight. 
The fundus of the eye, from the exudate in the 
vitreous, gives a grayish or yellowish reflex simu- 
lating the appearance of glioma retinae. J. H. 
Knapp- and Joseph Jacoby," among others, have 
noted this particular complication. In an epi- 
demic at Rastadt, near Heidelberg, J. H. Knapp 
saw ten such cases. In most of these cases there 
was but slight irritation of the eye, there being 
only a mild subconjunctival injection present, 
with some discoloration of the iris and synechicX. 
The patients frequently complained of slight pain 
in the head and eyes. In a few of the cases there 
were marked inflammatory symptoms. — swelling 
of the eyelids, intense redness of the eyeball and 
pus in the anterior chamber- The disease, as a 
rule, manifested itself in the second or third week 
of the meningitis and lasted from one week to a 
month or more, and left the eye soft and without 
sight. 

Panophthalmitis. — This formidable condition, 
fortunately, rarely occurs as a complication of 
epidemic meningitis. The sight is always lost in 
the affected eye. 

Photophobia. — This is an early and almost con- 
stant symptom of epidemic meningitis. 

Conjuncti^iitis. — Conjunctivitis is a very com- 
mon symptom of cerebrospinal meningitis, and in 
some epidemics is the only eye symptom noted. 
It usually appears early in the disease, as a rule 
is of a mild type, but may be very severe, with 
redness and swelling of the lids. 

The edema of the conjunctiva in these cases 
is due to the extension of the inflammation into 



the orbit along the veins which impedes the return 
flow of blood. 

Keratitis. — Keratitis of the parenchymatous 
type is a very serious complication in this disease. 
Xiemyer and Wilson have observed such cases; 
and the latter reports five cases w'ith blindness as 
a result in every case. Apparently, in epidemics 
where the conjunctiva is severely inflamed the 
cornea is more likely to be involved, either in 
an ulcerative process or with the deeper perin- 
chymatous inflammation. With involvement 
of the fifth nerve we may get a neuroparalytic in- 
flammation of the cornea — that is. of a trophic 
nature. When the seventh nerve is involved we 
are liable to have ulcerated keratitis as the result 
of the exposure of the cornea, as the patient is un- 
able to close eyelids. 

A few or many of the above eye symptoms may 
be present in epidemic meningitis ; at times, how- 
ever, no eye symptoms at all are to be observed. 
In the epidemic of cerebrospinal meningitis in 
New York City in 1904, in those cases observed 
by me, the most prominent symptom was that of 
ncuroretinitis, which occurred in eight cases. In 
seven of these cases both eyes were affected, in 
the other case the right eye only. In one the 
ncuroretinitis was complicated with markedly 
contracted pupils, in one with convergent squint 
and seventh nerve paralysis, and in one with 
conjunctivitis and keratitis. Four of these pa- 
tiencs died, two were cured and two discharged 
before the end of the disease because of some 
complicating contagious disease, as measles, the 
patients being sent to some contagious hospital. 

Conjunctivitis was present in eight cases. In 
every instance a smear was taken and a micro- 
scopical examination made. The Koch-Weeks' 
bacillus was found in two, staphylococcus in one, 
diplococcus in one, both staphylococcus and diplo- 
coccus in one, pneumococcus in one, gonococcus 
in one, and in one the examination proved nega- 
tive as regards the eye. although the lumbar punc- 
ture proved positive as to the diplococcus of men- 
ingitis. One case was complicated with converg- 
ent squint, one with dilated pupils and one with 
keratitis and neurotinitis. Four patients died, 
two were cured, and two discliarged before the 
close of the disease. In none of the cases except 
in the one with the gonococcus infection, was the 
conjunctivitis of a severe nature. 

Pupillary Chans;es. — In three cases the pupils 
were affected ; in one the pupils were very small 
with a mild ncuroretinitis complicating; in one the 
pupils were dilated, a conjunctivitis complicating; 
in one the pupils were unequal ; in this case no 
ftmdus examination was made, the parents tak- 
ing the child away. In both cases which remained 
death resulted. 

Venous Congestion of the Fundus. — In two 
cases there was marked dilatation and tortuosity 
of the retinal veins, while the optic disks were 
greatly congested, but without swelling. There 
were no other eye .symptoms ; one patient died and 
one recovered. 



April 8, 1905] 



MEDICAL PROGRESS: SURGERY. 



647 



Paralysis of the Ocular Muscles. — Two pa- 
tients had convergent strabismus, one of which 
was complicated with conjunctivitis and the other 
with seventh nerve paralysis and neuroretinitis ; 
both patients recovered with good vision. 

Keratitis. — This was present in one case, com- 
plicated with conjunctivitis and neuroretinitis; 
the patient died. 

Iridochoroiditis. Primary Optic Atrophy. — 
This very interesting case is still under observa- 
tion and warrants a brief description : M. R., 
aged two and one-half years, gave the following 
history : December 26, 1904, two weeks ago, com- 
plained of being tired, developed a fever and was 
very drowsy for a week; complained of pain in 
the head, and had cried a great deal in the last 
week. December 27, first examination ; right pu- 
pil contracted and irresponsive to light or con- 
vergence ; no redness of the eye or lids, while 
there is a grayish-white reflex from the fundus 
by oblique illumination. Left eye normal. Or- 
dered atropine instilled in the right eye several 
times. December 28, right pupil has not responded 
to the atropine, the iris is bound down to the an- 
terior capsule of the lens. Tension, — 2. January 
4, 1905. right eye, pupillary margin of the iris is 
bulged forward, half-way filling the anterior 
chamber. Tension, — 3; slight subconjunctival 
injection ; still a grayish-white reflex from the 
fimdus. Left eye normal. January 11, 1905, 
right eye — the pupillary margin of the iris is al- 
most in contact with the posterior surface of the 
cornea. Tlie eye is very soft, but there is only 
slight congstion. The optic disk in the left eye is 
pale, the pupil slightly dilated and sluggish. Janu- 
ary 25, 1905, right eye is in about the same con- 
dition as last noted ; in the left eye there is de- 
cided paleness of the disk, pupil dilated and slug- 
gish. The child is improving as to general symp- 
toms. Pulse and temperature both markedly im- 
proved. 

The Significance of Eye Symptoms in Epidemic 
Cerebrospinal Meningitis as Regards Diagnosis 
and Prognosis. — The diagnosis in epidemic men- 
ingitis, as a rule, may be made from the general 
symptoms, e.g., vomiting, irregular temperature, 
headache, retracted head, spinal irritation, pe- 
techial or herpetic eruptions, which, taken to- 
gether with lumbar puncture and Kernig's 
symptoms, make the diagnosis positive. But 
in a few cases the general symptoms are 
not well marked, when the eye symptoms, 
especially where there are changes in the 
fundus, may serve to clear up the diagnosis. Ine- 
quality of the pupils, particularly if accompanied 
with squint, should place the general practitioner 
on his guard. I am not unmindful of the diffi- 
culty and, at times, the impossibility of making a 
satisfactory examination of the fundus of the 
eye in children ; but as many of the symptoms in 
meningitis are motor in character, that is. paraly- 
sis of the different eye muscles, pupillary changes, 
ptosis, etc., all of which may be observed without 
the use of the ophthalmoscope, ignorance of the 



use of which instrument most practitioners give 
as an excuse for not making proper examination 
of the eyes, it is the more to be regretted that the 
eyes do not receive earlier and more careful at- 
tention. I may state here that since the introduc- 
tion of the electric ophthalmoscope in the last few 
years the examination of the fundus of the eye 
can be made easily while the child lies in bed, and 
even by one not experienced in the use of the 
ophthalmoscope. The light in these instruments 
always moves with the instrument, and it is an 
easy matter to keep the fundus of the eye il- 
luminated, especially where the pupil is dilated 
either with atropine or from the effects of the 
disease. 

Prognosis in these cases where there are eye 
lesions, especially where the fundus is affected, is 
always more grave than in those cases where there 
are no eye symptoms. In the epidemic observed 
by Randolph,^ in the six cases where optic neu- 
ritis was a complication five died, while in the 
other case the patient was alive when last heard 
from. In other words, in the five cases followed 
to a conclusion every one died, or 100 per cent. 
In the cases were therf were no fundus lesions 57 
per cent. died. In the epidemic observed by my- 
self, of the eight cases affected with neuroretinitis. 
four died, two were cured, and two discharged 
(not followed to a conclusion), making the per- 
centage of deaths equal to 66j^ per cent., while in 
the ten cases where there were no eye symptoms 
there were but 50 per cent, of deaths. Such sta- 
tistics speak for themselves and need no comment 

REFERENCES. 

1 Ziemssen and Hess. Klin. Monatsblatt fur .\ugenheilkunde. 
1685, p. J75 et seti- 

2 J. H. Knapp, Centralbl. f. med. Wissenschaften, No. 33, 
1S65. 

3 Wilson. Dublin Quart. Jour. Med.. Vol. XLIII. 1867. pp. 
302-6. 

4 Randolph. The Johns Hopkins Hospt. Bulletin, No. 32. 

5 Leichtenstern. Deutsch. med. Wochen., No. 31, 1885. 
6,\rchiv f. Ophthal., Bd. XI, 3, S. 165. 

7 Weekly Mecl. Review, Vol. 9, p. 416, 1884. 



MEDICAL PROGRESS. 



SURGERY. 
On Peritoneal Adhesions. — Cari, Beck (Am. Med., 
.\pril I, 1905) says the study of the adhesions form- 
ing after repeated attacks of appendicitis has also 
given us clearer insight into adhesion formations in 
general, revealing many obscure ailments in their 
true light. .-Adhesions are found more frequently in 
the ileocecal region than anywhere else. .As a rule 
there is a broad parietal adhesion especially if there 
is postoperative hernia. The peristalsis of the free 
part of the gut elongates it until it becomes a tense, 
unyielding band; and if an intestinal loop becomes 
ensnared below it, its circulation will be under pres- 
sure, and will give rise to more or less disturbance, 
sometimes even to complete strangulation, especially 
if there is procrastination, .\fter early operation 
postoperative adhesions are rarely found; another 
point in favor of prompt early surgical interference 
in appendicitis. Beck's experience in cases of 
chronic progressive adhesion-forming peritonitis,, as 
observed idiopathically as well as after appendicitis, 
is absolutely bad. The nature of this peculiar condi- 



648 



MEDICAL PROGRESS: SURGERY. 



(Medical News 



tion, characterized by a multitude of cobweb-shaped 
bands, is not yet sufficiently elucidated. 

Epiphyseal Separation. — In summarizing separa- 
tion of the epiphyses Kirmissox (La Med. Mod., March 
8, 1905) states that in general fractures and luxations 
are less grave in children than in adults, but frac- 
tures of the elbow are very important in the young. 
Fractures of the forearm in children are usually 
greenstick, because the bones are more elastic and 
the periosteum thicker than in adults. Here the 
characteristic deformity is a posterior convexity of 
the forearm with no abnormal mobility or crepitus, 
while fractures of the clavicle are shown only by 
ecchymosis and pain on pressure. Instead of frac- 
ture of the fibrils and tibia, which are so frequent in 
adults, we meet with fracture of the femoral diaphy- 
sis in children, which heal easily under extension 
without shortening. Fracture of the neck of the 
femur in children is not so uncommon as was for- 
merly supposed. Dislocation of the hip is occasion- 
ally seen in children, but more often dislocation of 
the elbow. On speaking of epiphyseal separations 
it must be remembered that between ten and thir- 
teen years the diaphysis and epiphysis are two bony 
parts separated by the epiphyseal cartilage. These 
separations, which between seven and fourteen years 
are not the result of a direct force or of traction, 
but are caused by twisting and are accompanied 
by a large tear of the periosteum. The break in 
continuity, as shown by the X-ray, usually comes 
between the diaphysis and epiphyseal cartilage with 
sometimes a slight fracture of the diaphysis. These 
epiphyseal saparations are particularly difficult from 
the point of view of diagnosis and treatment, as they 
are so near the joints. At the upper extremity of 
the humerus one must be careful to distinguish dis- 
location of the shoulder, and the upper fragment is 
so small that it is very hard to reduce. Besides the 
periosteum may be so torn that reduction is im- 
possible without incision. Laceration of vessels and 
nerves is most frequent in separations at the lower 
end of the femur when amputation may be neces- 
sary. There are two ways of reducing the disloca- 
tion: (l) To use traction and reduce in extension; 
(2) pass the left arm under the thigh and draw the 
leg down with the right hand flexing at the same 
time. The second is usually the more successful. 
If the periosteum has been button-holed by the 
epiphysis an incision m.iy allow reduction, otherwise 
resection must be done, which necessarily entails 
a subsccjuent shortening; of the leg. 

Gunshot Wounds in the Present War. — In view of 
the present Russo-Japanese cuntlict II. K. Cholin's ar- 
ticle in Roussky Vracli, February 18, 1905, presents some 
some special interesting features. The Japanese 
use a rifle of their own invention, and a bullet of a 
larger size than the Russians. In rapidity of its 
flight it also excels the enemy's bullet. The pene- 
trating wound caused by it heals very well; it is, 
however, when the bullet impinges upon and into 
the tissues that it produces a terribly devastating 
effect; there is a general tearing and bruising of 
tissues accompanied usually by a profuse and often 
alarming hemorrhage. The directness and the rapid- 
ity of the bullet's flight are such that no tissues 
can withstand the impaction, or in any way deviate 
its course. The wound is usually so cleanly incised 
that no pieces of clothing are ever carried in— an 
element of great importance in the favorable heal- 
ing of such wounds. The bone is rarely splintered, 
except in cases where shrapnel is used. The blood 



vessels are very often wounded and the author ob- 
served several cases of aneurism of the popliteal as 
well as of other arteries. Many of the nerve trunk^ 
are attacked. The wounds usually healed kindly 
and without reaction, but meddlesome examinations 
were sure to react on the course of healing uti- 
favorably. Pus appeared only in those cases where 
the tissues around the path of the bullet were in- 
vaded. Another complication was the frequently 
large cicatrices and tough adhesions. Out of 230 
gunshot wounds 13 were cranial, 1 1 through the sub- 
stance of the brain. The deep penetrating lesions 
in this region were not accompanied by any destruc- 
tion of the bones of the skuHl; this was observed 
only in the superficial wounds. Si.x of the cases 
were accompanied by paralysis of the arm and leg, 
one presented the symptoms of cortical epilepsj 
due evidently to pressure and removed by operation. 
The general results of wounds of the lungs were 
rather favorable; all of them, with one exception, 
being penetrating. There was hemoptysis in 21, 
subcutaneous emphysema in three, e.xtensive hemato- 
thorax in one, etc. The 27 cases of abdominal 
trauma were all penetrating wounds; of these only 
one died of what the author thinks was neglect ot 
treatment; but one case of peritonisis, and that wa^ 
favorable. There were several penetrating wonu'l- 
of the liver, spleen and kidneys. The injuries to tlie 
joints were usually severe and rebellious to treat- 
ment, but there was but one that required 0"»>ia::v<- 
inferference. From the foregoing, the author draws 
the following conclusions: (l) The Japanese bullet 
meets all the requirements of humanitarian war/are. 
and the wounds inflicted by it heal rapidlj- and with- 
out reaction. (2) The majority of wounds e-^pecially 
those in the region of the skull, abdomen niul spinal 
column require prolonged treatment on the battle- 
field. It thus becomes imperative to organize hos- 
pitals in the immediate proximitj' of the field of 
action, so as to obviate the necessity of transporta- 
tion that is usually attended by terrible suffering. 
f3) The possibility of late complications demands 
prolonged sojourn of the wounded at the hospital. 
(4) The present conditions of transportation are 
absolutel)' inadequate and demand immediate atten- 
tion. 

Fracture of the Patella. — In a very extensive 
article in which the foremost authorities are quoted, 
W. C. Jones {Chic. Med. Rec, March 15, 1905) sum- 
marizes the main points in the anatomy, etiology, 
pathology, diagnosis and treatment, as follows: In 
regard to the anatomy of the knee, the following 
are pertinent facts: (o) The oblique direction down- 
ward and inward of the superior border of the 
patella; (6) the position of the patella in relation to 
the femur, the center of the former resting on the 
edge of the condyles of the femur when the leg is 
in the position of semiflexion; (r) the insertion of 
the quadriceps tendon on the anterior portion of the 
patella; {d) the inseparable connection of the patella 
anteriorly with the patellar aponeurosis, posteriorly 
with the synovial membrane of the knee-joint, and 
laterally with the lateral and capsular ligaments of 
the joints. There is practical unanimity of opinion 
in regard to all forms of fracture of the patella, ex- 
cept recent simple transverse. The following fea- 
tures of this type deserve mention in this connection: 
(l) As to the etiology, this fracture is caused by 
contraction of the quadriceps extensor muscle, which 
breaks the bone over the lower edge of the femur. 
.\ fall upon the knee may be a simultaneous con- 



April 8, 1905] 



MEDICAL PROGRESS: MEDICINE. 



649 



tributing factor. (2) In the pathology, the follow- 
ing lesions are particularly significant: (a) The 
laceration of the libro-aponeurotic tissues about the 
joint; (b) the anterior V-displacement of the frag- 
ments or the possible rotation of one of them; (c) 
the interposition of blood and, in most cases, of 
aponeurotic structures between the fractured ends. 

(3) The diagnosis of this fracture includes not only 
the mere discovery of the presence of a fracture, 
but also the determining of the position of the frag- 
ments and the extent of the injuries to the soft parts. 

(4) In regard to the treatment, the tendency is de- 
cidedly in favor of operative rather than non-opera- 
tive measures; and the open methods usually are pre- 
ferred to the subcutaneous ones. The indications 
for operation are, wide separation of the fragments, 
interposition of soft tissues between the fractured 
ends, marked swelling of the joint, and the fact that 
the patient follows an arduous occupation. The 
operation must be undertaken only by experienced 
men and only under conditions where the asepsis 
can be completely controlled. The patient must be 
in good health and of suitable age. It is preferable 
to avoid, if possible, suture of the bone, uniting only 
the aponeurotic structures. If, however, the bone 
is sutured, use absorbable material. Begin massage 
during the first week and passive nintion :it the end 
of the second week. 

Penetrating Wounds of the Abdomen. — Of the two 
cases reported by Gi.ick,\i.\n Wrakt. I'lach. February 
II, 1905). one was a man of twenty-si,<c years of age, 
in whom there was a protrusion of the intestines 
through the wound; there was a wound in the pro- 
truded intestine 4 cm. long. The organs were re- 
placed and the abdominal wall closed with sutures; 
the postoperative course uneventful, the patient leav- 
ing the hospital cured two weeks after the occurrence 
of the accident. In the other case there was a pro- 
trusion of the pancreas. This was first resected, 
then rendered thoroughly aseptic and replaced. As 
in the first case the postoperative course uneventful. 
The author inclines to the view that in cases of 
protrusion of the pancreas the protruded portion 
should always be resected, especially if there be 
even the remotest possibility of infection; and in the 
pancreas this may always be expected. In a general 
way the author thinks that only in the very recent 
cases where absolute asepsis can be guaranteed may 
the protruded organs be replaced in its entirety. In 
Closing small abdominal wounds the author does 
not include the parietal wall of the peritoneum; it is 
only in wounds of great extent that such inclusion 
becomes necessary. In treating penetrating wounds 
of the abdomen it is more advisable not to close 
them tightly, but to leave a corner for the introduc- 
tion of iodoform or sterilized gauze. The prognosis 
of such wounds is more favorable at the present time 
than it used to be formerly, the more so with cases 
that are taken in hand early enough. 

MEDICIXE. 
Acute Meningitis. — W. T. Council.m.\n (Jour. A. M. 
A., April I, 1905) describes the conditions of acute 
meningitis with more special reference to that form pro- 
duced by the Diplococcus intracellulan's meningitidis. 
which he believes is constantly occurring in a sporadic 
form, aside from the not infrequent epidemic aggrava- 
tions. The infecting organism, he states, is one of low 
vitality and incapable of a purely saprophytic existence. 
The statistics fail to give any adequate idea of the fre- 
quency of the infection in ordinary years. His expe- 



rience, however, leads him to believe that with rare ex- 
ceptions all cases of primary meningitis are due to this 
micro-organism and that it would be impossible without 
sporadic infections to bridge over the intervals between 
the epidemics. It is possible, too, that the germ may 
even inhabit the normal mucous mcmbvanes, of the nose, 
for example, as has been shown in a few cases, where it 
it produces a rhinitis, and infection of the meninges may 
take place through the lymphatics or by continuity of 
surface. We can only explain the epidemics of the dis- 
ease, he says, either by an increase of virulence of the 
diplococcus or by a decrease in the resistance of the tis- 
sues. The underlying causes of epidemics are unknown, 
and even atmospheric conditions cannot be excluded. He 
discusses to some extent the relations of meningitis to 
pneumonia, as shown by the Massachusetts health statis- 
tics, and illustrates with a chart. Primary meningitis 
from the pneumococcus or staphylococcus is rare ; sec- 
ondary types are not so frequent. The paper concludes 
with a description of the pathologic conditions in acute 
meningeal disease. 

The Panama Canal Mismanagement. — In the Jour. 
A. M. A., April i, 1905, the Isthmian Canal Commission 
replies at length to the charges made against it by Dr. 
C. A. L. Reed, in the Journal A. M. A., March li. The 
commission states that neither from official conferences 
nor from interviews with members of the sanitary staff 
lias it been learned that the plan of sanitation is defective 
in scope or in elasticity, or that any troubles have oc- 
curred, except such as inevitably attend the organization 
of such enterprises. Dr. Reed was asked for a reply to 
go in the same issue of the Journal, but he reserves his 
reply for the ear of the Secretary of War, because he 
has been criticized for allowing publication of his first 
report without waiting for government approval of its 
publication. The Journal, however, expresses the con- 
viction that Dr. Reed has made out a case. In some de- 
tails he may have been misinformed, but even the reply 
of the commission itself proves, by the admissions made 
therein, that the sanitary department was very unwisely 
subordinated to, and hindered by. various officials and 
red tape methods. This was the main contention, and 
against this the Journal A. M. A. and many other med- 
ical journals protested before the commission was 
formed. 

Typhoid Perforation. — Morris Manges, New York 
City (Jour. A. M. A., March — ), reports nineteen cases 
of perforation in typhoid, with sixteen operations and 
five recoveries. He discusses the subject generally, but 
emphasizes particularly the diagnostic significance of 
pain, which under certain conditions in this disease may 
accompany non-perforative peritonitis. He considers 
that the most important facts in the diagnosis are the 
marked change in the patient's condition with the ab- 
dominal pain, which is very variable, and that the other 
abdominal conditions, distension, rigidity, tenderness, 
liver dulness, etc., with the anxious facies and sweating, 
are valuable aids in the diagnosis: Changes in the rate 
and character of the pulse are of more value than tem- 
perature or respiration. Manges believes in the occa- 
sional spontaneous cure of this condition, and refers to 
one case in his series in which this apparently occurred, 
and to another, in which, at the autopsy, a small, per- 
foration was found well sealed by omentum. The rule to 
operate, however, is not vitiated by these rare occur- 
rences, and operation itself does not add to the dangers 
and may be effective in preventing a perforation where 
one is not found. 

Rapid Bacteriological Diagnosis of Diphtheria. — 
11. A. HiGLEY (Med. Rcc. April i, 1905) says that by 
the following method it is possible to make a rapid 



6so 



MEDICAL PROGRESS: MEDICINE. 



[Medical News 



(fifteen-minute") and sure diagnosis by the examination 
of stained smears made directlj' from deposits or false 
membranes in cases wliicli present themselves for dif- 
ferential diagnosis of diphtheria. The material from 
which the smear is made is obtained by passing lightly 
over the false membrane a sort of curette formed from 
a wire-looped needle flattened by filing at its curved 
extremity. The following staining fluids, which should 
he freshly prepared, are used: No. i. Five drops of 
Kiihnes carbolic methylene blue in seven cubic centi- 
meters of tap water. No. 2. Ten drops of carbol- 
fuchsin in seven cubic centimeters of tap water. Method 
of Application. — (l) Fix smear by passing three times 
through the flame; (2) apply tain No. i for five sec- 
onds ; (3) wash with tap water and dry with filter pa- 
per; (4) apply stain No. 2 for one mitmte; (s) wash, 
dry and mount in balsam. When thus stained, the diph- 
theria bacilli appear as dark red or violet rods, irreg- 
ularly stained, often containing polar dots. The un- 
evenness of their contour and mode of division are reg- 
ularly and distinctly brouglit out, and these characteris- 
tics afford the essential differential points, for other 
micro-organisms take varying tints, and may appear of 
the same color as the diphtheria bacilli, so that upon 
color alone no differentiation is possible. 

Relation of the Nervous System to Visceral and 
Trophic Pneuomena. — J. Fu.\enkf.l's address {Med. 
Rcc, April I, 1905) is devoted to a consideration of the 
relation of the nervous system to the pathology of the 
vegetative functions. So-called visceral or vegetative 
phenomena accompany more or less prominently organic 
disease of the nervous system, and constitute the chief 
physiognomy of all functional states and functional 
symptom-complexes. Trophic, vasomotor and secretory 
disturbances of the skin, changes in the trophism of 
joints and viscera, disturbances of the physiologic 
rhythm of vaso- and viscero-motor innervation, perver- 
sions of visceral sensation, are often seen at the bedside, 
and not sufficiently appreciated. The author takes up in 
turn the various manifestations of such changes occur- 
ring in the various organs and functions of the body, 
and points out their relations to the underlying disease. 
Thorough study of these subjects promises us, he says, 
(i) greater exactness of localization of or.ganic disease 
of the nervous system and better interpretation of early 
symptoms; (2) more rational conception of functional 
conditions; (.3) clearer, therapeutic indications. 

Perineum, Perineorrhaphy and Prolapse. — A. 
Sturmdorf (Med. Rrc, April i, 1905) says that the 
keynote in the clinical significance and therapeutic in- 
dication of pelvic floor laceration is prolapse, while 
perineorrhaphy, immediate, intermediate and late, repre- 
sents respectively the prophylaxis and cure of such pro- 
lapse. The normal position of the uterus is maintained 
by deflection of the force of intra-abdominal pressure, 
which acts on the uterus, poised as a lever with unequal 
arms on a fulcrum formed by the intravaginal perineal 
crest. Restoration of the conditions resulting in injury 
to the perineum can best be repaired by innncdiate su- 
ture, and to facilitate accurate readjustment of original 
anatomic relations, the prelitninary introduction of what 
may be termed guide sutures, will be found helpful, 
time-saving, and, to some extent, prophylactic. At some 
convenient moment, prior to the descent of the fetal 
presenting part, two to three silkworm sutures are in- 
troduced under proper precautions into the structures 
between vagina and rectum, from the cutaneous base 
of the perineum to its apex, which serve as eflicicnt 
landmarks when the severed muscular and fascial layers 
are to be reunited after delivery. Late operations in- 
volve as their surgical objective point the remnants of 



the anterior loop of the levator ani muscle. Under all 
conditions of perineal rupture, the pubic attachments 
<if this levator loop present permanent palpable ridges. 
With these ridges serving as guides to the muscle, the 
posterolateral mococutaneous junction of the vagina is 
severed and the deep seat of lesion exposed by carefully 
raising the cicatrized vaginal coverings. Utilizable rem- 
nants of the levator muscle can thus be readily located, 
and after isolation and trimming, should be coaptated 
liy buried end-to-end sutures. 

Treatment of Cerebrospinal Fever. — Ch.\rles G. 
Stockton (Am. .Med., April 1, 1905) emphasizes the im- 
portance of bringing about the best hygienic condition 
for the patient. This is accomplished by the absolute 
quiet in well-ventilated, darkened rooms, with the ab- 
sence of all excitement and irritation. Giving the great- 
est attention to secure the proper performance of the 
various functions of the body. The trial of the hot 
baths after the method of Aufrecht in all cases in 
which they seem to do good. The practice of intra- 
spinal puncture, with drainage when necessary to re- 
lieve severe pressure symptoms, to be repeated, if nec- 
essary, provided benefit follows the first puncture. The 
use of antipyrin in cases in which the temperature is 
raised not only for the relief of this symptom, but for 
the mitigation of headache and hyperesthesia. Dr. 
Stockton has found this drug also useful in improving 
the mental state, and in his hands it has not been fol- 
lowed by the expected depression. The use of opium 
or the bromides alone, or in connection with antipyrin, 
if necessary, for the relief of convulsions, pain, hyper- 
esthesia and pressure symptoms generally, which are not 
relieved by the foregoing methods of treatment. The 
use of mercury when needed for its laxative effect, or 
when needed to assist in stimulating the organs of elim- 
ination opium and the bromides are indispensable in 
some cases and large doses are at times necessary. 

Immunity. — Chapter X of this article in the Journal 
of the .1 iiiencaii Medkal Assoeiation. April I, 1905. 
deals with the Gruber-Widal reaction and its use in the 
diagnosis of typhoid fever. It is stated that it is largely 
a matter of accident that the reaction is called Widal 
instead of Grunbaum. as Griinbaum was carrying on the 
same work at the same time, but Widal preceded him 
in the publication of his more extensive work. It is 
stated that when a normal serum is found to have a 
high agglutinating power the previous infection by the 
micro-organism is to be thought of, and attention is 
called to the fact that the serum of a new-born child is 
devoid of many of the agglutins which are found in later 
life, hence, many of the so-called normal agglutinins 
may be acquired properties. The term immune agglufin 
is applied to the agglutinating substance of a scrum 
when the property has developed as a result of infec- 
tion, or of systemic innnunization of the organism. This 
chapter takes up the variations in agglutinogcnic or- 
ganisms and the variations in agglutinin. It is stated 
that the agglutinating power of the serum of a typhoid 
patient varies from day to day, and that it may be thirty 
times as strong one day as the next, or may even disap- 
jiear for a day or two. The possibility of agglutinin 
being found in the scrum of a child whose mother had 
had lyjjlioid fever during pregnancy is discussed. The 
I'feilTcr reaction is considered and the technic of the 
agglutination test is described. 

Gastric Cancer.— G. W. MtC.\sKEY (Jour. A. M. A.. 
April I, 1905) points out that in the early diagnosis of 
malignant gastric disease there is no single symptom or 
analytic finding, the presence of which is diagnostic or 
its absence exclusive. The same is perhaps true of any 
combination of several symptoms, still the diagnostician 



April 8, 1905] 



NEUROLOGY AND PSYCHIATRY. 



6SI 



is not entirely at sea. A thorough study of each case as 
to the disturbed gastric function, its duration, develop- 
ment., etc., is essential. The external physical e.xamina- 
tion would be presumably negative. Examination of 
stomach contents before breakfast, both chemical and 
microscopic, luay afford aid. The presence of lactic 
acid, of the Oppler-Boas bacillus, of gastric catarrh, 
or broken-down blood cells are all more or less signifi- 
cant. Then tlic digestive processes should be studied. 
The presence or absence of hydrochloric acid and its 
amount, if present, the intensity of the biuret reaction 
or its absence and the presence or absence of the various 
enzymes are salient points here. All these may 
strengthen or dispel suspicion, but the patient sliould 
lie kept under critcal study and treatment, the therapeu- 
tic tests being of the utmost importance. McCaskey 
thinks that gastrectomy should be the operation of 
choice as affording a longer chance of life. If we are 
ever to get the better of gastric cancer it will be when 
the internist learns to suspect the condition early and 
lias the courage to act mi the suspicion before it be- 
comes a certainty. 

NEUROLOGY AND PSYCHIATRY. 

The Pathology of Infantile Paralysis. — A histolog- 
ical study was made by F. E. B.\tten (Brain, Autumn. 
1904), of sections of the spinal cord of three fatal cases 
of infantile spinal paralysis, from which the author 
draws the conclusion that this disease is due to a primary 
thrombosis of a branch or branches of the anterospinal 
artery supplying the gray matter of the anterior horn, 
that such thrombosis may be produced by many and 
various forms of infection, and the disease is not due to 
a special specific infection, that the condition is more 
likely to occur in the lumbar region owing to the blood 
supply of this portion of the cord being at a point most 
distal from the heart, and the long course of the rein- 
forcing arteries. , 

A New Symptom in Hemiplegia. — .\ phenomenon 
wliich is not described in the text-books, has been ob- 
served in cases of hemiplegia by K. Heilbronner (Dent. 
Ztsch. f. Ncrvenhcilk., December 29, 1904). In recent 
cases of hemiplegia the inner and outer contours of the 
thigh broaden out, lessening the anteroposterior diam- 
eter. While the circumference of the thigh on the 
healthy side approaches closely the circumference of a 
circle, the circumference of the paralyzed side gives the 
impression of a flattened oval. This symptom is a con- 
stant one in recent cases of hemiplegia. It is not the 
result of the limp rolling outward of the lower limb, 
for it is observed if tlie limb is brought close up to the 
healthy member. This manifestation is also observed 
in other parts of the body, but on account of the lesser 
degree of muscularity it is not so prominent. This 
symptom is of diagnostic value only in case the lesion 
is unilateral in order that these may be a healthy limb 
for comparison. This prenomenon does not appear in 
normal sleep, in which muscular tone is preserved. 
Likewise in ordinary cases of loss of consciousness this 
symptom is lacking, and the same is true of deep nar- 
cosis. The symptom is present in severe cases of acute 
alcoholic polyneuritis, and in recent cases of acute an- 
terior poliomyelitis. It is not a prominent manifestation 
in tabes dorsalis. In hysterical flaccid hemiplegia the 
symptom is not present. Of extremely practical import- 
ance from the diagnostic standpoint would be this symp- 
tom of " broad-leg," as it is termed, in cases of apoplectic 
coma, if it should be present at a time when every active 
or reactive muscular act is absent, and both extremities 
offer no resistance to passive motions. It is also of 



value in the differential diagnosis from hysterical par- 
alysis. 
Tumors of the Hypophysis Without Acromegaly.— 

That disease of tlie hypo(iby>is iloes not necessarily 
cause acromegaly, is clearly indicated by the histories 
of the two cases reported by J. Koi,i..\Rms (Veut. Ztsch. 
f. Ncrvcnheilk, December 29, 1905). The first case was 
that of a sixteen-year-old girl who contracted syphilis 
and six months later complained of severe pains in the 
head and neck, particularly at night. A few days later 
there occurred a right abducens paralysis, repeated vom- 
iting and vertigo. The swollen glands showed that the 
system was no yet free of syphilis, .^n intensive mer- 
curial treatment was instituted. In spite of this, to the 
aliove symptoms were added right-sided ptosis, and 
double abducens and oculomotor paralysis, whose inten- 
sity varied. On account of the severe pains .02 to .06 
grams of morphine were administered daily. A month 
later there occurred attacks of convulsions with dyspnea 
and unconsciousness. These attacks were frequently 
repeated. Four months later there occurred paralysis of 
the right accessorius and of the right vocal cord ; the 
sense of smell was also impaired. Tubercle bacilli were 
found in the sputum. The patient became weaker and 
complained of loss of vision. Two months later death 
occurred. Autopsy showed a sarcoma of the hypophysis 
in which no part was healthy. The first symptom of the 
disease occurred nine months before death. Besides its 
bearing on the question of acromegaly, this case showed 
that nocturnal headaches cannot serve as a diagnostic 
sign of lues as against tumor of the brain. The second 
case was that of a 28^-year-old woman who one year 
before her death complained of severe headaches at 
night, and a half year later suffered a diminution in 
vision and a paralysis of the left abducens. At first the 
fundus of the eye was normal but later there was ob- 
served a choking of the temporal border of the disk. 
The second branch of the left trigeminal nerve was af- 
fected with anesthesia dolorosa, which later disappeared. 
The area of innervation of the right trigeminal also 
became painful. Exophthalmos appeared. One year 
elapsed between the appearance of the first symptom 
and death. Acromegaly was at no time observed. Au- 
topsy revealed an angiosarcoma affecting the entire 
hypophysis. The nocturnal headaches at first pointed to 
syphilis, but the mercurial treatment was of no avail. 

Paralysis from Fright. — A case of paralysis from 
this cause in which the patient, a girl of sixteen years, 
sustained a complete loss of function in all four extrem- 
ities, is reported by E. v. Leyden (Bed. klin. Woch., 
February 20, 1904). Sixty hours after being badly 
frightened by an attempted burglary, the girl was sud- 
denly deprived of motion and sensation in legs and 
arms, together with paralysis of the lower abdominal 
muscles and the sphincters of bladder and rectum. The 
latter recovered their tone within a few days, but the 
paralysis of the limbs lasted for about ten days. It must 
be assumed that in psychical, as well as in traumatic 
shock, the nerve impulses to and from the cerebral cen- 
ters of motility and sensation, are interrupted. Examina- 
tion showed that electric conductivity in the peripheral 
motor nerves was not interfered with, but that the trans- 
fer of sensory impulses to the motor paths could not be 
accomplished. The voluntary motor impulses was also 
present but could not be transmitted through the spinal 
ganglia to the peripheral motor nerves. The author is 
therefore of the opinion that we have to deal here with 
the cerebral as well as the spinal ganglion cells, which 
leads to an inhibition of the normal impulses in both 
the sensory and motor systems. The prognosis of these 
cases seems to be quite good and the treatment should 



652 



PRESCRIPTION HINTS. 



[Medical News 



be psychical and stimulating, the latter consisting mainly 
of strong faradic currents sufficiently powerful to pro- 
duce contractions and sensations in the affected limbs. 

OBSTETRICS AND GYNECOLOGY. 

Pregnancy and Labor in Primiparae of Thirteen to 
Sixteen Years. — In a series of observatinns made in 
Buenos-Ayres, S. Cache (Ann. dc Gyncc. et d'Obstct., 
December, 1904) one notes the extraordinary procrea- 
live ability of the women of that city, which 
-tarting with a precocious menstruation, is pro- 
longed until the forty-fifth year. The occurrence of 
pregnancy in girls who have not yet menstruated in- 
dicates that there is no absolute correlation between 
ovulation and menstruation. From the thirteenth to 
the sixteenth year women are not more exposed than 
later to abortion or complication of pregnancy. Among 
91 cases studied, there was only one contracted pelvis, 
from defect of development, and three cases of slightly 
had a good result. The accouchement of these minors 
was normal, with the e.xceptinon that the labor was 
longer than usual. There were 85 vertex presentations 
and five pelvic. Forceps was applied si.x times. Le- 
sions of vagina, vulva and perineum were rare, and in 
all cases quickly healed. There were no cases of in- 
sertion of the placenta in the inferior segment of the 
uterus. The mean weight of the fetus was 3,039 
grams (6,6 pounds). The proportion of sexes was 
nearly equal, being 44 boys to 45 girls. 

Albuminuria and Nephritis of Pregnancy and 
Labor. — The problems of the relationship of preg- 
nancy and labor to kidney changes has led R. W. 
Stf.w.xrt (Am. Jour. Obstct., January, 1905), to pub- 
lish conclusions inferred from frequent analyses of the 
urine of five cases both before and after labor. The 
following facts may' be noted by referring to the details 
of the cases: (l) In four cases of nephritis the kidney 
function was normal until within the week preceding 
delivery. (2) In four cases there was a marked in- 
crease in albumin from the time of its first appearance 
and a very decided increase in albumin leucocytes and 
casts immediately after delivery. (3) In two cases there 
was marked diminution in the quantity of the urine. (4) 
The ending of pregnancy was followed in a relatively 
short time by a cessation of all threatening symptoms. 
(5) With one exception, in all cases .symptoms of renal 
insufficiency appeared before labor had set in. It is the 
prevalent belief among obstetricians that pregnancy is 
of itself responsible for kidney lesions. .Again.st this 
speak the facts that in the great majority of cases there 
are no symptoms which point to a change in kidney func- 
linn -. that in most cases the albuminuria will disappear 
under medical treatment, pregnancy not being interfered 
with. If pregnancy were a potent cause in the produc- 
tion of albumin the examination of the urine should 
show a constant increase in the number of cases in 
which it would be foimd, the further the woman prog- 
ressed in gestation. The writer's figures do not bear 
out any such assumption. In explanation of the facts 
observed in this series of cases the conclusion is offered 
that in cases of simple albuminuria the pressure of the 
enlarging uterus upon the intestines may produce slug- 
gishness in peristalsis and consequent constipation; this 
in turn may cause retention of the products of decom- 
position, then subsequent absorption into the general 
system and thus additional work thrown upon the kid- 
neys; the consequent effort on the part of tlie kidney to 
throw these products out of the system would in time 
produce hyperemia of these organs, kidney fag and hence 
albuminuria. In these cases normal function may be re- 
■ilored by unloading the intestines and the liver, in its 



■severer forms, cases in which the intestines are neglected 
<.>r digestion overtaxed, the persistent renal hyperemia 
may cause true nephritis. This theory would make the 
hepato- and autp-to.xemias secondary factors and re- 
move them from the category of primary causes. 

Ovarian Cyst Containing Lumbricoides. — .\n unu- 
-ual exaiuiilc of the migratory habits of the lumbricus, 
IS reported by IC. Dufouk (La Clituquc, March 4, 1905). 
The case was that of a seventeen-year-old girl who had 
never menstruated, and who a year before she came un- 
iler oliservation by the author had been under hospital 
treatment for what had been diagnosed as tuberculous 
peritonitis, for which she had been discharged improved. 
.SiKin afterward a tumor appeared in the suprapubic 
region extending upward and to the right. It caused 
but little pain and a slight difficulty in urination. The 
latter was exaggerated one month before she entered 
the service of the author. .\ median laparotomy was 
performed, and there was found in the right of the 
pelvis a large encysted tumor, adherent to the surround- 
ing parts and to the intestine, and presenting a num- 
ber of cysts on its surface. The efforts to "free the 
tumor from its adhesions revealed behind it a fungous 
tissue, and a cystic pocket on its surface, which con- 
tained a gelatinous liquid containing three living round 
worms. The examination of the intestinal loop to which 
the tumor had been adherent, revealed two minute per- 
forations. The latter were sutured and the tumor was 
freed and removed. A part of the fungous tissue could 
not be extirpated. There was no sign of tuberculous 
peritonitis. The tumor was a multilocular cyst of the 
ovary. The fungous tissue was of an inllainmatory na- 
ture. The patient made a good recovery w'ith the ex- 
cci)tion that a fistula remained, which up to the i)rcsciit 
has resisted all efforts to make it heal 



PRESCRIPTION HINTS. 



Sedative and Carminative. 

1^ Dionini gr. iii 

01. Cajuput m. iii 

Chloroformi ) , . 

F.xt. Caimah ind. fld....| =>=*■ '" '''^' 

Tr. Galanga. or 

I'r. Zingiberis m. x 

.\cid. Hydrocyan. dil m. ix 

.\lcohol, ad 5 ii 

Sig. : 30 to 60 droii^. in water. — Jas B. Johnston 

Treatment of Flatulence. 

R I'lriixiiii.' of nuiiine^iiun grs. vi 

lor line wafer Ici he t.ikeu lialf an hour before each 
nie.'il. 

.\fter meals, the follnuing powder: 

B Prepared chalk grs. xv 

Piicarb. of soda grs. viii 

Calcined magnesia grs. viii 

In case of binning sensation in the stomach and 
pyrosis: 

IJ Prepared chalk grs. xv 

Snbnitrate of bisnuith grs. vi 

Calcined magnesia grs. xii 

Codeine gr. 'A 

Powdered belladonna gr. f^ 

b'or one powder. 

Preparations of napbthxl should be avoided, as they 
irritate the stomach. 

Diarrhea of Consumptive Patients. 

If Melhylem: blue grs. iii 

Lactose grs. xx 

l"'or one wafer, to be given daily. 



April 8, 1905] 



EDITORIAL. 



653 



The Medical Ne 

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SATURDAY, APRIL 8, 1905. 

THE MILK IN THE ISTHMIAN COCOANUT. 

The controversy that has lately arisen be- 
tween Dr. Chas. A. L. Reed and the defunct 
Isthmian Commission is not only a very unfor- 
tunate one, but comes at a singularly inoppor- 
tune time. With the merits of this dispute we 
have, at this time, nothing- to do. It may be, as 
the Secretary of War claims, that Dr. Reed, who 
was sent to Panama as a member of a comfnis- 
sion to condemn the land used for the construc- 
tion of the canal, and was asked incidentally by 
Secretary Taft to give his ideas on sanitation 
derived from a personal view of the situation, 
rushed hastily into print before reporting to his 
superior officer. If such be the case, ' he has 
already been admonished by the letter of the 
President of the United States. 

It may also be true on the other hand, as Dr. 
Reed insists, that bureau circumlocution and red 
tapeism. like the mills of the gods, grind slowly, 
and it must be admitted in tlie refusal of the 
Isthmian Commission to grant a small appropria- 
tion to Dr. Gorgas. to enable him to insure the 
appointment of a desired assistant, that thev 
ground exceedingly small. Rut it is hot the 
merits of the claims of either party in this unfor- 
tunate quarrel that .is of the first imp'ortahce to 



the medical profession at large, but the effect that 
these charges and countercharges, these " re- 
ports " and " answers " will have upon the laity 
and lay press, and through them upon Congress, 
in whose hands the key to the whole situation 
really lies. 

Now, it must be borne in mind by every medi- 
cal man that while the work of the last few years 
in tropical climates has been marked in success 
and brilliant beyond words in achievement, that 
the agency of the mosquito and its action in the 
propagation of yellow fever and malaria, while 
it has been accepted by them as a fact, is yet 
looked on with doubt by the masses and still re- 
mains to them what it has been christened by a 
more or less scoffing pubhc press, " The Mos- 
quito Theory." They must also remember that 
yellow fever and malaria will occur in sporadic 
cases, no matter how carefully the modern pre- 
cautions are taken or improved sanitation is car- 
ried out. The situation in fact resembles that of 
the New England town after the installation of 
a fire engine, which was purchased by the " se- 
lectnien " against the wishes of a majority of the 
inhabitants. Soon after its appearance a fire 
broke out. This was in course of time followed 
by another conflagration, and then the wrath 
of the community was poured out in floods on 
the heads of the officials. They did not take 
into consideration that the fire was more easilv 
subdued and the resulting damage less ; thev had 
spent the mone_\' and they were dissatisfied with 
the result attained. Now the amount of ma- 
terials for use in disinfecting already purchased 
and forwarded is as follows: 14 tons of insect 
powder in 16 shipments ; 52 tons of sul]3hur in 17 
shipments ; 2 tons of sulphate of iron ; 23 tons 
of chloride of lime ; 500 pounds of sulphate of 
copper. 

Take this list of materials and add to it the 
expense of laborers, " which have been allowed 
as required and as necessary and have been num- 
bered by hundreds in the Health Department " 
(see "Reply Isthmian Canal Commission," page 
32) and let there be a few cases of vellow fever 
in the canal zone, and the .American Secular press 
will shout in glee from the very hilltops. Not 
only will they influence the people at large, and 
through them the Congressmen, in regard to ap- 
propriations, but they will cast discredit and un- 
belief over what has been the greatest triumph in 
.\merican preventive medicine. , 

There is another point, too, that should be re- 
membered, and that is, that the comparison so 



654 



EDITORIAL. 



[Medical News 



often made between the work at Havana and that 
on the Isthmus is not a fair one. For the sit- 
uation is a different one. In the first place, Ha- 
vana was a paved city, no matter how dirty it 
may have been, while the track of the canal lies 
through an uncut, almost impenetrable jungle. 
Again the work in Cuba was accomplished under 
the rule of Gen. Wood, who w'as not only himself 
a medical man, but he was also a military gov- 
ernor, with personal and direct command of un- 
limited money, for which he did not have to ac- 
count to the United States. He was a dictator, 
simply expending the revenues of Cuba, and had 
he so desired he could have drawn a check for a 
million of dollars and expended it for warming 
pans without being obliged to submit a voucher 
to the Treasury Department, for not one dollar of 
the funds of this government was spent in sani- 
tation there. 

Now, the one power similar to this is vested 
in Congress. If it had desired. Congress could 
have appropriated a lump sum to a medical com- 
mission who could by their orders have expend- 
ed it without delay, friction or red tape. But 
Congress did not only not do this, but particu- 
larly avoided it, so as every cent spent in this 
work has to be expended by rules laid down in 
the previous bill, it strikes us that the time has 
come when the whole energy of the medical 
profession should be concentrated on an effort 
to induce the next Congress to pass such a bill 
and not be wasted in expostulations with a com- 
mission appointed to carry out certain definite 
instructions. If the present restrictions are cum- 
bersome, as without doubt they have proved to be, 
then get Congress, who has the power to do so, 
to change them. Meanwhile bend every effort 
with the force and material at hand to make as 
good a showing as possible, and thus avoid a 
total loss of all that has been hitherto accom- 
plished. 

As we have already stated, we have at this 
time nothing to say in regard to the merits of 
this controversy, but we must admit that in one 
case cited the commissioners erred ; if not in the 
abuse of power, at least in the exercise of 
tact. When the " expert " from Panama pre- 
sented his letter from Dr. (iorgas to the chair- 
man at Washington, requesting that he might be 
permitted to select the X-ray and microscopical 
apparatus, he was informed that he could pro- 
ceed to New York invested with full power to 
make the purchase. At this he demurred and 
stated, " that the commission asked too much, 



that he had other things to do and did not care to 
work on his vacation, and that someone else 
should be asked to select them." Whereupon the 
matter was submitted to the Marine Hospital 
.Service, with the request that they should pur- 
chase them. Now, we are not ourselves " sur- 
geons in the service," but we have lived near the 
rose and recognize its perfume. Moreover, we 
can realize that nothing would be so galling to the 
Colonels and Majors of one branch as to be 
obliged to use the apparatus selected and pur- 
chased by the Admirals and Commanders of the 
other. 



HOME AND DISPENSARY TREATMENT OF PUL- 
MONARY TUBERCULOSIS. 

Ix the March, 1905, Post-Graduatc ar^ inter- 
esting accounts of the results of home and dis- 
pensary treatment of the consumptive poor, as 
carried on at the Post-Graduate Hospital Dis- 
pensary from 1898 to 1905. The plan of treat- 
ment was inaugurated by Dr. John F. Russell, 
and has been carried on by him and by his assist- 
tants, though the reports are from a committee 
of inspection appointed by the trustees of the 
institution. 

Starting with the assumption that consumptiort 
is only possible with defective nutrition, and 
notably with defect in the storage of fats, the 
plan of treatment is essentially dietetic, with es- 
pecial reference to the supply of fats. During 
examinations the patients remain at home in bed, 
but many have carried out the treatment to a 
successful end while pursuing their regular 
work. When under full diet the patient receives 
I^roteids, 181 gms., fats 316 gms., carbohydrates 
239 gms., of 4,668 calories. This is 608 more 
calories than prescribed in Playfair's dietary for 
a man doing hard labor, and two to three times 
its amount of fats, and about half the carbohy- 
drates most authorites regard as necessary for 
laboring men. 

Under this method of treatment the committee 
of inspection reports forty apparent cures, the 
cure being based upon the disappearance of tu- 
bercle bacilli from the sputum, disappearance of 
symptoms, and gain in weight. Of fourteen pa- 
tients whose histories are given in detail, who 
completed an eight weeks' course of treatment 
in bed, the average gain was 15. i pounds, the 
least gain being 5.5 pounds, the greatest 24.5 
priunds. 

P>eginning with the year 1905 the treatment is 
carried out at a small, specially equipped, hospi- 



April 8, 1905] 



ECHOES AND NEWS: NEW YORK. 



6S5 



tal, at 322 East Nineteenth Street. In these new 
surroundings, where the dietetic needs of its in- 
dividual patients can be more positively ascer- 
tained by means of chemical analysis of tissue 
waste, still more satisfactory results may be 
looked for. 



SOME ASPECTS OF PUBLIC SANITATION. 

The heated controversy between the New York 
municipal authorities and the Interborough Rapid 
Transit Company, over the right of the former 
to compel the removal of signs and other im- 
pedimenta from the subway, is awaiting judicial 

decision. 

Those who have followed the proceedings in- 
cident to this litigation may recall that each party 
has called to its aid the services of a prominent 
sanitarian. Dr. George A. Soper, on behalf of 
the city officials, submitted an affidavit affirmmg 
his belief that subway signs afford a nidus in 
which, under the favorable condition of absence 
of sunlight, a host of pathogenic bacteria may 
propagate at liberty. The parties interested m 
keeping these embellishments of the tunnel sta- 
tions retained the services of Dr. Wm. H. Park, 
who found experimentally that dust removed 
from the frames of the subway signs actually 
showed fewer colonies of bacteria than equal 
quantities of dust removed from different parts of 
the street and sidewalks above. 

At first sight, the results of these investiga- 
tions would seem to seal the fate of the people's 
case. But on close analysis, the bacteriological 
findings lose in significance. Would it be too 
exacting to ask whether the subway porters had 
been given secret instructions the day before to 
thoroughly wipe the gilded frames enclosing 
eulogies of somebody's " Consumption Cure " or 
" Hair Restorer " ? Moreover, it was too pre- 
mature to take account of such emergencies as 
the subwav strike, when the walls of the stations 
would naturally be neglected. Besides it is hardly 
fair to compare an enclosed space in which, as 
the strike has abundantly indicated, the public 
may be compelled to crowd and await indefinitely 
the arrival of the next express, with the broad 
open highway above, where no one is obliged 
to linger and where crowding is rare. It cer- 
tainly does not redound to the credit of the street- 
cleaning authorities that so many bacterial cul- 
tures could be obtained from the public high- 
way—but here we are giving the subway people 
a retort to fling back at the city officials. In 
short, the question narrows itself down to this: 



Shall any weight be given to bacteriological find- 
ings under the conditions cited above, at a time 
when the subway is new, and when far different 
results may be obtained at a later date, particu- 
larly when interested vigilance is apt to be re- 
laxed? 

The campaign against public expectoration is 
still being fought, and although a considerable 
degree of success is being achieved, a great deal 
remains to be done. The health officials are 
coming to realize that the almost total abolition 
of the spitting evil will not result from merely 
punitive efforts, but will be attained only by a 
general educational uplift of the masses. As the 
first step in this direction, little slips of paper 
will be pasted in all the text-books issued to the 
public-school children, on which are printed de- 
scriptions of the evils of expectoration. It is 
true that the children are not the main offenders 
in this direction, but the text-books come into 
thousands of households, and the pasters will 
certainly attract the attention of many offend- 
ing adults. It has been suggested that more 
immediate good would be accomplished by hav- 
ing these hygienic instructions printed on 
cigar labels, tobacco-wrappers, street-car trans- 
fers, etc. 

An evil whose consequences are far more bane- 
ful than those of expectoration, and which has 
been curiously overlooked by health authorities, 
is the practice frequently indulged in by pas- 
sengers in public cars of coughing indiscrim- 
inately without protecting their mouth by means 
of a handkerchief, or even their hand. During 
a grippe epidemic it is not uncommon to see a 
dozen individuals in the same car indulging in 
coughing and sternutatory efforts to their heart s 
content These two reflex acts, when the mouth 
or nostrils are unguarded, are far more danger- 
ous than expectoration ; in fact, the product of 
a cough may be termed a nebulous expectoration. 
Disseminated thus by a germ-laden atmosphere 
no wonder many diseases involving bronchial 
irritation are so markedly contagious. 



ECHOES AND NEWS. 

NEW YORK. 
The Meningitis Situation.-One hundred and 

thJ-fy-one persons died of meninges last week, as 
.^A ,lMtV, eiehtv-five the week before, and the 
iTtTernum^ of deaths was higher than that of any 
of the preceding six weeks, the figures running for 
the last eight weeks 27, 40, 48, 62, 78. 85 and 131- 
For the week of 1904 corresponding to last week 
The deathT from this disease numbered thirty-one. 



6S6 



ECHOES AND NEWS: NEW YORK. 



[Medical News 



Physicians in all parts of the city have- been called 
to attend hnndreds of cases of the disease in its 
milder form. 

Board of Estimate Appropriation. — The Board of 
Estimate has authorized the issue of bonds to the 
amount of $1,000,000 for the use of the Board of 
Health in improving hospitals, and $750,000 to im- 
prove the sanitary condition of the celebrated 
Gowanus Canal, in Brooklyn. Dr. Darlington, presi- 
dent of the Board of Health, had asked for $4,500,000 
for building new pavilions and additions to various 
hospitals and for general improvements. The board 
went through his list and selected what they re- 
garded as urgent matters and gave him $1,000,000 
for the year. This is in addition to the regular 
annual appropriation for current e.xpenses. 

Society of Sanitary and Moral Prophylaxis. — A 
meeting of this Society will be held at ,thc Academy of 
Medicine, 17 West Forty-third Street, on Friday evening, 
-A-pril 14, at 8:30 p..m. The following is the interesting 
program: (i) Adoption of Constitution and By-Laws; 
(2) Education in Sexual Hygiene, by Dr. John H. El- 
liott, of the Hudson Guild; (3) The Sexual Necessity, 
by Dr. Edward L. Keyes ; -(4) Attitude of the Church 
toward Sexual Hygiene, by Rev. Henry .\. Brann, Rec- 
tor of St. Agnes' Church; (5) Ignorance, Perversion and 
Degeneracy, by Frank Moss, Esq.. of the Society for the 
Prevention of Vice ; (6) Education within the Medical 
Profession, by Dr. Prince A, Morrow. The papers will 
be discussed by prominent members of the laity and of 
tlie medical profession. 

A Sanitary Census. — .\lthongh the taking of a 
sanitary census of the city has been contemplated 
for some time by Health Commissioner Darlington, 
the baffling persistence of cerebrospinal meningitis 
has emphasized its urgency, and the work is to be 
undertaken proinptly. Cards have been made out, 
by means of which the number of persons in each 
house, their nationality, condition of health, date of 
birth and other essential information can be re- 
corded. If a foreigner is suffering from any disease 
an attempt will be made to discover whether he con- 
tracted it before coming to this country or since. 
Also the number and character of cases of illness 
in any one house within a year will be set down, 
with file conditions prevailing in the house. 

The New St. Francis Hospital. — While the medi- 
cal board of the St. Francis Hospital has to express 
regret in the annual report that the new hospital 
is not yet ready fof occupancy, as it was expected 
that it would be by this time, it shows tjiat the work 
accomplished during the year in the present quarters 
has been more than ordinarily successful. The de- 
lay to the big new building now being erected on 
East One Hundred and I'orty-second Street has been 
caused by labor troubles, but as the strikes have 
been declared off, it is almost certain that the sisters 
will rhove to their new home at least by September. 
During the year 2,797 patients were treated, of whom 
1,684 were cured and 495 were reported as having 
distinctly improved. The death rate for the year 
was g.84 per cent. ' On January i, 1905, there were 
refnaining in the hosprtal, 251 patients. The de- 
tails of the medical report, in which figures are given 
concerning the treatment of every disease treated in 
the hospital, afford some idea of the diversity of the 
work of the physicians and surgeons. They cover 
no less than seventeen pages of the pamphjel. 

Poliklinik's New Home. — The Gernian PpliWinik 
of this city, which has rc(;ent]y purchased the build- 
ing of the German Dispensary, at No. 137 Second 



.-\venue. is making an appeal to its friends for sub- 
scriptions to its new building fund. The German 
Poliklinik is a charitable institution for the free medi- 
cal treatment of the sick poor, founded in the year 
1883. Since that time its corps of physicians have 
taken care of 327,282 patients, free of charge; these 
patients visited the Poliklinik 1,014,682 times, and 
received 723,355 prescriptions, which were com- 
pounded in the drug store attached to the institution. 
The present building, Nos. 78 and 80 Seventh Street, 
having become visibly inadequate for the work re- 
quired, the society contemplated enlarging its facil- 
ities by making extensive alterations, when it learned 
of the possibility of acquiring the building of the ■ 
German Dispensary, and after some negotiation with I 
the board of trustees of the German Hospital and 
Dispensary, the contract was signed for the purchase 
of the property. It is said for the Poliklinik and 
without fear of contradiction that this charity, with 
the old German Dispensary gone, will beconie ab- 
solutely indispensable to the sick poor of the lower 
East Side. Henry Schmidt, M.D., No. 78 "Seventh 
Street, is treasurer of the German Poliklinik. 

Meningitis Commission Meets. — The commission 
to investigate cerebrospinal meningitis, appointed by 
Health Commissioner Darlington, had its lirst meet- 
ing recentlj', in the Health Department building, at 
F",ift3'-fifth Street and Si.xth Avenue. The cominig- 
sion consists of Drs. W. F. Polk. W. B. James, W. P. 
N<irthrup. Simon Flexner, J. F. Van Cott, E. K. 
Dunham and William K. Draper. Dr. Polk, who 
is dean of the Cornell medical school, has not yet 
accepted the appointment. He was the only member 
absent at this meeting. His place as chairman of the 
commission was filled temporarily by Dr. James. 
Dr. Draper was appointed secretary. The commis- 
sion spent some time studying maps of the city with 
regard to the prevalence of the disease in certain 
localities, and in considering the conditions peculiar 
to those localities. They also had before them the 
tabulated statistics of the disease for several years 
back. Drs. Northrup. James and Draper, represent- 
ing the clinical end of the comtnittee, and Drs. F"lex- 
ner. Van Cott and Dunham, the bacteriological end. 
then considered in groups and points to be investi- 
gated under each head. The commission decided to 
issue cards to doctors in hospitals, with blanks to 
be filled in with desired data, as was dpne by th? 
pneumonia commission last year. While the final 
list of questions to be asked in these cards was not 
settled, the commission will want to know, under 
the bacteriological end of the investigation, what are 
the evidences of communicability and what is kno\yn 
of the biology of the disease bacilli, with reference to 
(liflferenliation, agglutination and pathogenesis. Un- 
der the clinical liead Ihey will inquire about the effec,t 
of drying on the bacilli and viability in spray, as 
liearing on isolation and infection. Complete in- 
formation about the patients' surroundings and the 
conditions under which the3' were stricken with Jhe 
disease w.ill also be collected. It is probable that 
the scope of tlie investigation will be world-wide 
and that inff>rmation will be sought from hospitals 
all oyer the globe. This commission is only the 
second of the kind that has ever been ajipointed iri 
New York. The pneumonia commission. appi>intcd 
last year, is still at work. 

Manhattan Dermatological Society. — Regular 
nionlhly iiui tiiig of ibis society was held on I'^riday 
evening, Warch 3, 1905, at the' residence of Dr. 1. P. 
Oberndorfcr, with Dr. E. L. Cocks, presiding. 



Ai'Rii. 8. 1905] 



ECHOES AND NEWS; PHILADELPHIA. 



657 



Dr. W. S. Gottheil showed the following cases: 
(a) Case for diagnosis; a boy of eight years showed 
lesions on the face, about arms and abdomen; lesions 
of tvvo years' duration; history shows a brother like- 
wise affected; the lesions consist of old scars aild 
the newer ones, of ulcerating, hypertrophic granula- 
tions of varying sizes and in all stages of evolution, 
from small beginning necrotic lesions to large ul- 
cerating masses. Dr. Gottheil believes the condition 
to be hereditary syphilis. Most of the members 
agree in calling it hereditary syphilis. Dr. Cocks 
thinks a tuberculous process may likewise be present. 
Dr. Allen is of the same opinion, (b) Dr. Gottheil 
again presented his case of acne cornea; new lesions 
are seen on the face and also on the hands. Old 
lesions disappear spontaneously. (f) Dr. Gottheil 
then showed a made adult with a lesion on penis. 
The patient states he had a sore on penis a short 
time ago; at present there is some induration at this 
.site; also dry scaly patches of eczema along the 
glans penis, extending from the urethral orifice; 
some macules observed on body and a few very large 
papules on lower limbs. Patient is not taking any 
drugs. . Drs. Bleiman, Weiss and Heinian regard the 
initial lesion as chancre and the scaling patches on 
body as a psoriasis. Dr. Kinch said the early ap- 
pearance of a scaly eruption on body coincident with 
the appearance of the chancre did not favor diag- 
nosis of a luetic body lesion; the latter he regards 
distinct and as psoriasis. Dr. Pisko favored diagnosis 
of syphilis for the lesion on body. Dr. Oberndorfer 
said the lesion on body was a very early manifesta- 
tion, if it were a syphilitic lesion. He had some 
doubts about it. The penile lesion was a hard 
chancre, id) Dr. Gottheil also showed a boy with 
well-marked patches of leucoderma; scabies was also 
present. 

Dr. A. Bleiman showed a case of prurigo in a boy 
of eight years (same case shown last spring), il- 
lustrating the result of treatment. A few papules 
and squamous lesions with slight induration of the 
skin over the shins are still observed, but in all the 
condition of the skin is considerably improved. The 
patient has never enjoyed freedom from eczematous 
lesions, for so long a period, now si.x months, since 
the process began when two years old, and the 
prognosis as to ultimate recovery seems to be good. 
The best results seemed to be obtained after the use 
of 2 per cent, ichthyol ointment, daily baths and 
internally syr. ferri iodati. 

Dr. B. F. Ochs presented a woman, showing 
gummatous lesions on the lower leg extending to 
and involving the foot. A second case (in a 
woman) of a complete perforation of the cartila- 
ginous septum of nose: ten years ago history of 
nasal catarrh with beginning flattening of the nose; 
one year ago similar symptoms. There is lio his- 
tory of infection and no other lesions present on 
any part of the body. Dr. Ochs presents it as a case 
of syphilitic necrosis. 

Dr. Kaplan showed for Dr. Gottheil a case of 
nevus unis lateris; a boy of four years presents an 
intensely blue nevus, covered abundantly with fine 
hairs, along the right upper and lower arm; a few 
isolated warty pigmented spots on back and left arm. 
Dr. Gottheil stated the condition might be better 
termed nevus pilosis, as pigmentosus verrucosus (con- 
genital) X-ray will cause epilation; as to ultimate 
results he is doubtful if any course of treatment 
would influence it. Dr. Bleiman said, as to progno- 
sis, in advanced adult life such a growth may be a 



source of danger and assume malignancy. Dr. Allen 
advocated X-ray and high frequency spark. Dr. 
Pisko saw a similar case in which X-ray and hig'h 
frequency currents showed no decided results; but 
electrolysis for destruction of the hairs partially 
succeeded. At present the case is under ultraviolet 
exposures and the condition still remains unchanged. 

PHILADELPHIA. 

A Benefit for the Hahnemann HospitaL — The pro- 
ceeds 1)1 ilie tableaux given last week at the New 
Century Club will go to the Hahnemann Hospital. 

Resigned. — P. W. Koons. superintendent of the 
Hahnemann Hospital, resigned his position, stating 
that he intends to resume his studies in medicine 
next fall. 

Portrait of Prof. Forbes to be Presented to the 
Jefferson Medical College. — As a token of their re- 
spect, the undergraduates and alumni of the Jeffer- 
son Medical College, will present to the College the 
portrait of Dr. Forbes. 

Leper Patient Improving. — Moses Kailioha. a 
Hawaiian leper, who has been at the municipal Hos- 
pital for one year, is improving rapidly under the 
treatment instituted. So encouraged are the physi- 
cians at the hospital that they cherish the possibiliy 
of curing the patient. 

To Discriminate in Dispensary Practice. — The 
Senate has passed a bill which gives to the State 
Board of Charities the power to license and regu- 
late dispensaries. The bill makes it a misdemeanor 
for any person to obtain medical or surgical treat- 
ment at the dispensaries on false representation as 
to their linancial onudition. 

An Act to Modify the Proceedings of the State 
Board Examination. —Through the influence of Dr. 
J. W. Ifcjlland, Dean of the Jeliferson Medical Col- 
lege, a bill has been introduced into the legislature 
which, if passed, will permit a medical student, at 
the end of his sophomore year, to take the State 
Board Examinatious in anatomy, chemistry and 
physiolog}'. 

Conference of Anatomists. — Upon April 11 and 12 
the American .Anatomists will meet in the Wistar 
Institute of .-Anatomy at the University of Pennsyl- 
vania, this city. The most important subject which 
will be brought up for discussion, is the founding 
i)f a central institute for cooperative investigation 
in the realms oi anatomy. On the evening of April 
I r the conference will be tendered a reception by 
General Wistar at his home, southest corner of 
Seventeenth and Sjiruce streets. 

Diplomas Awarded. — Last week eighteen young 
women, of the Pennsylvania Hospital Training 
School for Nurses, received their diplomas, which 
will entitle them to enter upon their chosen profes- 
sion. The diplomas were presented by J. T. Shinn, . 
secretary of the Board of Managers, and after tlie 
presentation Dr. .Alfred Stengel, of the hospital stag, 
delivered an address during which he informed the 
young women that they have chosen a profession 
which requires more sincere work and patience than 
any other calling and that their success will depend 
upon the exercise of skill and ability to the best 
advantage and upon the application of the accumu- 
lated practical knciwledge received at the hospital. 

Sanitation in Office Buildings. — This was the sub- 
ject of Dr. Henry Leffmann's paper read before the 
regular meeting of the Engineers' Club. He first 
spoke of the bad (piality of water supplied and then 
of the additional contamination of the water by ice 



658 



ECHOES AND NEWS: CHICAGO. 



[Medical Nbws 



which is infected by the buckets and containers 
in which it is distributed to the water tanks. He 
told his audience that the water which he drinks is 
cooled merely by contact, that is, he allows the bot- 
tle containing the water to lie in contact with the ice 
only. In speaking of cleaning a building, he main- 
tained that the vacuum system of removing dust is 
the proper one. for it gets rid of the dust while the 
ordinary method merely stirs it up from day to day. 

Academy of Surgery. — The meeting of this society 
was held .-Kpril 3. Dr. G. G. Davis read a paper on 
the " Treatment of Fractures about the Neck of the 
Femur in which Fixation was Accomplished by 
Means of a Screw." The paper was discussed by 
Drs. Keen, LeConte and Roberts. Dr. A. C. Wood 
read two papers; the first on "Strangulation of the 
Vermiform Appendix by an Abnormal Opening in 
the Mesentery;" a second one on "Vermiform Ap- 
pendix in the Sac of a Femoral Hernia." He re- 
ported two cases. This paper was discussed by Dr. 
Gibbon. Drs. Royer and Schwartz then read a 
paper on " A Case of Anthrax." Drs. Keen, Willard 
and Jopson discussed it. Dr. Keen then read a paper 
on " A Method to Fill Defects in Bone by Bone 
Chips." Dr. Stewart read a paper on " Osteomyelitis 
of the Tibia," in which the shaft was removed. 

Governor Vetoes Bill to Check Idiocy. — The Gov- 
ernor takes the ground in vetoing the bill that the 
language is not clear, in that it does not describe 
the nature of the operation that is to be performed. 
He maintains that the safest and most effective 
method of preventing procreation would be to be- 
head these individuals and such authority, he says, 
is given to the scientific men by the bill. A surgeon, 
he intimates, may be so eager to advance in skill 
as to forget the dangers he may subject his patients 
to. Such a bill, if passed, would violate the princi- 
ples of ethics. These feeble-minded and imbecile 
children, he declares, are entrusted to the institu- 
tions by their parents or their guardians for the 
purpose of training and instruction. It is proposed 
to experiment upon them not for their instruction 
but for the welfare of the society and without the 
consent of the parents or the guardians. The Gover- 
nor believes that if idiocy could he prevented by an 
act of Assembly such an act would have been passed 
long ago. 

The Pennsylvania Legislature has Passed the Fol- 
lowing Appropriation Bills. — Philadclf'hia, Woman's 
Medical College Hospital, $100,000; St. Agnes' Hos- 
pital, $100,000: Sanitarium Association, $10,000; 
Hospital Department, Hahnemann Medical Col- 
lege, $416,000; Pliiladclpliia Orthopedic Hospital. 
$35.000 ; German Hospital, $110,000; St. Luke's 
Homeopathic Hospital. $150,000; Philadelphia Home 
for Incurables, $50,000; St. Mary's Hospital, $37,- 
000; Wills Eye Hospital, $80,000; Philadelphia 
Lying-in Charity, $20,000; Rush Hospital for Consump- 
tives, $210,000; Pennsylvania Sanitarium and Benevo- 
lent Association, $20,000. Other Appropriations for 
Pennsylvania, Bedford County Hospital, $21,000; Todd 
Sanitarium, Cambridge Springs, $6,000; E?ston Home 
for Friendless Children. $3,000; Home for Aged and 
Infirm Women, Easton, $3,000; Good Samaritan Hospi- 
tal, Lebanon, $31,500; York Hospital and Dispensary, 
$30,000; Williamsport Hospital, $50,000; Florence Crit- 
tcnton Mission. Williamsport, $15,000; Home for 
Friendless, Williamsport, $15,000; Aged Colored 
Women's Home, Williamsport, $1,000; Chester Hospi- 
tal, $.30,000; Pottsville Hospital. $60,000; Meadville 
City Hospital, $14,000; Coatesville Hospital, $15,000; 



Todd Hospital, Carlisle, $7,000; Shenango Valley Hos- 
pital, New Castle, $41,000; State Hospital for Insane, 
Warren, $196,500; Western Pennsylvania Colored In- 
dustrial School, Lawrence County, $5.000 ; Valley Forge 
Park Commission, $116,815; Medical and Surgical De- 
partment of the Western Hospital of Pittsburg, $180,- 
000 ; Allegheny County Association for thp Prevention 
of Cruelty to Children, $7,000; St. Joseph's Hospital 
and Dispensary, Pittsburg, $75,000; Bradford City Hos- 
pital, $87,000; Phoenixville Hospital, $60,000; Mercy 
Hospital, Wilkesbarre, $45,000; Lock Haven Hospital, 
$25,000; Nason Hospital, Roaring Springs, $15,000; 
Women's Homeopathic Association of Pennsylvania, 
$85,000; Eagle Hospital for Consumptives at Summit 
Hill, Carbon County, $8,000; Charity Hospital, Pitts- 
burg, $100,000 ; Children's Industrial Home, Harris- 
burg, $9,000; Conemaugh Valley Memorial Hospital, 
Johnstown, $45,000; Beaver County General Hospital, at 
Rochester, $12,000; Benevolent Association's Home for 
Children, Pottsville, $2,000; Children's Aid Society of 
Pennsylvania, $30,000; Du Bois Hospital, $6,000; Spen- 
cer Hospital, Meadville, $20,000; Mary M. Packer Hos- 
pital, Sunbury, $10,000; Chester County Hosp'ital, West 
Cliester, $20,000 ; Pittsburg Hospital for Children, $68,- 
000 ; House bill to provide for a deficiency in the care 
of indigent insane, $100,000; House bill for the care 
and treatment of the indigent insane for the next two 
years, $2,000,000; Easton Hospital, $70,000; State Hos- 
pital for Insane, at Norristown, $223,000; to cover de- 
ficiency in the Pennsylvania Training-school for Feeble- 
minded Children, at Elwyn, $36,874; State Hospital, 
Phillipsburg, $22,195; Pennsylvania Reform School, 
Morganza, $117,588: for the erection of a State Hospital 
for the Criminal Insane, $160,000 ; establishing an emer- 
gency fund for the suppression of epidemics, $75,000; 
State Hospital for Insane. Danville, $251,450; Titus- 
ville City Hospital. $14,000; Miners' Hospital, at 
Spangler, Cambria County, $15,000; Beaver Valley 
General Hospital, Beaver County, $37,000 ; Adrian Hos- 
pital, of Jefferson County, $24.000 ; Clearfield Hospital, 
$21,000; North Pennsylvania General Hospital, at Aus- 
tin, $10,000; Monongahela Memorial Hospital, $20,000; 
Home for the Friendless. Harrisburg, $5,000; Wilkes- 
barre City Hospital, $70,000; Altoona Hospital, $50,000; 
St. John's General Hospital, Allegheny, $45,000: Sylvan 
Heights Home for Orphan Girls, Harrisburg, $10,000; 
Messiah Home Orphanage, of Harrisburg. $3,000; 
Johnstown City Hospital, $5,000; McKeesport Hospital, 
$80,000; St. Joseph's Hospital, Reading. $30,000; 
Homeopathic Medical and Surgical Hospital, Reading, 
$38,000; Reading Hospital, $39,000; Lewistown Hospi- 
tal, $15,000; Allentown Hospital, $30,000; St. Luke's 
Hospital, South Bethlehem, $56,000; Home for Friend- 
less Children, Reading, $7,000; Children's Home, South 
Bethlehem, $1,000; for two State institutions for the 
treatment of incipient tuberculosis, $,^00,000. 

CHICAGO. 

Epidemic Cerebrospinal Meningitis — Between the 

first of the year and llie present date. March 25. this 
disease has caused 550 deaths in New York City, a 
greater number than from any other cause except pul- 
monary consumption and the pneumonias, and the 
health authorities have secured a special appropriation 
with which to combat the pestilence. Of the four deaths 
reported in Chicago from this cause during the week, 
the latest, on Saturday, March 25, Dr. Wm. J. Class 
has completed his investigations of the first three, and re- 
ported tliat ihe evidence was not conclusive as to the 
nature of the disease. All three died of meningitis, but 
supervening on other diseases — two of them afflicted with 



Aprh. 8, igos] 



ECHOES AND NEWS: GENERAL. 



6S9 



measles, and simple meningitis is a not uncommon com- 
plication in such cases. Proof is lacking that this was 
of the epidemic type. Thus much space is given to this 
subject now, because cerebrospinal fever is epidemic 
elsewhere, and may become so in Chicago; and because 
the disease is contagious and all suspicious cases should 
be isolated and treated as other contagions, including 
prompt report to the Health Department. 

Sensational Medicine. — The Chicago Health Board 
Report remarks Dicken's fat boy " Joe " is again loose 
in the columns of the newspaper press and he " wants 
to make your flesh creep" with tales of half a million 
babies poisoned every year, with formalin in their milk ; 
of unnumbered others of all ages, more slowly but not 
less surely done to death by bora.x and similar preser- 
vations in their adulterated food and drink of every 
description; and of hecatombs of victims of rare and 
therefore terrible diseases. Where all these slain are 
■buried, bow their corpses evade the undertaker and the 
certifying physician, the burial-permit clerk, grave- 
digger and cemetery superintendent is a mystery — the 
only solution of which is that "Joe" lies. Here in Chi- 
cago, where the death rate of all ages has diminished 
from ip.g per i.ooo in 1890 to 13.6 per 1,000 in 1904, the 
deaths among the formalin-milk fed young have fallen 
from 707 in every 10,000 during 1890, to 347 in every 
10,000 during 1904. These assertions do not rest solely 
on the testimony of the Department's Bureau of Vital 
Statistics, but are corroborated by the experts of the 
Federal Census Office. 

An Act to Regulate the Practice of Optometry. — • 
After due consideration of a Bill which is now pending 
before the State Senate, the Chicago Medical Society 
is of the opinion that the adoption of this Bill would 
be unwise and not in the interests of the people, and 
therefore appeals to Senators to vote against it. The 
Society gives the following reasons: (l) If a person's 
eyesight is defective, the first question to settle is 
■whether the defect is due to disease or not. As the 
optometrists have not the requisite medical training to 
know whether an eye is sound or diseased, they are not 
competent to take care of and to prescribe for defects 
of the eyesight. (2) The fitting of glasses, especially 
for children and young adults, cannot be done accurately 
and satisfactorily without the use of the proper drugs. 
Innumerable instances could be cited, if desired, in 
which children received wrong glasses, to the detri- 
ment of their eyes and health, because no drugs were 
used in the examination of the eyes. This Bill, there- 
fore, not only fails to improve upon the existing prac- 
tice of opticians in prescribing glasses over the counter, 
but it puts the stamp of approval upon an unscientific 
and unreliable practice, and the Society believes it 
should be defeated. 

Antitoxin Treatment of Diphtheria. — Ten years 
ago the antitoxin treatment of diplitheria was begun by 
the Department of Health of Chicago. During the 
previous ten years ended December 31, 1894, there had 
been 13.566 deaths from diphtheria and croup reported 
to the Bureau of Vital Statistics, a yearly average of 
I>3S6, and a proportion of 13.53 deaths in every ten 
thousand of the population. During the ten years ended 
December 31, 1904, there were only 8,129 such deaths 
reported, a yearly average of 812, and a proportion of 
less than 5 (4.S8) in everj- ten thousand of the popula- 
tion. These figures show a reduction of 5,437 in the 
actual number of diphtheria and croup deaths since the 
Department began the antitoxin treatment. They show 
a relative reduction in proportion to increased popula- 
tion of nearly 64 per cent. — 63.9. Which is to say that, 
if the ravages of diphtheria had not been checked by 



the use of antitoxin during the last decennium, there 
would have been 22,538 deaths from this former scourge 
of the nursery, instead of the 8,129 that did actually oc- 
cur — a saving of 14,409 lives. The satisfaction of the 
Department with its diphtheria antitoxin record is 
heightened by the reflection that the present adminis- 
tration of the Department inaugurated the work upon 
which the records are based. 

GENERAL. 

A Royal Physician.— On February 23, His Royal 
Highness Duke Karl Theodor of Bavaria, celebrated the 
twenty-fifth anniversary of his graduation as a Doctor 
of Medicine. 

Dinner to Dr. Osier. — A farewell dinner to Dr. 
William Osier will be given at the Waldorf-Astoria, 
New York, on Tuesday evening. May 2, and invitations 
to subscribe can be obtained by applying to the Chair- 
man, Dr. James Tyson, 1506 Spruce Street, Philadelphia, 
until April 20. 

Gaillard's Southern Medicine.— Since the Amalga- 
mation of Soiithcnt Medicine and Gaillard's Medical 
Journal (in October, 1904,) it has been decided to con- 
solidate the name to Gaillard's Southern Medicine pub- 
lished by Gaillard's Southern Medicine, Inc. The offi- 
cers of the incorporation are William Edwards Fitch, 
M.D., President and Treasurer; M. C. Fitch, Vice- 
President, and E. W. Fitch. Secretary. 

Appointments of Drs. Barker and Thayer. — The 
Trustees of Johns Hopkins University elected Dr. 
Lewellyn Franklin Barker, now head of the Depart- 
ment of Anatomy in the University of Chicago and 
Rush Medical College, April 3, to the Professorship 
of Medicine made vacant by the resignation of Dr. 
William Osier. At the same time Dr. William Sydney 
Thayer, -Associate Professor of Medicine in Johns Hop- 
kins, was elected Professor of Clinical Medicine, a new 
chair. 

A Medical Author. — Major Louis L. Seaman, who 
served as a surgeon in the United States Volunteers in 
the Spanish-.\merican and Philippine wars and with 
the allied armies in the Boxer campaign in China, and 
whose account of the health conditions in the Japanese 
army has been more than once referred to in the various 
medical journals, has embodied his experience in a book 
entitled " From Tokio Through Manchuria with the 
Japanese," just published by D. Appleton & Co., New 
York. The work contains forty-two full-page photo- 
graphic illustrations. 

International Congress.— The Fifteenth Interna- 
tional Medical Congress will he held at Lisbon in 
.\pril. 1906. M a meeting of the National .American 
Committee, held at St. Louis last September, the 
following Executive Committee was appointed: 
Frank Billings, M.D.. William Osier, M.D., Freder- 
ick Shattuck, M.D., .Abram Jacobi, M.D., and J. H. 
Musser, M.D., chairman. .\ny communications re- 
garding the presentation of papers at this Congress 
can be sent to Miguel Bombarda, secretary at Lis- 
bon; or to Dr. Ramon Guiteras, New York, secretary 
for this country. 

An Antivivisection Story. — A prize was lately of- 
fered for an antivivisection story. If, says the British 
Medical Journal, we may judge from the accounts of it 
which we have seen, " Trixy," by Elizabeth Stuart 
Phelps Ward, an .iXmerican writer of some note, would 
■ieeem to be the kind of thing required. Here is the 
lady's description of the assistant director of a large 
surgical institute in which researches in physiology are 
carried out : " His face . . . was brutal. He had the 
eves of an inquisitor, lowering and shifty. To an ordi- 



66o 



ECHOES AND NEWS; OBITUARY. 



I,u,/- J re 

[MmicAL Nem 



nary cilizcn his was a face to be dreaded, It was 
the type that was common in the sixteenth century. It 
was broad, flat, and surmounted by a rebellious fiery 
mane. But if his face would inspire dread, his hands 
gave the layman a nameless apprehension." A charm- 
ing portrait; one wonders if it is from life. If it is, it 
is not unlikely that one of the antivivisectionist frater- 
nity unconsciously sat for it, for faces of the in(|uisition 
type are, as far as our observation goes, more common 
among them than among their opponents. 

Plague in India. — The terrific and increasing mor- 
tality caused by the i>lague in India is the subject of 
grave anxiety, as well as of mucli present hopeful- 
ness, on the part of the British authorities. At latest 
reports, deaths amounted to more than 35,000 a 
week. Nothing seems to avail against the disease 
except inoculation, to which the natives will not sub- 
mit. .■\t every return of cold weather the disease 
breaks out with renewed virulence. In the last week 
of December, 1902, the deaths were 14,000: in tTie 
same week of 190.^ ihey were 17,000; in the last week 
of December, 1904, the total reached 19,645. Since 
then the mortality has increased at a terrible rate. 
For some years the plague made little progress in the 
United Provinces of .^gra and Gudh, but during the 
last few months it has spread rapidly in this part 
of India, while in the Punjab the mortality threatens 
to be greater than ever. During the week ending 
January 28 the total number of deaths from plague 
reported throughout India was ,3,3,087; for the week 
ending February 4 the total was 36,167; for the week 
ending February 11, 33,660; for that ending Febru- 
ary 17, 27,837, and since then the mortality has risen 
again. Rather late in the day a special commission 
has been appointed to study the ethnology of the 
disease. 

Cancer in Young Subjects. — Ten recent cases of 
carcinoma in sul)jccts under thirty-one have been col- 
lected by Rhode (Inaug. Dissert., Greifswald, 1904). 
These cases are (i) cancer of the rectum in a tanner's 
boy, aged ten years; (2) cancer of the ovary in a maid- 
servant, aged nineteen years; (3) cancer of the stom- 
ach in a girl, aged twenty-two years; (4) cancer of the 
pancreas in a workman, aged twenty-three years; (5) 
cancer of the cardiac end of the stomach in a .shep- 
herd's boy, aged twenty-four years; (6) cancer of the 
duodenum in a tavern-inspector, aged twenty-five years ; 
(7) cancer of the pylorus in a maid-servant, aged 
twenty-six years; (8) malignant gastric ulcer in 
a girl, aged twenty-six years ; (9) cancer of the 
stomach in a maid-servant, aged twenty-nine years ; 
(to) colloid cancer of the rectum in a baker 
(female), aged thirty years. These 10 cases were 
taken from a series of 322, cancerous patients on 
whom necropsies were performed in the Greifswald 
clinic in the course of twelve years. The number of 
cases from thirty to fifty years of age was 121 ; from 
fifty to seventy, 156, and from seventy to ninety, 35, 
Thus, although the number of cases in aged subjects 
was three and a half times as many as the number in 
persons under thirty years, the latter are not so free 
from malignant disease as is generally supposed. — 
British Medical Journal. 

Medical Society of the Missouri Valley,— The 
seventeenth semi-annual meeting of this society met 
March 23, 24, 1905. The following program was 
given; "Surgical vs. X-ray Treatment in cases of 
Rodent Ulcer and Epitheliomata of the Face, with 
Demonstration of Operated Cases," by Dr. C. O. 
Thienhaus, of Milwaukee, Wis.; "Transverse Rib- 
bon-shaped Cornea Opacity," by Dr. J. M. Shcrer, 



of Kansas City, Mo.; "Some Points on Suprapubic 
Cystotomy," by Dr. E. N. Wright, of Olney, I. T. ; 
" Injuries to the Spinal Column," by Dr. C. E. Black, 
of Jacksonville, 111.; "Synchronous Extra and Intra- 
uterine Pregnancy, with report of a case," by Dr. 
i^. C. Brockman, of Ottumwa, la.; "Consideration 
of the Present Methods of Treatment of Retro-Dis- 
placements of the Uterus," by Dr. C- I'l,. Wallace, 
of St. Joseph, Mo. ; " Retrodisi)lacements of the 
Uterus; A New Method of Suspension," by Dr. O. 
B. Campbell, of St. Joseph, Mo.; "Surgical Treat- 
ment of Strangulated Hernia, with Remarks on 
Technic of Primary Bowel Resection, " by Dr. Johp 
Young Brown, of St. Louis, Mo.; " Pelvic Inflamma- 
tion, or Peri- and Parametritis." by Dr. H. C. 
Crowell, of Kansas City, Mo. Symposium or) 
" Puerperal Fever." (a) " Diagnosis." by Dr. Robert 
T. Sloan, of Kansas City, Mo.; (/') "Treatment," by 
Dr. R. C. Moore, of Omaha, Neb.; " Chorio-Epithe- 
lioma Malignum," by Dr. A. P. Condon, of Omaha, 
Neb.; "Renal Affections Simulating .\bdominal and 
Pelvic Diseases," by Dr. J. Block, of Kansas City, 
Mo.; "The New-born Infant; Its Care and Man- 
agement," by Dr. A. D. Wilkinson, of Lincoln, Neb.; 
■' Anesthetics," by Dr. Dora Greene-Wilson, of Kan- 
sas City, Mo.; "Some Observations upon the Treat- 
ment of Inguinal Hernia," by Dr. Prince E. Sawyer, 
of Sioux City, la.; " Functional Diagnosis of Kidney 
Diseases," by Dr. .■\. C. Stokes, of Omaha, Neb.; 
"Hypertrophy of the Thyroid Gland," by Dr. T. E. 
Potter, of St. Joseph. Mo.; "Rest in the Treatment 
of Select Cases of Mental Disease." by Dr. F. P. 
Norbury. of Jacksonville. Til.; "Uterine Displace- 
ments," by Dr. W. O. Henry, of Omaha; " .\bscess 
of the Rectum," by Dr. E. H. Trailkill, of Kansas 
City, Mo.; "Latter-day Aspects of the Pathogenesis 
of Cancer," by Dr. J. W. Ryan, of Coffey ville, Kans.; 
" Incipient I'orms of Insanity and their Treatment," 
by Dr. John Punton, of Kansas City, Mo.; " Drainage 
in .-\cute. Diffuse Septic Peritonitis," by Dr. Van 
Buren Knott, of Sioux City, la. ; '" The Business Side 
of It."" by Dr. J. R. Phclan. of Oklahoma City, Okla.; 
" Surgical Treatment of Postoperative Hernia,"' by 
Dr. Willelt Bartlctt, of St. Louis, Mo.; "Case of 
Choroiditis, probably due to Necrosing Ethmoiditis," 
by Dr. \V. W. Bulette, of Pueblo, Colo.; " Diagnosis 
of Progressive Spastic Ataxia in its Early Stages; 
with report of two cases," by Dr. J. M. Dunsmore, 
of St. Joseph, Mo.; "Suspicious Symptoms of the 
Upper Alxlomen; their Significance,'" by Dr. Jno. E. 
Summers, Jr., of Omaha; "Tobacco Amblyopia," by 
Dr. W. L. Kenney, of St. Joseph, Mo, 

OBITUARY. 

Dr. CiHOKcJK !■". Leick, one of the best-known physicians 
of Cleveland, Ohio, and for several years head of the 
Department of IKalth, died March 31, aged forty-nine 
years. 

Dr. Ciiari.es A. Olcott, ex-surgeon of the Fire De- 
partment, died last week in his fiftieth year at his home 
in Brooklyn. Me was surgeon-major of the Thirteenth 
Regiment, and when thai organization went to Mon- 
treal during Queen Victoria's jubilee he was made a 
member of the Queen's Own (iuard. 

Dr. William Boiienhamer, the oldest resident of 
New Rochelle and once the family physician of Com- 
modore Vanderbilt, died March 3 in his ninety-seventh 
year. He worked almost to the end in writing a con- 
tribution for a medical publication on disease of the 
lower boweN. lie diagnosed the last illness of Commo- 
dore Vanderliill. and he was one i>f the witnesses in the 



Apru- 8, 1905] 



CORRESPONDENCE: OUR LONDON LETTER. 



J6i 



will contest which followed the Commodore's death. 
He was also the physician of Gov. Ciirtin of Pennsyl- 
vania and of Commodore Garrison and other prominent 
men. For fifty years he had been almost a constant con- 
tributor to medical journals in America and Europe. 
[)r. Bodcnhamer said that he owed his long life to tem- 
perate living. He was moderate in the use of liquor 
and tobacco, but indulged in both when he felt like it. 
Since he was twenty-two years old he never ate break- 
fast without having a little whisky toddy mixed for him. 



CORRESPONDENCE. 

OUR LONDON LETTER. 

( Trom Our Special Correspondent.) 

London, March 25. 

THE GARCIA CENTENARY — THE PREVENTION OF CONSUMP- 
TION — INFLUENZA AS A FASHIONABLE CAUS-E OF DEATH — 
PHYSICAL DETERIORATION OF THE BRITISH RACE — HOSPI- 
TALS AND MEDICAL SCHOOLS. 

The great event of the past week was the celebration 
in honor of the hundredth birthday of the true begetter 
(if the laryngoscope, the Spanish singing master, Manuel 
Garcia. Medicine and music vied with each other to do 
lionor to the man who had annexed a new province to 
the healing art and who had trained Jenny Lind, Chris- 
tine Nilssen, Charles Santley and many other famous 
singers. The reception room of the great house of the 
Royal Medical and Chirurgical Society in Hanover 
Square was packed with representatives of learned 
bodies, laryngological societies and musical academies, 
who all presented addresses. The introducer of the 
deputation was Sir Felix Semon, himself a copious 
orator whose speech, although he has lived more than 
thirty years in London, has still a strong Teutonic 
twang. Of the foreign visitors most attempted to give 
vent to their feelings in what seemed to be meant for 
English. The centenarian bore it all with a staying 
power that would have been wonderful in a much 
younger man. He brightened up visibly when he was 
addressed in Spanish by fellow countrymen represent- 
ing the King of Spain, the Spanish Academy of Med- 
icine, and the Laryngo-Rhino-Otoiatric Society of 
Madrid. The Royal Society before which Garcia read 
the account of his invention and the observations he 
had made by means of it presented a short address 
which may have been intended as a kind of reparation 
for the utter indifference with which it treated both the 
communication and its author. The Society has be- 
stowed its Fellowship, which is the most coveted .scien- 
tific distinction in this country, on many who have done 
nothing nearly so worthy of recognition. The King 
conferred on Garcia a commandership in his Victoria 
Order, a decoration that enables the proud possessor to 
put the letters " C. V. O. " after his name. The opinion 
was pretty generally expressed that it would have been 
a graceful act if the "fountain of honor" had squirted 
just a trifle higher and made the old man a Knight. 
Manuel Garcia would do more credit to the order of 
knighthood than it could possibly bestow on him. In 
the evening there was a banquet at the Hotel Cecil, at- 
tended by nearly five hundred people, among whom 
were all the leaders in music and many of the bigwigs 
of medicine. There was an inordinate amount of speech- 
ifying, and I realized the force of Sydney Smith's sug- 
gested ecclesiastical punishment of being " preached to 
death by wild curates." The wonderful old man sat it 
out, however, and did not leave till late. He attended 
a Homeric banquet at the German Club an evening or 
two afterward, where he smoked cigarettes and drank 



a large glass of lager beer at midnight. I am told on 
good authority that he is not a bit the worse for the 
dissipation with all its attendant excitement and fa- 
tigue. He certainly is a marvel of vitality. Although 
somewhat bent he moves about without difficulty ; he 
can make himself heard in a large room, and his hand- 
writing is firm and beautifully distinct. He is alert and 
vigorous in mind, very ready in apt repartee and a 
graceful speaker. His great discovery was made when 
he was fifty, and he continued to teach till he was ninety. 
There is no apparent reason why he should not live 
for many years yet, to be a standing refutation of Pro- 
fessor Osier's doctrine. 

The National Association for the Prevention of Con- 
sumption and other Forms of Tuberculosis held its 
sixth annual meeting on March 23. From the Council's 
report it appeared that the financial position of the As- 
sociation was unsatisfactory, its expenditure during 1904 
having exceeded its income. A special meeting is to be 
held in May under the presidency of the Lord Mayor of 
London with the object of bringing the merits and the 
needs of the Association before the moneyed men of the 
city. It was stated that a further step toward the sup- 
pression of spitting in public places had been taken by 
the London County Council, in regard to the common 
lodging houses under its control. It was mentioned that 
tuberculosis in children, especially the surgical forms of 
the disease had engaged the attention of the Associa- 
tion during the past year, and a subcommittee had made 
recommendations urging the necessity of providing spe- 
cial hospitals for such cases in the country or at the 
seaside on the lines of open-air sanatoriums for pul- 
monary consumption. It was pointed out that if spe- 
cial hospitals were provided children could be admitted 
at any age, and thus it would be possible to begin treat- 
ment at an earlier stage than was now feasible, and the 
patients could be kept until they were cured or proved 
to be incurable. It was suggested that for incurable 
cases separate homes should be provided. The report 
went on to say that this country lagged far behind some 
other countries in its provision for such children. It 
was hoped that the London County Council would see 
their way to devoting to this purpose the mansions often 
standing in the parks they acquire, and inquiry was 
made, but for the present the matter remained in abey- 
ance. A gratifying step in the extension of public con- 
trol with regard to tuberculosis had been taken by the 
Sandgate Urban District Council, who were seeking 
power, inter alia, to exercise control over hospitals or 
sanatoria for tuberculosis to introduce notification of the 
disease and to regulate the milk supply. The council 
said that the time was evidently close at hand when 
provision of sanatoria, municipal and other, would be on 
the increase. The principles and possibilities of san- 
atorium treatment were as yet but ill understood in this 
country. Open-air treatment was only efficacious, or at 
any rate only powerful to cure, when undertaken in an 
early stage of the complaint, and there was a fear that 
the system itself might fall into discredit if not wisely 
applied. It would be the duty of the association to 
educate and guide public opinion and supply informa- 
tion, to urge that cases be carefully selected and classi- 
fied and kept under prolonged treatment, and that some 
means be found to provide for their after-care. Some 
system, too, must be devised to spread information as 
to the initial symptoms of phthisis and the importance 
of really early treatment. The Chairman, Lord Derby, 
in moving the adoption of the report, said that during 
the year new sanatoriums had been opened at New- 
castle, Keswick, Glasgow, Gloucester, and in West 
Wales. Sheffield and Sandgate were the only towns 



662 



CORRF.SPOXDF.NCE: Ol'R LONDON LETTER. 



[Medical News 



at present which had taken steps to enforce notification 
of the disease. I he more local authorities insisted on 
this Mieasnre the more the movement vould gather 
force. He expressed the opinion that in addition to thc 
liospital or sanatoria, there should be places of rest — he 
did not like to call them homes for the dying — for 
cases in advanced stages of the disease, or altogether 
heyond recovery. The motion was seconded by Dr. 
Nathan Raw, of Liverpool, who has taken a prominent 
part in urging on municipal authorities the duty of pro- 
viding sanatorium accommodation for the poor consump- 
tives within the area of their jurisdiction. He referred 
to the fact that the principles and possibilities of sana- 
torium treatment were even now ill understood. Many 
doctors, he said, are not convinced of the value of the 
treatment; it is not surprising, therefore, if the general 
public is sceptical. Another and stronger reason for 
unbelief is that during the last few years unsuitable 
cases have been rushed into sanatoriums, with the in- 
evitable result of failure, disappointment and wholesome 
condemnation of the system. The sanatorium, he 
urged, can be expectecf to confer benefits only on those 
patients in the early stages of the disease, who are also 
other suitable cases for treatment. The sanatorium 
alone will not stamp out consumption. County Councils 
and health authorities are holding their hands and the 
inevitable reaction has set in against sanatoriums. Dr. 
Raw feels sure that this will soon pass away. In the 
meantime he holds it to be the dutj- of every health au- 
thority to provide first of all a sanatorium for the treat- 
ment of early and suitable cases as a means of cure, and 
and also some means for the isolation of advanced cases 
He concluded by saying that with a few exceptions, the 
respectable poor when attacked by consumption have no 
refuge but the workhouse. This is not creditable to 
England and does not compare favorably with what is 
being done in other parts of the civilized world. -After 
the adoption of the report Sir William Broadbent moved 
a resolution to the effect that in the interest of the pub- 
lic health it is necessary that consumption and tuber- 
culous disease generally in London should be dealt with 
in a comprehensive manner; and that this will be done 
most efficiently by the Metropolitan Asylums Board con- 
stituting itself the sanatorium authority for consump- 
tion in London. He said that there was in London an 
enormous amount of consumption and tuberculous dis- 
ease. Some patients were actually paupers, and some 
just above that class. Many paupers suffering from 
tuberculous disease were in the workhouse, but most 
of them were in their own houses, and were a constant 
source of danger. Through the existence of advanced 
cases of consumption in the lower classes the well-to-do 
became afflicted; but with knowledge and better instruc- 
tion in hygiene the well-to-do had no business with con- 
sumption. The consuiTiption in the metropolis should 
be dealt with in a comprehensive manner; the only ex- 
isting authority who could do this was the Metropolitan 
.'\sylums Hoard. H that body undertook to deal with 
consumption they would make a definite impression upon 
the amount of disease which existed, and they would 
not only save life, but promote the public health. The 
resolution was passed unanimously. 

.\l a meeting of the Huntcrian Society of London on 
March 22. Professor Clifford .Mlhutt, of C.imbridge. in- 
troduced a debate on influenza, which in a mild form is 
somewhat prevalent at present. The Professor put 
forward some new points. For instance, he said that 
"influenza travels by express trains," and l.e cited facts 
to show that in the spread of epidemics towns at which 
through trains stopped were attacked first, while the 
smaller places served only by slow trains escaped for n 



time. Just as the Ganges was the home of cholera, so 
.Vorthern China was the home of influenza, and the 
opening of the Trans-Siberian Railway had much facil- 
itated the spread of the disease. " In the great epidemic 
of 1889 Bokhara was the point of dissemination into Eu- 
rope, whence it followed three trade routes. It reached 
New York from England in just the time taken by the 
fastest sleatncr running at the time." Professor All- 
butt stated his belief that only those cases were infec- 
tious in which the respiratory organs were implicated. 
He thought that occasionally the infection could be car- 
ried about by clothes for a few days. Children were not 
liable to the disease, and if they did catch it they soon 
recovered. The onset was always sudden — sometimes 
absolutely so. Thus a gentleman riding past the Pro- 
fessor's own house was stricken so suddenly with in- 
fluenza that he fell off his horse. He mentioned that Sir 
William Broadbent bad told him of a patient who drove 
in at one gate of a public park perfectly well and was 
prostrated by influenza before he reached the opposite 
gate. The Professor called attention to a new type of 
the disease, which he called continued influenza. Dur- 
ing convalescence all special sensations were affected 
Phus he himself was very fond of music, but after an 
attack of influenza he went to a concert and could not 
imagine how anybody could enjoy such a noise. At 
the end of an hour of boredom, he came out. Yet with 
complete recovery his enjoyment of music came back 
^uddenly. curiously enough together with a renewed ap- 
petite for food. He believed that the misery and de- 
pression which so often followed influenza could be cut 
short by a plain diet of milk and veget.ables. " Affec- 
lionate wives," he said, "dose their husbands with beef 
lea and other things supposed to strengthen, but these 
only delay recovery." Professor .\llbntt holds that one 
attack of influenza confers immunity for a period of 
:d)out six months against another. He also thought the 
tendency to suicide as a sequel to an attack of influenza 
was not so frequent nowadays as in the serious epi 
demies of the last decade. In the discussion that fol 
lowed Dr. Franklin Parsons, of the Local Govern- 
ment Board, said that a public speaker with influenza 
could spread microbes into his audience for a distance 
of forty feet. He showed by curves that the type of the 
disease had changed, and instead of disappearing for 
long intervals was now constantly in our midst; in 
fact, has become endemic. A week rarely passed with 
out several deaths from influenza being registered in 
London alone out of all the great centers of population 
included by the Registrar-Cieneral in his weekly mortal- 
ity returns. It was a singular fact that although the 
doctors recognized influenza as an actual cause of 
death, they were loth at first to enter it on death cer- 
licates, probably because, in the public mind, it was 
regarded as so trivial a disease " that it was considered 
discreditable to die from it." Now, on the other hand, it 
was considered somewhat fashionable to die of influenza. 
Dr. Parsons went on to say that we were ignorant of 
the meteorological conditions governing the epidemics of 
iiiHiien/a, but he thought it was pretty clear that we 
could not blame the weather, for epidemics had oc- 
curred in all seasons, though they were rare in the 
months of September, October and November. It was 
certainly not a " filth disease " such as enteric fever and 
typhus, and it was curiously infrequent where and when 
-ucb diseases were i)revalent. 

Some figures recently published in the annual report 
of Major General H. G. Miles, Director of Recruiting. 
throw an unpleasant light on the unsatisfactory physique 
of the British working-classes from which our army is 
recruited Of the men who presented themselves for 



April 8, igosj 



NEW YORK NEUROLOGICAL SOCIETY. 



663 



enlistment last year, 23,658, or more than 34 per cent., 
were rejected after medical inspection as physically 1111 
III. In addition to those rejected by tlie medical officers. 
iivtT jo.ooo were refused by recrniting officers in the 
nine months ending September 30. 1904. In many dis- 
iricts the rejections on account of defective teeth were 
very heavy. In commenting on the figures the Director 
iif Recruiting says: "The question of medical rejections 
is of great importance, and requires serious considera- 
tion in view of the large number of recruits that must 
.innually be obtained. It may be that when the new- 
pay conditions are thoroughly understood, recruits of a 
higher social class and physical development may be at- 
tracted, but it is unsatisfactory that such a large num- 
ber of lads should fail, for various reasons, to attain to 
the standard required for entrance into the army, a 
standard which cannot be considered exacting." To say 
th.it the standard is not exacting is to put the case very 
mildly. And low as the standard is, the authorities en- 
courage the medical officers not to be too strict in their 
rrtpiirements. I have heard of a too conscientious ex- 
aminer of recruits being reprimanded for excess of zeal, 
and on one occasion not many years old, a hint, which 
hke a royal invitation was in the nature of a command, 
uas given to all the medical officers engaged in the 
work, not to draw the tape too tight in measuring the 
chest. 

The report of the Royal Committee appointed to con- 
sider the relations of hospitals and medical schools, an 
account of which was given in a recent letter, has al- 
ready had two results, unexpected and doubtless unde- 
sired by the antivivisectionists whose agitation led to 
llie inquiry. The treasurer of the London Hospital has 
just announced that since the issue of the committee's 
report (which strongly condemned payments to medical 
schools out of moneys subscribed for the hospitals) a 
" discretionary fund " has been opened, which is to be 
used, according to the discretion of the governors, either 
for the purposes of the hospital or for those of the 
school. Within a week the subscriptions to this fund 
have flowed in to an amount twice as great as the sum 
ever before applied to teaching purposes. To-day it is 
announced that Mr. Alfred Beit, the South African 
millionaire, has been moved by a perusal of the report 
of the committee to increase the amount of his donation 
to the London University Institute of Medical Sciences 
from $25,000 to $125,000. He expressly states that he 
wishes by this gift to commemorate the great kindness 
of his friend Dr. Jameson, now Premier of Cape Colony, 
and the services of several members of the Faculty of 
Medicine during a recent illness. 



SOCIETY PROCEEDINGS. 

NEW YORK NEUROLOGICAL SOCIETY. 

Statt-d Mccling. Iwld Fcbrmvy -, igo^. 

The President. Joseph Fraenkel, M.D., in the Chair. 

Two Cases of Dysbasia Angiosclerotica ( Inter- 
mittent Claudication), with Demonstration of Cal- 
careous Deposits in the Pedal Arteries. — Dr. J. 

Kamsay Hunt read this paper, and the demonstra- 
tion of radiographs was by Dr. Arthur Holding. 
The first patient was a man, forty-nine years old. 
His occupation for the past thirty-two years had 
been that of an iceman, which necessitated long and 
frequent exposure of the feet to cold and wet. The 
patient had used alcohol and tobacco to excess for 
many years. He acquired syphilis in 1879. The 
following year he had some ulcerations on the right 



leg, and (w^: years later suffered from ulceration of 
the palate, with perforation. In September, 1903, he 
had an attack of delirium tremens, for which he was 
treated in the alcoholic pavilion of Bellevue Hos- 
pital. Restraint was necessary, and he was bound 
in the usual manner by sheets attached to the 
wrists and ankles. The first symptoms of the pres- 
ent affection appeared immediately after his dis- 
charge from the hospital, and was attributed by the 
patient to the restraint used. He complained of 
stiffness in the toes and the left leg; also the ankle, 
and paraesthesia of the toes and edges of the feet. 
Alter walking a quarter of a mile, the prickling pain 
and stiffness became so distressing that he had to 
sit down until it wore off. which was the case 
after a few minutes rest. His symptoms were much 
worse in winter than in summer, and were especially 
severe on a cold day. On rising in the morning the 
feet and legs felt perfectly well and natural. To- 
ward the end of the day the feet became puffed tip 
and swollen, and presented a mottled and cyanotic 
hue. He complained that they felt cold most of 
the time. The posterior tibial artery was not pal- 
I>al)le on either side. The dorsalis pedis was full 
and larger than normal. The femorals and popli- 
teals pulsated normally on the two sides. The feet 
were cold, and on standing became red and swollen, 
with a distinct purplish tinge. Numerous venules 
and minute venous varicosities were present about 
both ankles, and along the anterior tibial region. 
The toe-nails on the left fool presented transverse 
ridges. The reflexes and sensations of the lower 
extremities were normal. Signs of a general arterio- 
sclerosis were present, and the urine contained a 
faint trace of albumin, but no casts nor sugar. Its 
specific gravity was 1.017. Subsequent examination 
revealed an occasional faint pulsation in both pos- 
■ terior tibials, weaker on the left side. 

The second patient presented by Dr. Hunt was a 
man sixty years old, who for fifteen years had been 
a longshoreman. For the past ten years he had 
worked in barrooms, where his feet had been ex- 
posed a good deal to the cold and wet. He denied 
lues. For the past fifteen years he had smoked 
from ten to fifteen cigars daily, and had used alcohol 
to excess. About five years ago he began to suffer 
from numbness, stiffness and cold sensation in the 
toes of the right foot, coming on about two hours 
after beginning work in the morning. At the end 
of the first year he was compelled to rest after about 
three hours. At the end of two years, his condi- 
tion had grown worse; the paresthesia and stiffness 
had extended as high as the ankle, and rest was 
necessary after two hours work. After resting, and 
in the morning on arising, all his symptoms had 
disappeared. The symptoins in the left foot .grad- 
ually grew worse, and six months ago similar symp- 
toms appeared in the right foot, beginning in the 
toes. Both feet assuined a mottled appearance on 
standing, but did not swell. .'V pulsation of the fem- 
orals, popliteals and posterior tibials could be felt 
on both sides, while the pulsation of the dorsalis 
pedis was entirely absent on both sides, although 
the artery could be felt as a fine rounded cord. The 
reflexes and sensations of the low^er extreinities 
were normal. There were well-marked signs of a 
generalized arteriosclerosis. The urine had a specific 
gravity of 1.023; it contained a trace of albumin, no 
sugar. The symptoms presented by the cases shown 
were to be ascribed to an arteriosclerosis of the ves- 
sels of the leg and foot — the so-called dysbasia 



664 



NEW YORK NEUROLOGICAL SOCIETY. 



[Medical News 



angiosclerotica (intermittent claudication of Char- 
cot). The X-ray photographs demonstrated by Dr. 
Holding showed very exquisitely deposits of lime 
in the posterior and anterior tibial arteries and the 
dorsalis pedis, marking out very definitely the course 
of the vessels. As might be inferred from the gen- 
eral evidences of arteriosclerosis in both cases, the 
pathological process in the pedal arteries was the 
usual arteriosclerosis of Gull and Sutton, with de- 
posits of lime in the media. These cases are sup- 
posed to be less amenable to treatment than the en- 
darteritis forms; hence this method of demonstra- 
tion might have a certain prognostic value. Both 
cases had shown a very moderate response to treat- 
ment. 

Dr. S. Sachs called attention to the similarity of 
the lesions met with in this condition to those of 
erythromelalgia. 

A Case of Probable Infectious Myelitis of the 
Cervical Region, Following a Compound Fracture 
of the Jawf. — This also was presented by Dr. Hunt. 
The patient was a man thirty-six years old, a painter 
by occupation, who, until the onset of the present 
trouble, had enjoyed excellent health. He had never 
shown any symptoms of lead poisoning. On De- 
cember 7, 1904, he fell on the street and fractured 
his lowxr jaw in two places. The fracture was a 
compound one, and the wound, which w-as on the 
inside of the mouth, bled for several hours. Three 
weeks later he had rigors at night, on one occasion 
followed by profuse perspiration. On January 5, 
1905. after a h^vy slumber, he awoke with severe 
pain in both arms, which were also verj' weak, so 
that he could hardlj' lift them. The weakness was 
chiefly in the muscles of the shoulder, especially on 
the left side. The pains continued all day with 
great severity, sharp and lancinating in character, and 
shooting through the whole length of the arms, al- 
though more severe in the shoulders. The next 
morning the pains had ceased entirely in the right 
arm, and the power of the extremity had returned. 
He was unable, however, to elevate his left arm, and 
the severe pains still continued, especially in the 
region of the left shoulder. There were no vesical 
symptoms. For several nights following the onset 
of the paralysis he had chills of moderate severity. 
The patient was first seen by Dr. Hunt on January 
20, 1905, two weeks after the onset of the symp- 
toms. He still complained of sharp, shooting pains 
in the region of the left shoulder, and the deltoid 
muscle was somewhat tender to deep pressure. It 
might be added, however, that on compressing the 
muscle bundles of the deltoid between the fingers, 
the same pain and tenderness was elicited as on deep 
pressure. The nerve plexus above the clavicle and in 
the axilla and along the inner side of the arm was 
absolutely free from any tenderness. The left arm 
was the seat of a slight general atrophy which was 
very marked in the deltoid muscle. All movements 
of the left arm and shoulder could be carried out 
with practically normal power, excepting adduction 
of the arm. On attempting adduction some of the 
posterior bundles of the deltoid were felt to con- 
tract, but little or no movement of the extremity 
was produced. All the arm-jerks were present, and 
were equal on the two sides. On testing the sensi- 
bility it was found that the tactile, pain and tempera- 
ture senses were retained over both upper extremi- 
ties, and that the deep sensibility was also normal. 
A more careful sensory test, however, showed that 
the sensation was relatively diminished for pain, 



temperature and touch along the outer side of the 
arm from the shoulder to the wrist, corresponding 
very closely to the recognized sensory distribution 
of the fifth cervical segment of the cord. On the 
right arm a similar relative obtunding of sensation 
was also present, but less marked and not so ex- 
tensive, being practicallj' limited to the region of 
the deltoid. The gross motor power and tendon 
reflexes of the lower extremities were normal. The 
Babinski phenomenon was absent. The deltoid 
muscle failed to respond at Erb's point to the gal- 
vanic or faradic current, although good contractions 
were produced in the biceps and the supinator 
longus. The direct faradic current produced a slug- 
gish response in the posterior portion of the deltoid; 
no response in the anterior half. By the direct gal- 
vanic current a slow, vermicular response was 
elicited, with reversal of the poles. The urine con- 
tained some albumin and hyaline casts. A blood- 
count' showed 4,112,000 red blood corpuscles; 
10.000 white cells, and 75 per cent, of hemoglobin. 
The erethrocytes were normal; no granular baso- 
philia. The differential count was as follows: poly- 
morphonuclears, 70.6 per cent.; lymphocytes, 10.2 
per cent.; large mononuclears, 18.8 per cent.; eosino- 
philes, o; mast cells, 0.4 per cent. 

On February i, 1905, the patient still complained 
of a dull aching, with occasional sharp, shooting 
pains in the left shoulder. The moderate tender- 
ness in this region still persisted. The gross motor 
power of the deltoid had greatly improved, so that 
the arm might now be elevated above the head. 
This occurred chiefly through the medium of the 
posterior half of the deltoid muscle, the anterior 
portion remaining entirely relaxed and flaccid. The 
slight sensorj' changes still persisted. There was 
no Babinski phenomenon. A small piece of dead 
bone had been removed from the inside of the 
mouth. The breath and excretions from the mouth 
were very fetid. The interesting features of this 
case, Dr. Hunt said, were those of localization and 
etiology. Considering the patient's previous good 
health, and the absence of any other demonstrable 
cause, it was natural to refer the symptoms to the 
suppuration and the carious process in the lower 
jaw, more especially as mild symptoms of sepsis 
directly preceded and followed the onset. While 
the persistent pains and apparent tenderness over 
the left deltoid might suggest a neuritis of the cir- 
cumflex nerve, it might be emphasized that the par- 
alysis of the deltoid w-as incomplete, and evidences 
of objective sensory changes limited to the circum- 
flex were absent. The speaker also emphasized the 
absence of tenderness or other evidences of inflam- 
mation in the plexuses and cellular structures of 
the neck. On the other hand, the initial paralysis 
and severe pains, symmetrical and bilateral in dis- 
tribution, tlie rather sudden recovery of the right 
arm and the more gradual recovery in the left; the 
unequal distribution of the paralysis in the left del- 
toid, and the gradual improvement which this par- 
alysis had undergone; the relative diminution of 
sensation on both sides in an area corresponding 
very closely to that of the fifth cervical segment, 
all pointed strongly to a central cord lesion. The 
nature of this case could only be inferred. A polio- 
myelitis or a myelitis of infectious origin naturally 
suggested themselves. 

Dr. Charles L. Dana said he had seen Dr. Hunt's 
patient some days ago, when there was still some 
paralysis of the left arm. The condition could best 



April 8, 1905] 



NEW YORK NEUROLOGICAL SOCIETY. 



66s 



be explained on the theory of a thrombosis, plug- 
ging one of the central arteries, and affecting the 
left anterior horn, about the region of the fifth 
cervical segment. 

Dr. Fraenkel said there were a number of cases 
reported in literature where septic conditions, par- 
ticularly that known as angina Ludovici — an acute 
suppurative condition of the connective tissues of 
the neck — had given rise to a septic neuritis. The 
speaker said he saw such a case in consultation about 
three years ago. The case was one of a septic throat 
condition, and eight or ten days later, after the 
acute symptoms had subsided, there were evidences 
of a bilateral brachial neuritis. It began with severe 
pain, in that wa)' differing from the case shown by 
Dr. Hunt. 

Address of the Retiring President, Dr. Pearce 
Bailey. — The speaker stated that while the member- 
ship of the Society had been materially enlarged 
during the past year, notably by younger men, the 
new members had not shown the active partici- 
pati6n in the proceedings which was absolutely es- 
sential for the Society's continued prosperity. 
.Many interesting cases had been shown during the 
year, and the general discussions had brought out 
large audiences, and had been fruitful in valuable 
information. While individual clinical cases and 
general discussions perfected the art of the cliiii- 
cian, they did not give neurology all that neurology 
had a right to expect from as representative a body 
as the New York Neurological Society. For the 
science to be advanced, more fundamental contribu- 
tions were essential. It was commonly said, and 
with much truth, that neurology was living to-day 
on its past achievements. So much the more neces- 
sary was it to try to give it new life, to start it again 
on that progress which, only a few- years ago, made 
it the most brilliant branch of medicine. 

Address of the President-Elect, Dr. Joseph Fraen- 
kel. — The speaker stated that while neurology had 
a glorious past, its future, viewed with the bias of 
the sentiment prevailing at present, appeared dis- 
couraging. A pessimistic attitude had crept in; the 
transactions of the meetings of neurologists seemed 
to lack the animation and enthusiasm of former 
days. Why this was so he did not know; it had 
happened because it had to — it was a phase of evo- 
lution. Dr. Fraenkel said that personally he did 
not believe that the present augured ill for the fu- 
ture. There was a wealth of fundamental questions 
awaiting investigation. New methods had been 
elaborated that promised valuable aid. Chemo- 
Ijathology, which seemed especially adapted for the 
elucidation of some neurological questions, with its 
l)r(imise of better therapeutics, was well established. 
The physiology of the ductless glands was closely 
allied to neurological themes, and deserved parti- 
cular attention. All neurologists were thoroughly 
dissatisfied with our conception and interpretation 
of the so-called functional conditions. It was en- 
couraging to note a decidedly rational spirit in the 
newer literature on the subject. The relation of the 
nervous system to the pathology of the vegetative 
functions was a subject which the speaker believed 
to be of fundamental importance to clinical neu- 
rology and psychiatry. The subject had not been 
lacking in votaries, but had proven refractory and 
unyielding. .A good deal of preparatory work had 
been done for the better understanding of the sub- 
ject. So-called visceral or vegetative phenomena 
accompanied more or less prominently organic dis- 



ease of the nervous system, and constituted the 
chief physiognomy of all functional states and func- 
tional symptom-complexes. Trophic, vasomotor 
and secretory disturbances of the skin, changes in 
the trophism of joints and viscera, disturbances of 
the physiologic rhythm of the vaso- and viscero- 
motor innervation, perversions of visceral sensation, 
were often seen at the bedside, and were not suf- 
ficiently appreciated. The visceral and vegetative 
symptoms of tabes and hysteria were good illustra- 
tions of familiar types. The innervation of the duct- 
less glands was manifestly a matter of importance, 
and the histology of the blood-vessels of the brain 
and their innervation were morphological questions 
of broad application to physiology and pathology. 
Phenomena of disordered trophic influence were 
not uncommonly encountered by the neurologists, 
and very little was known about most of them. 
The palmar and plantar mal pcrforant of tabes, the 
cutaneous ulcerations of syringomyelia, the decu- 
bital ulcers observed in the course of organic dis- 
ease of the cord or brain, the hysterical skin erup- 
tions, the glossy skin, scleroderma, morphea, etc., 
were hardly understood. Atrophy of the hair of 
the limbs in tabetics, and hypertrichiasis in cases 
of poliomyelitis were frequently seen. It was in- 
teresting to observe that in cases of disease of the 
anterior horns, when the disease was limited to the 
anterior horn cells, as in amytrophic lateral sclerosis, 
for instance, this change in the growth of the hair 
did not take place. Atrophy of muscles severed 
from their connection with the peripheral nerves 
was frequently observed. Atrophy of visceral mus- 
cles under similar conditions was doubted. The 
trophic changes of the joints in tabes and syringo- 
myelia, and the nature of arthritis deformans were 
still mysteries. The pituitary body was generally 
believed to exert trophic influence upon some parts 
of the skeleton. A large number of vasomotor dis- 
turbances were still puzzling problems. The gen- 
eral vasomotor ataxias observed so frequently in 
the course of Graves' disease, and the climacteric 
neuroses, were, on clinical grounds, referred to per- 
verted function of the thyroid glands or of the 
ovaries, respectively. Angioneurotic edema was be- 
lieved by many to be explained on the basis of a 
toxemia. The question of erythromelalgia was still 
sub judicc. Sachs' and Wiener's findings of disease 
of the blood-vessels and peripheral nerves had been 
frequently corroborated. The condition was in dan- 
ger of losing its clinical identity, and of being classed 
with the arterial diseases of the extremities (an- 
gina pectoris of the foot, intermittent claudication). 
For the explanation of the spasmodic di5turb.mces 
of the respiratory function, asthma nervosum, tachy- 
pnea, dyspnea hysterica, little definite pathologic 
information was at hand. The bradycardia of direct 
and indirect vagal lesions was frequently described. 
.According to Oppenheim, neuritis of the vagus was 
indicated by acceleration, rarely by slowing of the 
heart beat. The vast variety of symptoms referable 
to disordered innervation of motion, sensation and 
secretion of the gastro-intestinal tract were well 
known and often very perplexing. Cases of cord 
lesions were not infrequently met with which began 
with visceral, particularly gastro-intestinal symp- 
toms, and which were often treated for a long time 
under this mistaken diagnosis. In a large number 
of cases of lead colic the celiac nerves and ganglia 
were found evidently diseased. Changes in the con- 
stitution of the urine were frequently observed in 



666 



SOCIETY FOR EXPERIMENTAL BIOLOGY AND MEDICINE. 



[Medical News 



nervous diseases. .-Mbuminuria was often a symp- 
tom of a pontine lesion, while glycosuria was fre- 
quently associated with disease of the posterior 
fossa. The symptomatology of disordered genital 
functions was also beginning to be studied along 
the lines suggested in Dr. Fraenkel's paper 



THE SOCIETY FOR EXPERIMENTAL BIOLOGY AND 
MEDICINE.i 

Tenth Regular Meeting, held February /j, igoj. 

Pile President. S. T. Meltzer, M.D., in the Chair. 

Members Present. — Atkinson, Auer, Burton-Opit/. 
Dunham. Ewing. Fle.xner. Gies, Jackson. Lee, Levenc. 
Levin. Mandel. Meltzer. Noguchi. Norris, Oertel, Opie. 
Park, Richards. Sweet. Wadsworth. Wallace, Wolf. 
Yatsu. 

Members Elected. — George W. Crile, Haven Emer- 
-on. Cyrus W. Field. Hideyo Noguchi, H. C. Sherman. 
J. Edwin Sweet. Victor C. Vaughan. 

Officers Elected. — President. Edmund B. Wilson ; 
Vice-President, Edward K. Dunham ; Librarian, Gra- 
ham Lu.sk; Treasurer, Gary N. Calkins; Secretary, 
William J. Gies. 

ABSTR.\CTS OF REPORTS OF ORIGIN.AL INVESTIG.\TIONS. 

Degrees of Susceptibility to Diphtheria Toxin 
among Guinea-Pigs. Transmission from Parents 
to Offspring. — by Theobald Smith. (Presented by 
William H. Park.) Dr. Smith called attention to the 
usefulness of the antitoxin unit furnished by the In- 
stitute for Experimental Therapy under the direction 
of Professor Ehrlich in the routine testing of the 
strength of diphtheria antito.xin. The one uncertain 
element is the relative resistance of the guinea-pigs to 
diphtheria toxin. In the course of the past nine years 
the writer has given considerable personal attention to 
this subject, and found that different dealer"; furnished 
guinea-pigs of slightly different susceptibility. This 
difference was attributed to environment and care. The 
animals bred under the writer's supervision generally 
showed maximum resistance. Irregularities in the 
routine tests during the past year led the writer to look 
tip the genealogy of the pigs used and he found that 
the different degrees of resistance belonged to certain 
families or litters and were constant for those fami- 
lies. Thus one mother gave birth to young which did 
not react to what was the usual fatal dose. Four suc- 
cessive litters possessed the same resi-stance. As each 
pig could be tested but once the precise degree of rc- 
■iistance could not be measured, but it appeared proba- 
ble that this family could stand forty per cent, more 
toxin when mixed with the antitoxic unit than those of 
average susceptibility. Other mothers \vere traced 
who.se offspring possessed less resistance than the ones 
described but could still neutralize 20 per cent, more 
toxin when mixed with the antitoxic unit than the 
average. 

Tf would seem from these observations that tliffcrent 
degrees of susceptibility to toxin arc to he found among 
guinea-pigs, and that the special degree possessed by 
any one is not to be attributed to individual variation 
but to a family trait or character. The resistance in 
the rases cited could not be attributed to any prelimin- 
ary treatment with toxins and antitoxins. 

Experiments arc now under way to determine the 
part played by the male in the transmission of toxin 



I Proceedings reported by the Secretary. William J. Gies. 
Pti.D.. of New York. The authors of the reports have written 
the abstract:,. The Secretary has made a few abbreviations. 



resistance. In the case of the most resistant family, the 
four litters were the offspring of two males. 

The Protective Action of Venom Upon Blood 
Corpuscles, with Demonstrations. — By Hideyo Xo 
guchi. t Presented by Simon Flexner. ) That concen- 
trated solutions of venom fail to destroy and tend to 
preserve blood corpuscles was noted by Mitchell and 
Stewart. Among the recent writers who have paid 
especial attention to the interpretation of this phenom- 
enon are Kyes and Sachs. They ascribe it to devia- 
tion of the hemolytic complement through the excess 
of venom amboceptors. The study which forms the 
basis of this brief communication shows the hypothesis 
of Kyes and Sachs to be untenable, since it could be 
dcmon.strated that (l) the protective action fails to 
occur with venom in which, through heating to from 95° 
to 100° C. the hemolytic principle has been preserved, 
lint certain other constituents have been coagulated, 
and (2) the action extends to protection of the cor- 
puscles from laking by water, ether, saponin, etc. The 
conclusion which has been reached by the author is that 
\enoni unites with the globulins and especially with the 
hemoglobin of the red corpu.scles. yielding a water-in- 
soluble compound to which the protection is due. Va- 
rious substances, but only salts, acids and alkalis, re- 
store the hemolyzability of the corpuscles by dissolving 
the venom-hemoglobin compound. The permeability of 
tlie corpuscles is not markedly altered. 

The Results of Attempts to Cultivate Trypanos- 
omes from Frogs. A Preliminary Report. — By Jo- 
seph Lewis and Herbert I". Williams. (Presented by 
.■\ugustus B. Wadsworth. ) Dining the year 1904 an 
effort was made in the pathological laboratory of the 
University of Buffalo to make studies on hematozoa in 
tlie lower animals. In a considerable number of nor- 
mal cats. dogs, rabbits and .guinea-pigs no hematozoa 
were found. The other examinations were as follows : 
51 English sparrows {Passer doinrsticus). half in the 
winter, half in the spring, all negative: 27 mudpuppies 
iNerlunis iiiaeulattis) in March, all negative; 40 toads 
in the summer, all negative. In 140 frogs from the 
X'iagiira River, there occurred the following infections; 
14 with Trypaiiosiima. 5 with Drefanidium. 1 with Fi- 
laria. Drepanidium was found both in the summer and 
fall. The infections with Try/^aiii>soiita were distributed 
as follows: 

In July of 15 frogs. 2 showed trypanosomes. 

In .\ugust of 25 frogs. 10 showed trypanosomes. 

Ill September of 14 frogs. 2 showed tryiianosomes. 

From October to December of 8.=; frogs, o showed try- 
panosomes. 

In one case Try/'aiidsiniui and Dret'auidiunt occurred 
in the same blood. The trypanosomes had the usual 
characters of Trypanosoma rolaloriuiii (ranarum). 
rhey were in no case numerous : two were rarely seen 
in one low-power field. The frogs appeared healthy. 
Eight attempts to inoculate normal frogs by way of the 
|)eritoneuni with the blood of infected frogs gave ne.ga- 
tive results 

Attempts at Cultivation. -The blood of frogs and 
toads was taken to make blood-agar (used by Novy 
and MacNeal for the cultivation of trypanosomes). 
The blood was first examined carefully to see that it was 
free from parasites. The animal was etherized and 
placed in HgCI-.-. solution T to I.OOO for fifteen minutes, 
rinsed in distilled water, opened with all precautions, 
the blood from the heart taken with a sterile pipette, 
.Tiul mixed rapidly with the water nf condensation on 
slanted ag.ir tubes (made with meat extract and pep- 
tone, and slightlj alkaline to litmus). Two or three 
drops of blood were used for each tube. The tubes were 



April 8, 1905) 



SOCIETY FOR EXPERIMENTAL BIOLOGY AND MEDICINE. 



667 



sealed with ruLiLicr stoppers and allowed to stand live 
to ten days so that contaminations with bacteria mighi 
be detected. 

(1) The blood of frogs infected with Trypanosoiim 
rotatoriuiii. collected in the same manner, was mixed 
with that in blood-agar tubes prepared and tested as jtist 
mentioned. The tubes were kept at the temperature of 
tlie room. Cultures made from two infected frogs 
showed, after two weeks, growths of flagellate protozoa 
(both on toad's blood-agar and frog's blood-agar). The 
organisms were of a very long oval form, the bodies of 
the largest being 2 m x 18 ^. There was a single flagel- 
lum. which was often nearly as long as the body. Only 
the largest forms showed a trace of an undulating mem- 
brane, which never approached the development of this 
structure in Trypanosoma rotatorium. and which did not 
appear in stained preparations. Motility was not very 
pronounced. Numerous small forms were seen evidently 
representing various developmental stages. In prepara- 
tions stained according to Romanowsky a blepharoplasl 
(micronucleus. centrosome") was seen at the base of the 
flagellum and near the anterior end. The nucleus ap- 
peared to be represented by numerous chromatin gran- 
ules in the posterior end. It may be noted that Smedly 
{Journal of Hygiene, January, 1905) found the centro- 
some at the anterior end in the cultural forms of the 
rat trypanosome. Numerous observers have seen try- 
panosomes lacking the undulating membrane under arti- 
ficial conditions. The growth in the tubes was never 
luxuriant. Arrangement in rosettes was not seen. One 
generation only of subcultures grew. All the cultures 
soon died. A single attempt to inoculate a normal frog 
gave a negative result. These experiments were inter- 
rupted, as both the authors went out of town. 

(2) As is mentioned below, the blood of frogs in- 
fected with Drefanidiuin was added to frog's blood- 
agar tubes to see if Drepanidinm could be made to live 
or undergo further development. Tubes thus inocu- 
lated, in one case, showed trypanosomes in about ten 
days. For the moment it appeared as though trypano- 
somes had developed from Drepanidinm. Having some 
of the same blood-agar to which no Drepanidinm blood 
had been added, this was examined again and found to 
contain the same trypanosomes. They must of course 
have been derived from the frog from which the blood- 
agar was made. The frog's blood was examined for 
parasites before using it to make the medium and just 
before inoculating it, so that trypanosomes must have 
been present in numbers too small to show in several 
large cover-glass preparations, or they existed in some 
developmental stage not recognized. Novy and Mac- 
Neal have also secured cultures of trypanosomes from 
birds, where none were found by direct examination of 
the blood with the microscope. 

In some preparations from the blood-agar tubes as 
many as four trypanosomes appeared in one field 
(Zeiss D.n., No. 3 ocular'), and there can hardly be any 
doubt of their having multiplied. The motion of the 
trypanosomes was active and characteristic. They wen- 
much smaller than Trypanosoma rolatnrium with rare 
exceptions, the body being usually about 3 ft x 16 m- 
The flagellum was hardly half as long as the body On 
I be small forms the undulating memlirane was not dis- 
tinct, but the flagellum was plainly marked. Large 
forms similar to Trypanosoma rotatorium. except that 
the flagellum w:i^ lacking. ocr\irred but were rare. The 
nucleus and blepharoplast were placed as in Trypano- 
soma rotatorium as far as could be determined, bnl 
ihe amount of material was so small that satisfactory 
"•tained preparations could not be secured. 

With trvpanosomcs there were associated spindle- 



shaped or crescentic bodies, about 12 m in length, look- 
ing much like the crescents of sstivo-autumnal malaria 
except for lack of pigment. These bodies contained 
several (usually four) shining chromatin granules 
symmetrically placed in the midddle. Motility was 
doubtful and in any case slight. Flagella were not 
seen. The crescentic forms were probably some devel- 
opmental stage. The crescentic bodies were observed 
for eight weeks. Motile trypanosomes were observed 
for five weeks. No growth occurred in subcultures. 
Two frogs were inoculated by way of the peritoneum 
from tubes containihg the crescentic bodies, with nega- 
tive results. 

i ^) Attempts to produce development of Drepanidium 
were made from three frogs infected with this parasite, 
both on frog's and toad's blood-agar. The results were 
negative, although motile Drepanidia were discovered 
after ten days, and the parasites remained for weeks 
apparently unaltered within the blood-corpuscles. 

Conclusions. — Trypanosomes from the frog may be 
cultivated on blood-agar. but. in the authors' experience, 
with considerable difficulty. From a frog infected with 
Trypanosoma rotatorium a flagellate organism was cul- 
tivated, showing important points of difference from 
Trypanosoma rotatorium. It is possible that, owing to 
the technical difficulties of the experiment, some other 
organism may have found its way into the tubes. This 
is improbable. 

Undoubted trypanosomes developed in blood-agar 
prepared from a frog whose blood, during life, showed 
no trypanosomes. They resembled Trypanosoma rota- 
torium. but were usually much smaller. .Xs tliis blood- 
culture medium was inoculated with blood from another 
source containing Drepanidinm, it nearly led to the 
conclusion that Trypanosoma might develop from 
Drepanidium. We have here an illustration of the ease 
with which mistakes may occur in the cultivation of 
hematozoa which are suspected of passing through 
cycles. Such a possibility had been pointed out in 
advance by Novy and MacNeal before this Society 
(October. 1Q04'). 

There was no evidence from our experiments to 
show that development of Drepanidium c.in occur on 
blood-agar. 

It is unlikely that material with which further studies 
may be made can be secured before next summer. As 
trypanosomes are now exciting so much interest and 
are being so widely studied, the authors deemed it best 
to report their results, although the work is incomplete. 

Experimental Measles. — By Ludwig Hektocn 
(Presented by Eugene L. Opie). The search for the 
cause of an infectious disease like measles becomes 
greatly simplified when we learn how to secure the un- 
know-n "virus" in relatively pure form unmixed with 
common microbes. 'Various methods may now be ap- 
plied to the investigation of the virus. The transmis- 
sion of measles from mother to fetus would seem t^ 
point to the presence of the cause of the disease in the 
blood. In the twenty cases of fetal measles collected 
by Ballantyne, it seemed that the infection of mother 
and fetus must have been simultaneous because the 
eruption in both corresponded in character. In order 
to learn something further as to the presence in the 
blood of the cause of measles, inoculations of human 
beings would seem to be necessary because, so far a? 
we now know, this disease is probably not communica- 
lile to animals. Griinbaum's experiments with measles 
in the chim[ianzce appear to have .given negative 
results. 

Critical review of the literature shows that almost 
without exception the recorded experiments in the 



668 



SOCIETY FOR EXPERIMENTAL BIOLOGY AND MEDICINE, 



[Medical News 



inoculation of measles, for which positive results have 
been claimed, are without real significance. The claims 
that the experiments of Home, of Wachsel, of Sper- 
anza, of Katona, of McGirr, of Bufalini, gave definitely 
positive results do not stand close scrutiny in the light 
of the evidence at hand. In many instances the rubeo- 
lous nature of the sickness, sometimes very mild, fol- 
lowing the inoculation and regarded by the experi- 
menters as measles, is not at all securely established, 
and in practically all cases the possibility of natural 
infection has not been excluded. These experiments, 
practically all of which were undertaken with the idea 
of producing a modified form of the disease, conse- 
quently permit no conclusion as to the infectiousness 
of the blood or other substances in measles. If we 
accept Mayr's results as they are given by him, it may 
be concluded that in measles, nasal mucous and cutan- 
eous scrapings (containing blood, epithelial debris, and 
tissue juices) may contain the cause of measles at or 
near the height of the eruption. 

In the following experiments the author tried to 
determine whether or not, in measles at the height of 
the attack, the blood contains the cause of the disease. 
In these experiments special care was taken to exclude 
natural infection. 

I. The blood injected was taken from a boy of nine 
years who, in the later stages of desquamation after 
an uncomplicated attack of scarlet fever, developed a 
rather mild but typical attack of measles. The first 
symptoms of measles appeared after he had been free 
from fever for about two weeks. There was headache, 
coryza, cough, running of the eyes, and mild febrile 
symptoms. Three days later a papular eruption was 
noted, and on the fourth day a typical rubeolous rash 
was present that soon began to fade and was followed 
by typical branny desquamation. 

On the fourth day 4 c.c. of blood were withdrawn 
from the vein at the right elbow after carefully scrub- 
bing the skin with soap and water followed with alcohol. 
Two flasks with ascites broth 50 c.c. (peptone broth two 
parts, ascitic fluid heated to 55° C. for forty-five min- 
utes one part) were inoculated' at once with i and 3 
c.c. of blood respectively and placed in the incubator at 
37° C. for twenty-four hours. At the end of this time 
both flasks appeared sterile, the corpuscles having set- 
tled, the supernatant fluid being clear. Subcultures 
made at this lime upon ascites agar, glycerin agar and 
Loffler's serum and kept under xrobic and anxrobic 
conditions remained sterile : and the contents of the flask 
of ascites-broth containing i c.c. of blood remained per- 
manently sterile. 

Four c.c. of the flask of 50 c.c. of ascites-broth mixed 
with .3 c.c. of blood and kept in the incubator at 36° C. 
for twcntj'-four hours were injected under the skin of 
the chest of a healthy medical student twenty-four years 
old, just finishing desquamation after an uncomplicated 
gttack of scarlet fever, and who readily gave his consent ^ 
to tlie experiment. This man was not in the same hos- 
pital as the boy furnishing the blood for injection, but 
had been for twenty-six days in a diflferent institution, 
at that time as well as before and afterward entirely 
free from measles.' So far as could be learned, and 
careful inquiry was made, the man injected had not had 
any disease at all resembling measles except scarlet 

1 In experiments i and 2 a few drops of hlood were allowed 
to run out before inoculating the ascites-broth which was done 
without the ncedle_ of the syrinirc louchinj? the culture fluid. 

2 In both experiments the injections were made by me. .'\t 
the time the injections were made I had not seen any cases 
of measles within twenty-four hours. When in the measles ward 
the usual precautions were used and of course similar precau- 
tions were followed when visitinp the subjects of the experi- 
ments — clean long gowns, caps, clean hands, etc. Freshly auto- 
clave4 syringes were used for the injections. 



fever. At no time did any local symptoms appear at 
the site of the injection. On the thirteenth day after 
injection the temperature was I0I° F. ; in the evening 
it rose to 103° F. At nine o'clock the following morn- 
ing he was given a warm bath and immediately after- 
ward a red, papular, blotchy eruption broke out on the 
forehead and spread quite rapidly to the face, neck and 
chest. Dr. James B. Herrick, who saw him at this 
time, felt no hesitancy in inaking the diagnosis of 
measles. By two o'clock an unmistakably typical full 
blown, rubeolous rash was present over the greater part 
of the body. The temperature remained above normal 
for two days, when it fell to normal about the same 
time that the eruption began to fade. An uneventful 
recovery followed without any complications whatso- 
ever, the desquamation being branny. There was dur- 
ing the entire illness freedom from respiratory symp- 
toms of all kinds. Even during the pre-cruptive period 
there were no special local symptoms (morbilli sine 
catarrho). The patient's subjective condition was not 
much changed if at all at any time during his illness. 
The appetite continued unimpaired. 

2. In this case the blood was furnished by a well- 
developed Irish servant girl, twenty-one year-; old, who 
passed through an uncomplicated attack -of .typical 
measles. About thirty hours after the earliest .appear- 
ance of the rash, which still was coming out upon the 
extremities, 10 c.c of blood were withdrawn from a 
vein at the elbow and distributed equally among four 
flasks, each containing 50 c.c. of broth and 25 c.c. of 
ascites fluid. These flasks all remained jierfectly sterile 
so far as bacteria demonstrable by the usual methods 
are concerned. 

After twenty-four hours at 37° C. 5 c.c. of the mix- 
ture of blood in ascites-broth were injected subcutane- 
ously in the back of M.. aged twenty-eight years, who 
had not had measles so far as he knew and who readily 
gave his consent to the experiment. This patient was 
also recovering from a mild attack of scarlet fever and 
bad been at time of inoculation for twenty-four days 
the sole occupant of the isolation room of a general hos- 
pital in which at that time there were no other cases of 
measles. There were no local changes at the site of 
the injection. The temperature and general condition 
remanied normal until the evening of the eleventh day, 
when the temperature rose to 00.8° F.. and the next 
day a mild conjinictivitis already suspected a day or so 
previously became definitely apparent. On the thir- 
teenth day there was some cough, the tonsils were 
bright red, and there was an increased amount of 
mucus in the throat. In the afternoon the temperature, 
which was rising, reached 103° F. During the next 
night a typical rubeolous eruption came out. the first 
spots being noticed on the nose and then on the fore- 
head, face, scalp, chest, back and abdoinen. The rash 
consisted of pink macules and papules which disap- 
peared readily on pi'essure, being largest and brightest 
red over the face. The forehead was quite uniformly 
red. The patient w'as not seriously ill ; there was soine 
loss of appetite, but he slept well durin.g the night, hav- 
ing been somewhat restless the preceding night Re- 
covery was prompt. 

Cultures of the blood on the thirteenth day (i c.c. of 
blood in each of three flasks each containing 50 c.c. of 
broth and 25 c.c. of ascites fluidl remained perma- 
nently sterile. 

Conclusions.- — The results of these two experiments 
pcnnit the conclusion that the virus of measles is pres- 
ent in the blood of patients with typical measles some- 
time at least during the first thirty hours of the erup- 
tion ; furthermore, that the virus retains its virulence 



April 8, 1905 1 



SOCIETY FOR EXPERIMENTAL BIOLOGY AND MEDICINE. 



669 



for at least twenty-four hours when such blood is in- 
oculated into ascites-broth and kept at 37° C. This 
demonstration shows that it is not difficult to obtain the 
virus of measles unmixed with other microbes and in 
such form that it may be studied by various methods. 

The Formation of the Centrosome in Enucleated 
Egg-Fragments. — By Naohidc Yatsu. To test 
whether the centrosome is a permanent cell- 
organ or not, E. B. Wilson (igoi) made an 
experiment on the sea-urchin egg by treating, with 
a salt solution, enucleated egg-fragments obtained by 
shaking. He observed that asters containing cen- 
triole and capable of division were produced in the 
enucleated fragments. He, therefore, came to the con- 
clusion that at least some of the centrioles in the asters 
thus formed must have arisen de novo. Some writers 
criticised his results, saying that the formation of the 
centrioles in the enucleated fragments observed by him 
might have been due to the shaking-out of the nuclear 
fluid into the cytoplasm. Wilson, therefore, suggested 
to the author to repeat his experiment in a somewhat 
different manner ; instead of shaking, to cut eggs singly 
and to treat the nucleated and enucleated pieces sep- 
arately. The author tried this experiment on the egg 
of Ccrebratulus in the summers of 1903 and 1904. Strict 
precautions were taken to prevent accidental fertiliza- 
tion, everything used for the experiment being sterilized. 
Individual eggs were cut into nucleated {i.e., containing 
the first maturation mitotic figure) and enucleated frag- 
ments. The latter were kept for an hour in a solution 
of calcium chlorid. Then they were transferred to ster- 
ilized sea-water. Asters were produced in almost all 
enucleated fragments thus treated. What is more 
striking, all the asters had centrioles which were identi- 
cal with those found in the whole eggs subjected to the 
same treatment. The nucleated half was stained and 
shown to have had two original centrosomes intact. 
From these experiments no other conclusion can be 
drawn than that the centrosome, with centriole, of 
the enucleated fragment was formed dc novo. 

Structure of Vaccine Bodies in Isolated Cells, with 
Demonstrations. — By James Ewing. One of the few 
points on which all observers of vaccine bodies are 
agreed is that these structures are extremely suscepti- 
ble to artificial changes. The author has for some years 
endeavored to find a method of examination of these 
bodies by which artificial changes could be avoided; and 
this object seems to have been accomplished by the very 
simple procedure of making Klatsch preparations of 
corneal vaccine ulcers. 

A glass slide is cleaned with soap and water, and 
thoroughly heated in a Bunsen flame. It is then found 
to be unusually cohesive. The cornea of an anesthetized 
rat or rabbit, presenting a vaccine ulcer at any stage, is 
exposed by holding back the eyelids and protruding the 
eyeball. The cooled slide is then lightly applied to the 
ulcer and quickly withdrawn without lateral motion. 
The slide carries away with it an impression of the ulcer 
in the form of isolated cells or groups of cells loosened 
by edema. In this way ten to tw'enty impressions may 
be taken in serial order, and the minute ulcer may be 
completely excavated without sacrificing the animal. 
The isolated cells dry instantly and may be fixed by 
gentle heat, and afterward by methyl alcohol, and then 
stained by various methods, preferably by Nocht-Ro- 
manowsky for ten minutes. The vaccine bodies are 
then presented with a clearness equal to that of the 
malarial parasites in blood spreads. 

In Klatsch preparations stained by Nocht's method 
the following features of the vaccine bodies appear to 
be demonstrated. The vaccine body is a portion of the 



cytoreticulum, its reticular structures being continuous 
on the one liand with the cytoreticulum and on the other 
usually with the nuclear reticulum. The clear zone sur- 
rounding the vaccine body in sections of tissue is an 
artifact. The reticulum of the vaccine body takes the 
chromatin stain indicating that it contains chromatin; 
and many of the bodies are so intimately connected 
with the nucleus, the meshes of one passing insensibly 
into the other, as to force the conclusion that these par- 
ticular bodies have arisen by r"cent extrusion of nuclear 
chromatin into the cytoreticulum. Other bodies are 
disconnected from the nucleus and these may have 
arisen partly from the chromatin of the cytoplasm, a 
possibility which is furnished by Hertwig's theory of the 
constitution of cell protoplasm. Many of the vaccine 
bodies closely resemble the chromidial substance de- 
scribed by Hertwig in some lower animal cells. In the 
meshes of the reticulum the author has been unable to 
demonstrate any organized structure, but the meshes 
sometimes present nodal points of an underlying reti- 
culum. In the fresh condition the meshes contain 
homogeneous refractive globules which disappear on 
drying. 

Two series of changes may be followed in the vaccine 
bodies in Klatsch preparations. Many of them develop 
basic staining areas with loss of the central reticulum, 
and this process may continue until the entire body is 
transformed into a homogeneous globule resembling 
mucus or colloid. In others the reticulum breaks up 
into granules with or without the development of a cen- 
tral basic mass. 

The author has been unable at any stage or in any 
derivative of the vaccine body to detect the slightest 
definite trace of a protozoon. Yet there are several hy- 
potheses on which it may be claimed that this cyto- 
plasmic and nuclear material harbors an organized virus 
of vaccinia. (l) The meshes of the reticulum may con- 
tain a submicroscopic organism or one which disappears 
on drying. (2) The vaccine body may represent a 
fusion of the protoplasm of the host cell with that of 
the parasite, forming a mycoplasni, as is claimed to ex- 
ist in some diseases of plants (wheat-rust). (3) Some 
other method of fixation and staining of isolated cells 
may succeed in demonstrating in the meshes of the vac- 
cine body an organized structure. In any event it must 
be claimed that if the vaccine body contains a parasite 
it is one quite different from any recognized type of 
protozoon or from any interpretation which has yet 
been placed upon the structure of vaccine bodies in 
sections of tissue. 

Besides vaccine bodies there are other structures re- 
sembling protozoa to be seen in Klatsch preparations. 
One of these is 54 to i'/2 >t in diameter, ring-shaped 
and containing a chromatin granule. Myriads of these 
bodies are sometimes visible on the flat corneal cells. 
They appear to be peculiar cell granules and are present 
in normal animals. 

On the Tetanic Element in Bile.— By S. J. Meltzer 
and W. Salant. The toxic effects of bile are manifold 
and have been the subject of numerous investigations. 
The authors referred only to the general effects : coma 
and convulsions. Of the early investigators of the 
effects of injection of bile into animals, some observed 
only coma, others convulsions and stilP others stated 
that they observed both. The last work on this sub- 
ject, the work which is now frequently quoted, was done 
by Rywosch about fourteen years ago. Rywosch claims 
that coma is the only effect of the two which the injec- 
tion of bile or bile salts produces. 

In their extensive series of experiments on frogs the au- 
thors established the fact that the injection of bile can 



7C 



SOCIETY FOR EXPERIMENTAL BIOLOGY AiN"D MEDICINE. 



[Medical News 



produce coma as well as tetanus. Coma is the frequent 
and the more reliable result. By a certain device, how- 
ever, they were able to demonstrate the presence of tlie 
tetanic element even hi bile which infallibly produced 
coma; it was by the addition of a subminimum dose of 
strychnine. A frog of medium size will not respond, 
even with the slightest hyperesthesia, to an injection of 
one hundredth of a milligram of strjxhnine. When 
such a small dose, however, is injected into a frog, 
which has received a certain quantity of bile, the animal 
reacts sooner or later, with a distinct tetanus. The 
effective dose of bile varies with the animal from which 
it is obtained. For instance, of ox bile hardly more 
tlian 0.3 c.c. need be used, otherwise the coma will com- 
pletely mask the tetanic element. Rabbit's bile, on the 
other hand, may be given, sometimes even in doses of 
2 or 3 c.c, without suppressing any of the tetanic feat- 
ures. The setting in of complete coma usually mask? 
the tetanic element as already stated. A close observa- 
tion however will reveal in many cases some distinct 
differences between the coma of animals which re- 
ceived a- subminimum dose of strychnine and that of 
animals which had not received any strychnine. 

The bile of rabbits, which thus far has been more 
extensively studied than that of other animals, produced 
in many instances distinctly convulsive effects even 
without the addition of strychnine. From an anah'sis 
of their observations to the present time the authors 
feel justified in making the following statements: The 
toxic effect of bile from normal rabbits shows an indi- 
vidual variation ; the effect of the bile from some of 
the animals is predominantly coma and from others 
tetanus. Heating the bile seems to reduce the stupefy- 
ing, paralyzing effect and to favor the appearance of the 
tetanic element. In the bile of nephrectomized rabbits 
the tetanic element was distinctly more pronounced than 
in the bile of normal rabbits. 

The bearing which these observations might have 
upon the understanding of the complex symptoms of 
cholemia and uremia was not discussed. 

A Preliminary Communication on the Pharmacol- 
ogy of Thorium. — By E. D. Brown and Torald Soll- 
mann (Presented by William J. Gies). Thorium nitrate 
precipitates proteids and is intensely astringent. Its 
intravenous injection is promptly fatal by embolism. 
Applied subcutaneously, it causes local necrosis. ."Xd- 
ministered by the stomach, even large doses have no 
appreciable effect. 

Solutions in sodium citrate were found to be non- 
precipitant and non-astringent. As much as i gm. of 
thorium nitrate, per kilogram of dog, injected subcu- 
taneously and intravenously, in citrate solution, had lit- 
tle acute action ; however, the animals appeared de- 
pressed and became emaciated. The post mortem ex- 
amination, made after several weeks, showed extensive 
and widespread calcification of tissues. Thorium could 
not be demonstrated in the calcified areas. 

A method for the quantitative estimation of thorium 
was elaborated; this gave satisfactory results with urine 
to which known quantities were added. But in actual 
experiments on animals it was found inaccurate, a largo 
proportion of the injected thorium escaping detection. 
However, it was found that on intravenous or subcu- 
taneous injection, the thorium appeared in the urine and 
not in the feces. When administered by mouth, it ap- 
peared in the urine, but not in the feces. The conclu- 
sion appears justified that absorbed thorium is ex- 
creted by the kidneys, but that the metal is neither ab- 
sorbed nor excreted through the intestine. 

A Preliminary Study of the Toxicological Action 
of Thorium, -r.y Arthur F. Chace and William J. Gies. 



Our experiments comprised the third series in a study, 
still in progress, of the toxicology of rare elements.' 
They were 27 in number and were performed on as 
many animals (frogs, mice, dogs). They were carried 
out before Baskerville's announcement of his discovery 
that thorium consists of tis.<o elements, named by him 
hcrcclium and carolinium. Publication of our results was 
deferred because of our desire and intention to complete 
the work with a study of the toxicological effects of 
these two new elements, which Prof. Baskerville has 
generously agreed to furnish at a later stage in his in- 
vestigation. The foregoing communication by Prof. 
Sollmann has induced us, however, to present here our 
results as they stand. In some of the early experiment> 
( igoo) it was found that thorium (nitrate) had a uniform 
precipitative effect on various connective tissue mucoids. 
In our study, with Prof. Loeb (1902), on the antitoxic 
influence of ions, thorium (nitrate) was used as a tetra- 
valent element, and was found to exert only very slight 
almost inappreciable antitoxic effects in Jg m. NaCl, with 
fertilized fundulus eggs as the indicators. At that time 
we observed the strong precipitative effect of thorium 
on protoplasm, and the marked toxicity on various 
tishes and on both fertilized and unfertilized Fundulus 
eggs in sea water, although these facts were, not re- 
corded in our paper. 

In the experiments on frogs and warm-blooded ani- 
mals the tetra-chlorid was used exclusiveb'. Of our re- 
sults the following were in harmony with those reported 
by Brown and Sollmann : Thorium exerts marked as- 
tringent action. The chlorid is acid in reaction (in 
water). The aqueous solution of the chlorid blanched 
and hardened tissues, proteids were precipitated by it, 
and blood not only precipitated but blackened. Injected 
directly into the circulation even very small dose^ 
caused intravenous precipitation and resulted fatally 
.Subcutaneous injection resulted in local necrosis. Thus 
far we have not had any experiments with thorium in 
citrate solution or on the excretion of thorium. 

The following results extend the observations reported 
by Brown and Sollmann : 

(1) In frogs weighing about 25 grams no effect wa' 
observed after introduction per os, when less than 40 
milligrams was introduced. This amount caused only 
slight symptoms. Subcutaneous injection of 40 milli- 
grams caused death in about sixty hours. Injection of 
the same amount per rectum appeared to be more quick- 
ly followed by toxic results than when introduction oc- 
curred through either of the former channels. Intro- 
duction per OS caused irritation of the throat, increased 
gastric secretion, ejection of gastric contents and in- 
creased peristalsis. It required per os approximately 1.5 
gram per kilo to produce general toxic results, among 
which were anhydrosis, twitching and progressive weak- 
ening of the muscles, with paralysis of the forelegs pre- 
ceding paralysis of the hind ones. In fatal cases the 
reflexes were abolished in the usual order. The general 
toxic effects after introduction subcutaneously or per 
rectum were about the same as those following intro- 
duction by way of the stomach. 

(2) In warm-blooded animals (mice and dogs) rela- 
tively large doses administered subcutaneously caused 
restlessness, twitching of the muscles, progressive para- 
lysis, labored breathing, stupor, death. Paralysis of the 
forelegs preceded loss of power in the hind legs. In- 
jection of 5 grams of the chloride into a dog weighing 
15 kilos failed to cause death. Ingestion of 2 grams, 
with TOO grams of meat, by a dog weighing 6 kilos, was 
followed in two hours by vomiting. The ejected mat- 
ter was gradually eaten during the next few hours, 

1 We have already reported our observations on the toxicology 
nf tellurium Oooo^ and of <;clcniuin (1902). 



April 8, 1905J 



MEDICAL AND CHIRURGICAL SOCIETY OF MARYLAND. 



671 



with no other apparent effect thereafter than loss of 
appetite and increased desire for water. 

(3) The most constant and pronounced general effect 
of the tetra-chlorid of thorium was a progressive weak- 
ening of all the voluntary muscles. 



MEDICAL AND CHIRURGICAL SOCIETY OF 
MARYLAND. 

Regular Mccti)tg, held January 20, 1903. 

Pulmonary Stenosis. — Dr. Darling showed the 
heart of a patient who had died suddenly from vio- 
lence and hemorrhage. There was stenosis and in- 
sufficiency of the pulmonary valve but no potent 
foramen ovale or ductus arteriosus. Thickening of 
the whole heart watl was extreme. 

Flint Murmur in Ulcerative Endocarditis. — The 
murmur described bj' Flint in 1862 had, Dr. Thayer 
said, been heard in about fifty per cent, of the cases 
of pure aortic insufficiency seen at the Johns Hop- 
kins Hospital; it was not, however, common to find 
it in ulcerative endocarditis. Four such cases he 
reported, the patients showing symptoms of ulcer- 
ative endocarditis with a presystolic murmur and the 
autopsy findings revealing no mitral lesions. It was 
easy to see how the anterior mitral curtain, prac- 
tically continuous as it was with the aorta, vibrated 
with aortic regurgitation; and the attachment of the 
papillarj' muscle (which arose from the anterior cur- 
tain) being just above the apex might account for 
the thrill and murmur being most intensely heard at 
that point. The diagnosis of Flint murmurs was by 
no means easy. If, with aortic insufficiency a mode- 
rate mitral stenosis murmur was heard but no shock 
or snapping first sound suspicion of Flint murmur 
should be aroused. The pulse, too, did not have the 
" mitral " character.";. 

Paroxysmal Tachycardia. — Dr. Gamble reported an 
obscure heart case. The patient had had his atten- 
tion called to his heart in boyhood by his physician 
and had always lived around its beats. Attacks of 
fluttering w-ith changes in disposition, which varied 
with the character of the pulse, were the prominent 
features of the case. The physical signs were vari- 
able, signs of myocarditis with congestion of the 
liver and edema of the feet gradually developing. 
There was no pain, but attacks of apparent angina 
occurred with fair frequency. At autopsy fibrous 
myocarditis, sclerosis of the coronaries. and a mural 
thrombosis of the left ventricle were found. Many 
diagnoses had been made on this case and it illus- 
trated the great difficulty of the diagnosis of myo- 
carditis in the early stage. Dr. Thayer emphasized 
the importance of making patients exercise during 
the examination of the heart; a murmur which de- 
veloped under exercise was suspicious. 

Malnutrition in Children. — Dr. Kilmer, of New 
York, read a paper on this subject. The first cause 
of the condition was, he said, parental ignorance. 
The healthy conditions with which the parents of 
present parents had surrounded them during child- 
hood had been forgotten. Breast milk was being 
superseded by condensed milk and patent foods. 
Education was begun too early, " higher education " 
was being overdone, the great social demands made 
on mothers were taking them away from their chil- 
dren. The second cause was found in disease of the 
children. Adenoids and tonsils were familiar ex- 
amples. Disease of the parents was the third cause. 
This was most often lues, an old chancre in the 
father sometimes expressing itself in the child, as 



malnutrition without other symptoms. If other treat- 
ment was tried without result lues should always be 
suspected and mercurials and iodides (both borne 
well by children) should be ordered. In the general 
treatment, good sleeping room, plenty of fresh air, 
suitable bedclothing, medium underclothing, plenty of 
exercise and a warm bath once a day should be pro- 
vided. School should not be begun until the seventh 
year. A daily nap should be taken, and the child 
should sleep from 6.30 p.m. to 7.30 a.m. Food should 
be high in proteids and poor in carbohydrates, and 
the stomach should be carefully treated. Iron, qui- 
nine, sherry and cod-liver oil were important drugs 
for malnutrients. Malnutrition should always be 
eliminated in the diagnosis of obscure cases. Dr. 
Riihrah referred to the fact that comparatively little 
metabolism work had been done on children, though 
in infancy and adult age it had been well worked up. 
Probably in these patients it was not a case of poor 
absorption from the intestines but there was some 
break after assimilation, between that and excretion 
of end-products. A somewhat analogous condition 
w-as seen in diabetes. Dr. Mitchell said that the 
general environment was most important, and com- 
pared with it adenoids, etc., relatively insignificant. 
Dr. Kilmer said that feeding was overcarefully done 
up to the end of the first year and after that neg- 
lected. 

BOOK REVIEWS. 



How TO Study Literature. By B. A. Hi-ydrick. Hinds, 

Noble & Eldredge, New York. 

This manual aims to facilitate the study of literature 
by means of outlines with suggestive questions arranged 
for the different classes of literature, narrative, lyric 
and dramatic poetry, the essay, the oration and prose 
fiction. The application of these outlines is aided by 
specimen studies in which they are employed, and an 
excellent list of suggested reading appears as an ap- 
pendix. Versification and figures of speech are briefly 
treated in other appendices. 

Report of the Government Hospital for the Insane 
TO the Secret.-^ry of the Interior, 1904. Washing- 
ton Government Printing Office. 
This modest volume is a model of clearness, con- 
ciseness and interest, a report that really reports. From 
it one may gather a genuine appreciation of the vast 
work, pathological and executive, which is accomplished 
at the Government Hospital, and of some of the difficul- 
ties which it has to encounter. A number of excellent 
half-tones of the buildings add to the interest of the re- 
port, and the elaborate statistic tables are readily get-at- 
able for any information needed. Altogether the man- 
agement of the hospital is to be congratulated upon its 
success in presenting its work to the public in such an 
effective way. 

In the Year 1800, Being the Relation of Surgery 
Events occurring in the Life of Doctor Jonathan 
Brush during that year. By Samuel Walter Kei- 
LEY, M.D. Vol. III. The Doctor's Recreation Series. 
The Saalfield Publishing Company, Chicago, Akron, 
0., and New York. 

This, the third volume of the Doctor's Recreation 
Series, purports to be an arrangement of a package of 
old papers rolled in a leathern wrapper tied with a strip 
of the same materia! and marked in scarcely legible char- 
acters " The Property of Dr. Jonathan Brush, Private," 
which fell into the hands of a modern doctor. He found 



672 



BOOKS RECEIVED. 



[Medical News 



them to contain not what too many doctors leave as 
their sole legacy to posterity, a collection of unpaid ac- 
counts of unpaid services, nor yet, as I half expected, 
clinical records of cases in practice, but a fairly con- 
nected narrative of events that transpired_ during the 
year 1800. It is really a story that brings out the fea- 
tures of the practice of medicine and surgery, with an 
account of a social status of the profession at that time, 
which will undoubtedly prove interesting reading, es- 
pecially for those, and they are fortunately growing in 
number, who have acquired an interest in the old things 
of medicine. Many familiar names come into the book 
and it is very cleverly put together. 

The Surgery of the Diseases of the Appendix Vermi- 
formis and their complications. by william 
Henry Battle, F.R.C.S., Surgeon to St. Thomas' 
Hospital, Formerly Surgeon to the Royal Free Hos- 
pital, etc., and Edred M. Corner, M.B., B.C., F.R.C.S., 
Surgeon-in-charge of out-patients to St. Thomas' Hos- 
pital, Assistant Surgeon to the Great Ormond Street 
Hospital for Sick Children, etc W. T. Keener Com- 
pany, Chicago. 

This little book from the skilful hand of one of the 
originators of the most frequently used abdominal in- 
cision, — the Kammerer-Battle, — is certain to be very wel- 
come to all. The authors have endeavored to summarize 
briefly the conflicting views of the physician, the path- 
ologist and the surgeon, and have tried in an impartial 
way to place before the profession, the surgeon's views 
and conclusions in this very important malady. The 
book is rendered further interesting and valuable by 
having appended a most interesting and lucid chapter 
on the " Acute Abdomen " and one on life insurance 
in its relation to appendicitis. The authors are strict 
adherents to that school which advocates the wet method 
of treating peritonitis and that chapter on the subject 
is fraught with particular interest. Their notes on con- 
cretions and the role which they play as causative factors 
in appendicitis are interesting and concise. Considerable 
attention is devoted to the mode of formation of these 
concretions, the authors concluding that micro-organisms 
play an all-important factor. One cannot ask for every- 
thing in such a small book, but it may be permissible to 
suggest that in a future edition the distinguished au- 
thors will devote more attention to a consideration o5 
the still unanswered problem : when to operate. If this 
question is answered in the book, it was not given a suffi- 
ciently prominent place. The volume is very attractively 
made, the printing and paper being of the best. It can- 
not be too strongly said that if this small and easily 
read book, which is much of the type and character of 
the writing of Sir Frederick Treves, were placed in the 
hands of every general practitioner of medicine, it would 
save hundreds of lives. 

First Annual Report of the Henry Phipps Institute 
FOR THE Study, Treatment and Prevention of 
Tuberculosis. The Henry Phipps Institute, Phila- 
delphia. 

The first annual report of this institute has a special 
interest in the fact that it is the first, and we can trace 
the development, gratifyingly rapid in this case, of its 
efficiency and magnitude. It is a well printed volume of 
254 pages, and includes the lectures which have been 
delivered during the year under the auspices of the In- 
stitute by Dr. Trudeau, Dr. Osier, Dr. Biggs and Dr. 
Maragliano. The statistics are scientific rather than ad- 
ministrative, and give evidence that the threefold pur- 
pose of the Institute is being kept in mind in just 
proportion. 



New Methods of Tre.\tment. By Dr. Laumonier. 

Translated and edited by H. W. Syers, M.A., M.D., 

Cantab. W. T. Keener & Co., Chicago. 

The author of this book has "endeavored" to quote 
his own words, " to furnish those interested in the sub- 
ject of therapeutics with a definite and complete, and at 
the same time short and clear, information concerning 
the new drugs and methods of treatment whose worth 
has been established and which are sufficiently well 
known to be described in a definite and practical man- 
ner." The book certainly responds to a genuine need. 
The published formularies of the new remedies which 
appear from time to time do not always discriminate in 
accordance with a criterion of value, and sometimes 
fail to reach the men for whom this book is especially 
designed, the practitioner who meets the exacting de- 
mands of daily routine work with little time to investi- 
gate the new remedies and methods that multiply so 
rapidly. Special effort has been made in this work to 
include those methods of treatment which are not purely 
pharmacodynamic. It is to be regretted that the treat- 
ment of the subject-matter as a whole is somewhat frag- 
mentary, but completeness in such a work is hard to ar- 
rive at, and the book may well prove a valuable aid to 
the practitioner. 



BOOKS RECEIVED. 



First Annual Report of the Henry Phipps Insti- 
tute. 8vo, 265 pages, Philadelphia. 

Anemia in Porto Rico. Hon. B. Winthrop. 8vo, 150 
pages. Government Printing Office, Porto Rico. 

Manual of Operative Surgery. By Dr. J. F. Binnie. 
i2mo, 64s pages. Illustrated. P. Blakiston's Son & Co., 
Philadelphia. 

Translations of the American Rhinolocical As- 
sociation. Twenty-sixth Annual Meeting. 8vo, 360 
pages. Illustrated. 

The Diseases of Society. By Dr. G. F. Lydston. 
8vo, 626 pages. Illustrated. J. B. Lippincott Co., Phila- 
delphia and London. 

Twentieth Annual Report of the Bureau of Ani- 
mal Industry. 8vo, 618 pages. Illustrated. Govern- 
ment Printing Office, Washington. 

A Manual of Gynecology. By Drs. D. B. Hart and 
A. H. F. Barbour. Sixth edition. 8vo, 736 pages. Illus- 
trated. W. T. Keener & Co., Chicago. 

International Clinics. Volume IV. Edited by Dr. 

A. O. J. Kelly. 8vo, 314 pages. Illustrated. J. B. 
Lippincott Co., Philadelphia and London. 

An Elementary Treatise on the Light Treatment 
FOR Nurses. By Dr. J. H. Sequeria. i2mo, 83 pages. 
Illustrated. The Scientific Press, London. 

Examination of the Urine. By Dr. G. A. De 
Saxe. i2mo, 391 pages. Illustrated. W. B. Saunders 
& Co., New York, Philadelphia and London. 

A Manual of Personal Hygiene.. By Dr. W. L. 
Pyle. i2mo, 441 pages. Illustrated. W. B. Saunders 
& Co., New York, Philadelphia and London. 

A Text- Book of Insanity. By Dr. R. von Kraflft- 
Ebing. Translated by Dr. C. E. Chaddock. 8vo, 638- 
pages. Illustrated. F. A. Davis Co., Philadelphia. 

Diet in Health and Disease. By Drs. J. Frieden- 
wald and J. Ruhrah. 8 vo, 690 pages. Illustrated. W. 

B. Saunders & Co., i\ew York, Philadelphia and London, 
don. 

Essentials of Bacteriology. By M. V. Ball. Edited 
by Dr. K. M. Vogel. i2mo, 243 pages. Illustrated. 
W. B. Saunders & Co., New York, Philadelphia and 
London. 



THE MEDICAL NEWS. 

A WEEKLY JOURNAL OF MEDICAL SCIENCE. 



)L. 86. 



New York, Saturday, April 15, 1905. 



No. 15. 



ORIGINAL ARTICLES. 

NTRACRANIAL TRAUMATIC HEMORRHAGE. 

UY J. SIIEKMAN WIGIII . U.S., .M.l>.^ 

OF BROOKLYN, N. V. 

ITRACRANIAL trauiiiatic hemorrhages may be 
ural, pial, or cortical. The deeper hemor- 
;es are derived from the vessels of the pia 
;r and from or through the cerebral cortex, 
are always originally situated beneath the 
;ral arachnoid membrane, although if the 
avasation is sufficiently large it will secon- 
ly break through into the arachnoid cavity. 
; extension has no clinical or other impor- 
e, but to specialize them as subarachnoid 
er than as subdural would somewhat more 
;ly define their anatomical position. The 
^nation pial and cortical as the sabarachnoid 
orrhage is of meningeal or visceral origin, 
topographically exact and pathologically dis- 
:ive. 

pidural hemorrhage may be derived from the 
jic vessels, and is usually inconsiderable in 
unt. If it escapes from the cranial cavity 
appears externally beneath the pericranium 
tuations noted in connection with bone frac- 
s its importance is mainly diagnostic, and if 
retained it is difficult to occasion symptoms, 
lay be derived from the dural vessels, anrl 
the extent is in proportion to their size, and 
:ase the middle meningeal or either of its 
lary branches is involved the danger to life 
imes imminent. The lacerations may be oc- 
3ned by a wound inflicted by a fragment of 
inner table, by a rupture in the line of frac- 
, or by contre-coup, and may even occur 
out cranial lesion. The dural sinuses are a 
'ler source of large hemorrhages, ])rol)ably 
,1 direct rupture of their walls, but more 
"rally from wounds by an osseus fragment. 
I accumulation of coagula is less than in the 
lingeal variety, since the fragment which 
ies the injury so often closes it till disturbed 
jiterference. 

al hemorrhage is occasioned by rupture of 

i'essels of the pia mater and is primarily con- 

il to its meshes. It is one of the results of 

Ij.cranial contusion and is independent of epi- 

rjl extravasation. It may appear as punctate 

llivasations. It more characteristically forms 

lin sheet over the verte.x ; if it is in large 

ftity it breaks into the arachnoid cavity. It 

1! occur in patches or be universal, covering 

-ertex upon one or both hemispheres. 

rtical hemorrhage is the direct result of a 

id of the brain substance which may be su- 

cial or mav lie subcortical with an access of 



blood to the surface by rupture of the interven- 
ing tissues. It varies in e.xtent from a small 
oozing to an enormous effusion, breaking through 
the pia mater into the arachnoid cavity. If the 
hemorrhage does not reach the cerebral surface, 
it differs from an apoplectic effusion only in 
cause and attendant conditions. The epidural 
i)lood never penetrates the dura unless that mem- 
brane has been ruptured by the violence of the 
original injury. If no cortical laceration can be 
discovered, it is impossible for the hemorrhage 
to be of cortical origin except in those cases that 
admit of the following classification: 

1. Traumatic apoplexy occurring simultan- 
eously with the injury. In these cases, rare, but 
of great medical importance, the patient, im- 
mediately after a blow on the head, develops the 
symptoms of a hemorrhage of the- internal parts 
of the brain. Usually the blow is not severe and 
all evidences of injury to the scalp or skull may 
lie wanting. The symptoms are those of spon- 
taneous apoplexy and may be quickly fatal. 
There may be hemiplegia, involving arm^ leg, 

and face, with more or less recovery. Such 
hemiplegia is more complete than in traumatic 
cases, and the evidences of irritation and the 
symptoms of concussion are wanting. In addi- 
tion unmistakable signs of general vascular de- 
generation are present. In a recent case a pa- 
tient was struck on the head in a street brawl. 
He became momentarily unconscious and com- 
pletely hemiplegic. Examination a few days 
later showed left hemiplegia, complete restora- 
tion of psychic function, no general brain symp- 
toms, but a well-marked arteriosclerosis of the 
peripheral arteries, and a hypertrophied heart 
with a systolic murmur at the apex. The expla- 
nation of these cases consits in a pre-existing 
weakness, by miliary aneurisms or otherwise of 
the walls of the cerebral arteries, which, when 
subjected to a sudden rise in blood pressure, give 
way. It is possible that the rise in blood pres- 
sure is due to the mechanical effect of the blow. 
In many cases attendant circumstances leave lit- 
tle doubt that the psychic factors of fright and 
excitement were the most active causes of the 
blood-pressure increase and the consequent ex- 
travasation. 

2. Traumatic apoplexy occurring shortly af- 
ter the injury (traumatische spat Apoplexie). 
This condition, described by Bollinger,' comes 
on a few days or weeks after a head injury. The 
hemorrhage which is fatal takes place in the 
neighborhood of the fourth ventrical and the 
aqueduct of the sylvius. Bollinger maintains 
that the hemorrhage is preceded by local soften- 

I Virchow's Festschrift, Berlin. 1891. 



674 



WIGHT: INTRACRANIAL TRAUMATIC HEMORRHAGE. 



[Medical 



ing, which in turn has been caused by unequal 
pressure of the cerebrospinal fluid. This latter 
hypothesis remains to be proved for all cases. 
The injury is invariably to the head. It may 
or may not cause unconsciousness. In any event 
the patient recovers and is able to return to work. 
A considerable proportion of cases have been in 
j-oung persons. After a few days or weeks, 
headache begins, somnolence and coma, with 
paralysis of the extremities or of the cranial 
nerves sets in. or after the same period of free- 
dom an apoplectic stroke may occur without any 
warning. 

3. Apoplectiform symptoms occurring long 
after the injury. The symptoms in this class 
point to a slow increase in vascular occlusion in 
parts long before the seats of traumatic insults 
and are those of slow thrombosis. It is generallv 
seen in cases of fracture of the skull with ex- 
tensive laceration of the brain. The increase of 
symptoms begins after a lapse of many years. A 
man. reported in the Lancet. 1904, sustained a 
compound depressed fracture of the vertex by 
being hit with a brick in 1861. The left leg was 
paralyzed, but recovered in a few weeks. Ten 
years later the leg became weak and finally al- 
most completely paralyzed. The arm also lost 
considerable power and the intellect became 
blunted. Frost, in the American Journal of In- 
sanity, 1903, reports the case of a man who, 
twenty-six years after a compound fracture of 
the skull with extensive loss of substance, slowlv 
developed paralytic symptoms in the limbs of the 
opposite side. The autopsy showed general de- 
generation in the cerebral arteries, but more 
marked on the affected side of the brain. In this 
region also the brain showed cavities, the results 
of small areas of softening. 

The injury and amount of violence vary ex- 
tremely. In cases of severe violence, lacerations 
or contusions of the brain are frequent complica- 
tions, with less violence either no fracture mav 
be present, or if one be present it is often only 
a fissure and may involve the internal table only. 

The interval of consciou.sness between the 
stunning effects of the injury and the onset of 
compression from tjie eflfused blood varies when 
present from a few minutes to days. In a second 
class it is but little marked and' may be easily 
overlooked altogether. In the third and last set 
of cases this interval is never present at all, owing 
to a very large liemorrhage-producing compres- 
sion symptoms ; coexisting depression of bone ; 
coexisting injury to tlic l)rain. or drunkenness 
of the patient. 

1 lemiplegia, though well marked in a large 
proportion of cases, must not be looked upon as 
essential. It may be ill marked or replaced by 
some other condition of the limbs and we find : 

(a) Hemiplegia present and well marked. The 
leg or arm. and usually Ixjth, when taken up and 
let go, drop like tliosc of a corpse. The hemiplegia 
is occasionally on the same side as that injured. 



the extravasation taking place on the side c 
site that struck. 

(b) Hemiplegia present but little marked 
these cases, which are not uncommon, th< 
travasation may be overlooked. They fall 
at least two divisions. In one the hemiplec 
little marketl throughout, owing to some p 
of accommodation on the part of the brain 
the circulation remaining feeble, owing t< 
coexisting shock from the time of injury t 
moment of death. In another group of 
the hemiplegia is ill marked because of 
duration, coming on as it does in these 
toward the close, giving but little warning 
leaving but short time for interference. 1 
tests should be made ; resistance to passive 
tion of the limbs, the power of the grasp, if 
the result of the needle prick, whether th< 
tient moves either of his hands, or whic 
them, when the cornea is carefully touchy 
the cilia gently pulled. 

(c) Hemiplegia present but temporary, 
duced by the brain being able to accommi 
itself to the blood, which is a very rare c 
tion. The mechanical compression which 
brain suffers as the result of the intrusion o 
ditional matter into a cavity with unyie 
walls which the viscus exactly fills, the o 
quent disturbance of the circulation and r 
tion by more or less complete obliteration o 
cerebral capillaries, has been generally hei 
be entirely adequate to explain all the ch 
teristic attending symptoms. It has been 
pcrimentally demonstrated that when wax i 
jected into the cranial cavity in excess 
maximum amount of 6.5 per cent., it bcinj 
capable of absorption, distinctive symptoms 
produced, and when the amount reaches 
twelfth to one-sixth of the cerebral capacit 
its situation is epidural or subdural, fatal < 
results. In compression from hemorrhage 
resultant vascular disturbance leads to defi 
nutrition. This is preceded by displacemei 
the cerebrospinal fluid into the vertebral c 
This continues till the capacity of that divei 
lum is exhausted, and then circulatory inte 
ence begins as the tension of cerebrospinal 
is augmented under pressure of continued 
travasation and by increasing resistance ir 
yerteliral canal, capillary lluw is checked 
may cease altogether with complete cerebral 
mia and abolition of all functional control, 
intercurence of edema from capillary trans 
lion may further increase intercranial pres 
If the hemorrhage is epidural, sudden and 
fuse, ])ermanent inhibition of consciousnes 
the same extravasation is more gradual, cer 
anemia may never be complete or not until 
has been afforded for relief; if it be of mo 
amount as well as gradually effused, it MJ 
capable of absorption without the necessity < 
terfcrcnce. The jiial and cortical hemorri 
are rarely sufficiently copious to produce w: 



IL 15. 1905] 



WIGHT: INTRACRANIAL TRAUMATIC HEMORRHAGE. 



67s 



ebral anemia, but they are associated with 
er lesions which contribute to a fatal result, 
these instances of hemorrhage serious inter- 
:nce vvith the vascular supply and the occur- 
ce of answerable inhibitory symptoms are 
iprehensible. 

d) Monoplegia, or paralysis more marked in 
; limb than in the other, is a very rare condi- 
1, as the hemorrhage generally causes pres- 
e upon all the motor area. 
c) General paralysis is another rare condi- 
i which may be explained by a very large clot, 
, on the left side, rapidly effused and making 
ssure through the left side of the brain upon 
right as well, or by coexisting extravasation 
) the brain itself. 

/) Absence of any paralysis is due to the ef- 
ed blood finding its way through a fracture 
the skull beneath the scalp. 
g) Limbs rigid, convulsed or twitching is 
bably ilue to contusion of the brain substance 
nore spots than one. 

f the pupils are normal in reaction to light, 
case is more likely to be one of compres- 
1 only of the brain without other injur}- and 
prognosis is good as to recovery if trephining 
mmediately performed. If the pupils are in- 
sitive at the same time dilated, the conipres- 
1 is probably extreme, and, while trephining 
irgently called for, it is less likely that in these 
es the brain will recover itself after the re- 
val of the clot. If one pupil is found widely 
ited, the other being normal or contracted, 
I if the dilatation be present opposite to the 
I of the body which is paralyzed, taken with 
er evidences of hemorrhage, it points to a 
je clot reaching down into the base and press- 
forward upon the sphenoidal fissure and com- 
ssing the third nerve." 

rhe pulse will vary according as the case is 
; of well marked uncomplicated extravasation 
complicated with contusion or laceration of 
brain, and if the concussion stage has been 
ere. according to the degree to which the 
.rt has recovered from this. In well marked 
implicated compression it will be slower than 
Tiial down to 52 and still falling and some- 
at full and laboring. 

fhe degree of coma varies with the amount 
1 rapidity with which the blood is effused, 
lere effusion is rapid and compression great 
coma may be as deep and complete as in apo- 
x}-, but it may be found that though the coma 
ipparently deep, this is not really so; the pa- 
it may moan constantly or may move his limbs 
bly when disturbed. Commencing coma may 
taken for normal sleep or drunkenness. In a 
J cases the onset of coma is deferred till late, 
■s and even months. Its onset is here sudden, 
course rapid, and it generally ends in death. 
Jelirium, irritabilit}' and restlessness, when of 
nediate occurrence and when the effusion is 



moderate in amount, may be considered symp- 
toms of hemorrhage, but only in the sense that 
a pleuritic pain is counted a symptom of pneu- 
monia. 

Respiration in well-marked cases is often ster- 
torous and somewhat slow. The still greater al- 
terations in breathing are, catchy short resjiira- 
tions, cyanosis and gasping, irregular breathing, 
ceasing for intervals of time, ten to fifteen sec- 
onds, and then repeated. 

Case I. — C. N., a young man in fair health, 
received a severe blow on the left side of the 
head. Though dazed by the violence, he was 
able to get upon his feet and stagger off. On ar- 
riving home he became unconscious and remained 
so for several hours. On emerging from the at- 
tack his power of speech was gone and his right 
side paralyzed. Subsequently he again lost con- 
sciousness for some hours and again recovered. 
The hemiplegia and aphasia persisted for some 
lime and it was only after the lapse of weeks that 
he could articulate or get about. About this time 
he suft'ered from repeated attacks of Jacksonian 
epilepsy and later, hirough a period of years, 
from flightiness, consisting of lapses of memory 
and confusional states. Eleven years later these 
seizures had become very rare and he became af- 
flicted with severe and unremitting cephalalgia. 
There was nothing very typical about this pain ; it 
involved the whole head, with occasional tend- 
ency to acuity in the left parietal region. Pres- 
sure disclosed no unusual tenderness, and the 
ophthalmoscope could find no token of any in- 
crease in intracranial pressure. There was no 
disturbance of locomotion. T'he right patellar 
reflex was a trifle increased. Iodides were given 
in large doses with no benefit. Morphine gave 
some relief. The following operation was per- 
formed at each corner of a quadrangle measur- 
ing two inches on a side and embracing in its 
area that portion of the left parietal bone situated 
immediately above the anterior central and pos- 
terior central convolutions, an opening was made 
with a small trephine. A chain saw was used to 
divide the bone between these openings and a flap 
of bone was turned back with periosteum and 
scalp attached. The dura was found slightly 
thickened at the upper portion of the opening 
but no adhesions. The dura was thickened and 
adhesions well marked at the inferior margin of 
the opening and extending below it for some dis- 
tance. The adhesions were thoroughly broken 
up, the flap replaced and the wound closed. Re- 
covery took place and the cephalalgia entirely 
disappeared. 

Corning, who reported this case, states that 
the manner in which the relief was obtained in- 
volves at once the pathology of hematoma and 
the morbid physiology of intercranial headache. 
On the one hand we have the insensitiveness of 
the hemispheres demonstrated by both vivisec- 
tion and operative incursions, on the other the 



676 



WIGHT: INTRACRANIAL TRAUMATIC HEMORRHAGE. 



[Medical 



fact that neoplasms embedded in their substance 
may and often do give rise to excruciating pain. 
In Xienieyer's Practical Medicine, \o\. II, p. 159, 
it is stated that the filaments of the trigeminus 
going to the dura mater are irritated in these 
cases and give rise to pain. The vagus also gives 
off sensory branches to the dura. 

Case II. — N. D., age fifty-two years, a grocer, 
was thrown from his carriage. He fell on his 
head and received a large scalp wound on the 
right side of his forehead and a small one about 
the middle of the forehead. He remained un- 
conscious from the stunning effect of the injury 
or the concussion for a few minutes. He was 
taken to a hospital, the wounds were sewed up. 
dressing applied, and he was allowed to go home 
in a carriage. He was seen that day by his fam- 
ily physician who found him suffering from 
partial loss of the sensation of the lower extrem- 
ities, their movements slow and showing great 
exertion, temperature subnormal, and pulse about 
normal. The following day the temperature rose 
to 99° F. and the pulse became fuller, there was 
some vomiting, and severe frontal headache. 
Left hemiplegia was present but very little 
marked. The hemiplegia disappeared and the 
wounds healed up so that he left his bed at the 
end of three weeks, showing vertigo, iritability, 
partial anesthesia and some muscular weakness. 
At the end of two months he did some light work. 
Muscular weakness continued to increase mark- 
ing a return of the left hemiplegia, pain in the 
head became more severe, vertigo more pro- 
nounced, so that his wife was obliged to follow 
his movements about the house to prevent his 
falling, avoiding this accident on several occa- 
sions by prompt action. Three and a half months 
after the accident he became so much worse that 
he was obliged to take to bed again. I saw him 
in consultation two weeks later and recorded the 
following facts : Coma, but moved his limbs feebly 
when disturbed and complained of pain in his 
head when aroused. Respiration stertorous and 
slow, pulse 60, temperature 99.2° F. per rectum. 
Tongue swollen and coated and was protruded 
straight out. The eyes and head deviated to the 
right side. The pupils were insensitive and 
somewhat dilated. He was voiding feces and 
urine in bed. There was no reaction to the needle 
prick. The grasp of both hands was feeble. 
There were rigidity and muscular twitchings of 
the extremeties and paralysis was more marked 
on the left side. He was placed on his feet and 
stood for a .short time and then fell to the left 
side. Urine analysis was negative. .A diagnosis 
of hemorrhage and compression was made and 
operation advised, which was refused. He grew 
steadily worse ; general paralysis became fully 
developed and he went into deep coma and died 
thirteen days later. 

I'ost-mortcm examination showed a large 
curved scalp wound with a radius of about two 
inches and its highest jx)int about three inches 



above the nasion, extending from the middle c 
forehead into the right temporal fossa ; a ! 
curved scalp wound about three-quarters c 
inch long situated one inch above the nasion 
one-quarter of an inch to the left of the m 
of the forehead. No atheroma of the ve 
Fracture of the outer table and slight depre 
of the inner table of the frontal bone at th< 
of the small scalp wound, some discoloratic 
the bone resembling necrosis. Removal o: 
calvarium showed the depression of the 
table to be slightly to the right of the longitu 
sinus. The right cerebral hemisphere was 
ered by an encysted clot of blood extending 
the seat of fracture along the sagittal mid ] 
for 4^ inches, measuring 2-)4 inches at its 
est point, and depressing the cerebral corte 
inch and a half. This came from a pial he 
rhage that had broken into the arachnoid c; 
It had its origin in a venous tributary nea 
depressed inner table where there was evic 
of recent bleeding. The clot itself showed d 
ent stages of coagulation corresponding to 
cessive accumulations of blood. The fourth 
tide contained a small amount of cerebros 
fluid. .See Figure i. 

Fig. I. 

X 




Ihis was a case of pial hemorrhage she 
as points of interest : ( i ) An interval of 
sciousncss following the stunning effect o 
injury of over four months. (2) Cerebra 
emia completed in about four months, whicli 
preceded by deficient nutrition for a perio( 
termined by the degree of the vascular dis 
ance from compression. (3) Hemiplegia pr 
early but little marked. It was temporary a 
extravasation was gradual and the brain ac 
modated itself to the pressure. (4) There 
a period of improvement during which he 
rhage ceased. (5) Hemorrhage recurred at 
cessive periods as shown by the different s' 
of coagulation and additions to the original 
(6) Toward the end hemiplegia became 
marked. (7) Paralysis was more marked 01 
side than the other. (8) General paralysii 
peared at the end. (0) The clot at death 
about one-eighth of the cerebral capacity. 

Allingham rejxirted a case of pial hemorr 
in the British Medical Journal. Vol. I. 188 
887, which he operated on one week after tli 
cident and gc)t a recoverx . 



April 15, 1905] 



HUBER: CEREBROSPINAL MENINGITIS. 



Phelps has reported a miniber of fatal cases. 
Fifteen days was the longest time recorded from 
the date of injury to the date of death. 

Case I. — Violent delirium for two days, re- 
covery on the sixth day followed by unconscious- 
ness and hyperesthesia. Temperature 103° to 
104° F., later 100° to 103° F. ; final temperature 
103° F. Death in twelve days. The autopsy 
showed pial hemorrhage over the left occipital 
lobe extending into the median fissure, subarach- 
noid serous effusion, and absolutely nn fracture 
of the skull. 

Case II. — Delirium, normal pupils and respira- 
tion, temperature 101.4° F., pulse 114. Later ex- 
cessive sensitiveness and irritability. The de- 
lirium continued, though it did not prevent ra- 
tional reply to questions, temperature rose to 
103.2° F. on the fifth day, and afterward fell very 
gradually to 100° F. ; on the fourteenth day it 
was 103.4° F., and on the fifteenth, five hours 
ante mortem it was 103.8° F. and one hour post 
mortem it was 104.2° F. The autopsy showed 
pial hemorrhage over both hemispheres and in 
largest quantities over the parieto-occipital junc- 
tions, some subarachnoid serous effusion in the 
left frontal region, general hyperemia with punc- 
tate hemorrhages most marked on the left side, 
and no fracture of the skull. 

Case III. — Absolute unconsciousness till death, 
one hour and a half after the reception of the in- 
jury; small wound behind right ear, dilatation 
and immobility of both pupils, respiration on ad- 
mission 42, an hour later 21, ceased at death 
rather suddenly ; no cyanosis, pulse feeble and 
soon became imperceptible, temperature on ad- 
mission, 98.6° F. an hour later 98.2° F. The 
autopsy showed fractures of both tarsi comminu- 
tion of both calces and right astragalus, fracture 
of the left leg. The patient fell, landing upright 
on both feet, transmitting the force through the 
lower extremities. There was a pial hemorrhage 
to the extent of several ounces of fluid blood 
mainly at the vertex and in larger part on the left 
side extending into the median fissure and which 
had broken through into the arachnoid cavity, 
also in considerable quantity upon the inferior 
■surface of the cerebellum about the median line 
and covering the pons, optic thalami, and corpora 
striata in the order named, thrombosis of minute 
vessels generally most pronounced in the optic 
thalami and the pons, edema of the pons. 

BIBLIOGRAPHY. 
I. Bailey. Medical Record. Oct. i, 1904. 
.;. Hutchinson. Lond. . Hos. Rep., 1867, Vol, IV, p. 29, 

3. Jacobson and .Steward. The Op. of Surg., Vol. I, 1902. 

4. Annals of Surgery, Vol. Ill, No. 6, p. 522. 

5. American Journal of the Medical Sciences, April, 1886. 

6. La Sent. Med., April 12, 1899, 

7. Trans. .\mer. Surg. Ass'n, Vol. II. p. 116. 

S. Trans. Roy. Acad, of Med., Ireland, Vol. \'I, p. 15s. 
9. British Medical Journal, Aug. 11, 1888. 



Pennsylvania Society for the Prevention of Tuber- 
culosis. — Tile annual meeting of this society was 
held Wednesday. ."Vpril 12, at the Academy of 
Natural Science. .\t this meeting the annual elec- 
tion for officers was held. 



A PRELIMINARY REPORT ON THE CSE ( 
DIPHTHERIA ANTITOXIN IN EPIDEMIC 
CEREBROSPINAL MENINGITIS. 
BY FRANCIS HUBER, SI.D., 

OF NEW YORK. 

" Tii./\ r branch of bacteriology which dea 
with the mutual antagonistic relations of pat 
ogenic germs is still in its infancy. The fac 
already discovered suggest important develo 
nients in the future. To what extent clinicia; 
will be able to utilize these antagonisms in tl 
treatment of disease it is difficult to forete 
Medical News, March 4, 1905. 

The above extract serves as an excellent i 
troduction to the following: 

Dr. Arthur J. Wolff, of the Board of Healt 
Hartford, Conn., " early found that there is 
decided antagonism between the Klebs-Loffl 
bacillus and the meningococcus, and during t 
course of study on this portion of the investic 
tion found that pure cultures of the mening 
coccus were killed by the antidiphtheritic serui 
and not only precipitated when mixed with t 
latter, but active cultures, when mixed in bii 
with the antitoxin are precipitated in the sar 
manner. The ubiquitous newspaper man g 
hold of the whole matter, ere we had time 
finish our work or our paper." — Medical Recoi 
.March 11, 1905, page 3. 

On the strength of the above Dr, E. Wait 
felder used large and repeated doses of dip 
theritic antitoxin subcutaneously. The methi 
was given a fair trial and his impressions a 
reported in the journal just quoted. The resu 
obtained at Roosevelt Hospital have not tend 
to confirm the enthusiastic reports of the ben 
ficial effects observed at Gouvemeur Hospita 

In Beth Israel Hospital and, a little later, 
Roosevelt Hospital, in the service of Pro; 
Jacobi and Peabody, diphtheria antitoxin, I: 
cause of the negative results obtained from : 
use subcutaneously, was injected directly in 
the subarachnoid space. A lumbar puncture w 
performed, 4 to 6 drams and even larger qua 
titles of cerebrospinal fluid were allowed to t 
cape, then 1,500 to 2,000 units of antitoxin we 
slowly injected. No ill effects followed in t 
series of cases in which this was done. In o: 
case an antitoxin rash was observed seven da 
later. In some of the cases only one dose w 
given, in others the injections were repeated t\ 
or three times. 

It appears to the writer that the results a 
promising, though final judgment is suspend' 
until the nutnber of cases is larger and the o 
servations have extended over a longer peri( 
of time. Of course the treatment should be r 
.sorted to early, before the anatomical chang 
due to the seropurulent, purulent or fibrinous e 
udate, have taken place. The malignant type 
not affected in the least by the method. 

In two cases, one of which was of the fo 
drr)\ant tvpe. lumbar puncture revealed a gel 
tiiioiis exudate, but a few drops of a thick, te 



WRIGHT: HIGH FREQUENCY MACHINES. 



[Medical News 



ious secretion escaping. Here it was impossi- 
; to inject the remedy into the spinal canal. In 
i children's service at the Beth Israel Hospital, 
; fluid obtained by lumbar puncture was exam- 
?d at once and when the characteristic diplo- 
ccus was found, the injections were made 
rough the same needle — strict asepsis being 
served. 

Not only did we observe an amehoration of 
i clinical features, but in several instances in 
lich lumbar puncture was repeated within 
irty-six to forty-eight hours the number of 
lynuclear cells was less and the diploccocci 
d diminished in number. In two cases in 
lich the cerebrospinal liquor originally was 
:amv in color and consistence, the character 
the fluid showed decided changes — becoming 
rbid and thin. 

The above remarks are merely intended as a 
eliminary report, a more detailed account, with 
nperature charts, will be presented at a later 
te. 

Dr. Wolff, during a recent visit, suggested 
at better results might be obtained if the anti- 
xin were used subcutaneously as well as intra- 
inal. He bases his views upon the fact that 
iproved methods have established the frequent 
esence of the meningococcus in the circulation. 



IME POINTS IN THE CONSTRUCTION OF A 

HIGH FREQUENCY MACHINE, i 
BV CL.XRENCE A. WRIGHT, F.K.C.S., F.F.P.S.G., 

OF LEYDENSTONE, ENGLAND. 

It is the sudden pulses of judicious criticism 
ther than the orderly vibrations of unqualified 
iproval that best enable us to distinguish the 
■ms of true knowledge from the paste of pre- 
rlogical assumption : I therefore invite your 
:icism of the experimental data that form the 
.sis of the present comnumication, in the hope 
at a full fliscussion may lead to the improve- 
ent in instrumentation which we all so much 
isire. 

Without entering upon the vexed question of 
e very problematic advantages and more mani- 
st disadvantages of employing oscillatory cur- 
nts of low tension but large amperage in thera- 
;utics, it may without fear of contradiction be 
iserted that the demand of the moment is for a 
gh frequency machine, whose output of current 
ill approximately equal, if not even exceed, one 
npere: I purpose, therefore, to consider in 
•ief detail some of tlie physical data which have 
bearing upon the subject, and in so doing, inci- 
:ntally to point out certain other details in 
hich construction can be improved. 

I will not waste valuable lime in imposing on 
)ur attention the explanatory details of the two 
lethods by which an alternating current of high 
equcncy can be generated, for every student 
[ electricity is familiar with these. He is also 

I Read before the Roentgen Society of London on Februarv 
1905. 



aware that the mechanical process was first in 
the field in order of time, and that it has ever 
since exhibited strong tendencies to somniscence 
from which it has lately been aroused by the 
superlative resuscitative efforts of Mr. W. Dud- 
dell and Herr E. Ruhmer. I will not, however, 
venture to predict the results of this new revival, 
nor claim a "great and glorious future" for these 
machines; as I fear that my efforts to shine as 
Saul among the prophets of high frequency would 
only convince }ou that my lips at birth were not 
graced by the silver spoon of prophecy — a fact 
of which I personally am well aware. 

It may, however, be advantageous to recall 
stuidry details connected with the electrical proc- 
ess of generation. Most modern text-books of 
electricity are careful to insist on the oscillatory 
character of condenser-discharges, and to detail 
in a ver)- methodical manner the limiting circum- 
stances ; some go further and point out the condi- 
tions under which the spark-discharges of an 
induction coil or static machine can participate 
in these peculiarities ; a few even venture to dis- 
cuss the advantages that accrue from the com- 
bined use of an induction coil and condensers 
as a source of oscillatory currents : but the num- 
ber of those which afford a scientific explana- 
tion of the phenomena of spark-discharges is 
extremely limited, although it is the theory of 
spark-discharges alone which can furnish us with 
the much-desired clue to further improvements 
in high frequency instrumentation. 

The manuals of electricity, which purport to 
teach the young idea how to shoot, proclaim more 
or less loudly the disruptive nature of a spark- 
discharge. They talk learnedly about the poten- 
tial difference between the electrodes producing 
a stress, to which the dielectric resistance of the 
gaseous contents of the air-gap eventually suc- 
cumbs, and by so doing allows a spark to pass. 
Carefully analyze this statement, and you will 
find that it essentially consists of a verbal para- 
phrase — a restatement in scientific terms — of a 
fact of observation, and as such affords no real 
explanation of the cause of the phenomena, nor 
yet a valid answer to the question, "What con- 
veys the current ?" 

\\'itliout superlative conceit one might imagine 
that this oft-reiterated assertion would cease 
when attention was called to the error, l^nfor- 
tunately, human nature is not built on these lines, 
and the poet, Moore, with a deep knowledge of 
human frailty, asserts that : 

" Of all the concatinations of sound, about which 
tlie world makes a pother. 
None with so much glory redound as when one 
blockhead re-echoes another," 

To return to our muttons — it may be said that 
the ionic theory of electrical conduction, which 
is the bed-rock of physical chemistry, affords 
us the best answer to the question : "What con- 
veys the current?" for it recognizes that the air 
must be converted from an insulator into a con- 



April is, 1905I 



WRIGHT: HIGH FREQUENCY MACHINES. 



679 



ductor before a curent can pass — in other words, 
that ionization is essential as an antecedent to 
electrical conduction. 

I need not remind you that the movement of 
an electric current through an electrol>tic solu- 
tion is accompanied either by the revolution of 
gases at the electrodes, or by the deposition of 
substances held in solution about thest- two points. 
To explain electrolytic conduction we are rlrivcn 
to hypothecate the existence in the solution of 
free ions, which act as carriers of the current. 
The question is : "Whether this idea of free ions 
can be applied to substances in the gaseous state, 
so as to explain the conduction of electrical dis- 
charges through them?" 

Let us institute a comparison between the two 
cases. In dealing with an electrolytic solution, 
we are accustomed to regard the solute rather 
than the solvent as the chief source of free ions. 
and we speak of the dissociation of the mole- 
cules of the electrolyte, meaning thereby the 
solute, as having been produced by the action of 
the solvent upon them. Now, in the case of an 
absolutely pure elementary gas, what is it that 
promotes dissociation? From whence are the 
free ions derived ? Do all pure substances in the 
gaseous state contain free ions? These are 
questions we may well ask ourselves. 

Let us regard some pure elementary gas as 
being alone present in the air-gap, and see 
whether we can learn anything regarding its 
electrical properties. Now, the researches of 
Thomson, W'arburg, Strutt and others have 
shown that a perfectly pure elementary gas is in 
an electrically unstable state, and when perfectly 
dry and freed from all traces of contamination, 
will stand a potential difference several times as 
great as is ordinarily required to produce a spark- 
discharge through one less scrupulously freed 
from contamination. It is evident, therefore, that 
such gases must contain a minimum of free ions 
and that the tendency to electrical instability is 
reduced by admixture with a small quantity of 
aqueous vapor or by traces of other gases pres- 
ent in it as a contamination. 

Further, we notice that if the gas employed be 
enclosed in a glass tube (fitted with fixed elec- 
trodes and connected with an exhaust pump), the 
sjiark-potential diminishes as the pressure of the 
contained gas is reduced, until the critical spark- 
length is arrived at. It is evident, therefore, 
that diminution of pressure within certain limits 
favors ionization. The superheating of gaseous 
compounds has been also found to promote dis- 
sociation. .\re we then to suppose that ionization 
of the air in the spark-gap proceeds from either 
of these causes? Not necessarily; for there are 
other influences equally, if not more, potent to 
which it can more reasonably be ascribed. What 
then are the factors which promote dissociation 
of the gaseous molecules in the air-space? 

Let us proceed in an orderly manner, and arri\c 
at a difterential diagnosis of the cause by the pro- 



cess of exclusion. As the terminal knobs of the 
discharger are not rendered incandescent prior 
to or during the passage of the discliarge-cur- 
rent, it is evident that ionization by incandescent 
.solids is quite out of court in so far as primary 
ionization is concerned. 

.Vgain. if we regard the s]3ark-gap as enclosed 
in a perfectly fitting glazed earthenware or 
wooden bo.x, guaranteed perfectly opaque to all 
luminous vibrations, the possibility of ionization 
being due to the photo-electric effects of external 
light can also safely be excluded. We can pro- 
ceed thus through the whole category of known 
ionizers until at last circumstances compel us to 
refer it to the direct action of the electric field, 
which, before sending an electric current through 
the air-space must first render its gaseous con- 
tents conductive. How is this effected? 

All who accept the ionic theory of conduction 
admit that every electric current traversing a 
metallic conductor is essentially anionic, and it is 
the wire connected with the negative pole that 
initiates ionization of the air-space by projecting 
into it a multitude of negatively charged par- 
ticles — the electrons. These, in their onward 
movement, collide with the molecules of the gas, 
and by so doing promote their dissociation. This 
can be readily substantiated by noticing that the 
photo-electric effects of light, more particularly 
ultraviolet light, are mainly exerted upon the 
negative pole, a point which has been established 
by the experiments of Hertz, E. Wiedemann and 
Ebert, Swyngedauw. Warburg and others. War- 
burg ascribes this efifect to the diminution of the 
"/a.<^" rather than to any direct influence upon 
the "spark potential." 

Again, if the air present in the spark-gap be 
at ordinary atmospheric pressure, the number of 
undissociated molecules present must be rela- 
tively great. The electrons, therefore, will not 
have to travel far before they encounter an undis- 
sociated molecule ; consequently ionization of the 
air-space must primarily be restricted to the 
immediate neighborhood of the cathode. Here 
the positive ions produced by the disintegration 
of the molecules tend to accumulate, and by so 
doing to favor the evolution of a further dis- 
charge of electrons. Meanwhile, their electro- 
negative better-halves, in moving anodeward. 
are brought into collision with other undissoci- 
ated molecules. Once the process of ionic frac- 
tionation of the gaseous molecules in the spark- 
gap has sufficiently advanced to render the air 
conductive, a spark passes. 

With the passage of the first spark, an imptir- 
tant alteration in the medium of electrical con- 
duction takes place. Schuster and Hemsalecb 
have shown that if the sparking distance be not 
too great, it is only the first spark of a con- 
denser discharge which passes through air; the 
succeeding ones all pass through a medium com- 
posed of the vapor of the metal of which the ter- 
minals are formed. Further, the introduction of 
self-induction into the discharge circuit tends to 



WRIGHT: HIGH FREQUENCY MACHINES. 



[Medical News 



banish the air Hues from the spectrum of the 
spark and to render the metal Hnes more bril- 
liant ; for self-induction, by increasing the time 
during which the oscillations last, allow time for 
the volatilized metal to become uniformly dif- 
fused throughout the air space. Having reached 
the stage where the successive sparks traverse 
an atmosphere of metallic vapor, let us consider 
the factors now at work in producing and main- 
taining ionization. 

You will doubtless remember that the heating 
effects of a spark-discharge greatly exceed that 
of the electric arc, and that elevation of tempera- 
ture facilitates the splitting of the molecules. 
This is a factor of great importance. It is need- 
less to add that the rarification of the vapor in the 
spark-gap promotes the more efficient discharge 
of electrons, and allows them to acquire a greater 
velocity. In this aerially constituted Crookes' 
tube tlie velocity acquired by the positive ions in 
traversing the Crookes' dark-space is accelerated, 
and so promotes further ionization. Nor are we 
yet at the end of our list of possible causes ; there 
are still others, among which the folowing 
deserve notice : 

(a) Ultraviolet Rays. — These are generated 
by the spark in quantities which depend some- 
what on the nature of the substance used to form 
the electrodes. Projected upon all surfaces in 
the vicinity, a certain proportion of the rays find 
their way back, by reflection, to the negative pole, 
and so diminish the lag. 

(b) Derma Rays. — These pulses are caused 
by the acceleration of all charged ions under the 
influence of the electric field. They are the ana- 
logues of the secondary and tertiary Roentgen 
rays noticed by Perrin, Sagnac, Roentgen, Lan- 
gevin, Townsend and others. Hoffmann has 
proved that they possess a remarkable capacity 
for ionization. 

(c) Entladung.strahlen. — These are better 
known to us in England as Townsend's easily 
absorbed radiation. In America they constitute 
what is known as the "Piffard" rays. They are 
probably ether vibrations ; they undergo no deflec- 
tion in a magnetic field, excite thermo-lumines- 
cence, and bv ionizing the air discharge and 
electroscope even when positively charged. They 
are generated in the greatest abundance when 
the sparks pass between aluminum terminals, and 
the ionization they cause lasts several minutes 
after the cessation of the discharge. 

It is obvious, therefore, that in proportion as 
the ionization of the gaseous contents of the 
spark-gap advances, the dielectric resistance of 
the air is reduced : so that with a constant spark- 
potential the output of current becomes greater. 
Without dilating upon so self-evident a proposi- 
tion, we may, as time presses, pass on to the 
consideration of certain other experimental data, 
which have a bearing upon electrical conduction. 

The first of these to which I .shall draw atten- 
tion is Prof. Slaby's experiments to determine 
the proportional conductivity of single versus 



multiple spark-gaps. The following procedure 
devised by him was employed in the experiments : 
An oscillatory circuit was formed by connecting 
in series two spark-gaps (the one of fixed, the 
other of variable length), along with a condenser 
and inductance, a graphite rod which serves as a 
variable resistance, and a delicate hot wire mill- 
iammeter. To prevent the final potential of the 
fixed spark-gap from being affected by altera- 
tions in the length of the variable spark-gap, the 
latter was shunted with an electrolytic resist- 
ance. Ammeter readings were taken with the 
variable gap at different lengths from zero 
upward the current was thus obtained as a 
function of the spark-length. In the next series 
of experiments the graphite resistance was 
brought into play, and its length altered so as to 
compensate for the decrease in the length of the 
variable spark-gap, a new series of records were 
then obtained. When plotted at equal ordinates, 
these two curves gives the resistance of the 
spark-gap in ohms. 

Prof. Slaby's results plainly proved that the 
resistance rose parabolically for small lengths, 
and then increased linearly. It was likewise 
noticed that increased capacity, which is tanta- 
mount to diminished oscillation frequency, pro- 
duces a diminution in the resistance per mm. 
of air space at all lengths. By plotting the con- 
ductance of the air-gap on an oscillation period 
base, it was found that as the frequency dimin- 
ished, the conductance also fell, at first linearly, 
then much more rapidly, so that for all periods 
small spark-gaps were more than proportionately 
better conductors than a longer air-space. For 
instance, the effective resistance of a gap of lo 
mm. under a discharge potential of 30,000 volts 
amounted to 13 ohms, while that of three gaps 
of 2.5 mm. each when coupled /;; series did not 
exceed 0.6 ohms with the same discharge volt- 
age. These experiments point to the fact that 
there is a distinct gain in amperage by the use 
of the multiple spark-gap. 

The second point to which I will refer is culled 
from a communication made by Herr W. Weicker 
to the Elektrotcehnisehe Zeitschrift for Novem- 
ber 3, 1904. He has shown that the relation 
between air-gap and disruptive voltage only fol- 
lows the straight line law, when the discharge 
takes place between points. When, however, 
metallic spheres, such as the knobs of a dis- 
charger, are employed, the character of the plie- 
iiomenon depends upon the way in which the 
knobs arc arranged. In these are placed verti- 
eally, i.e., one above the other, there are two dis- 
tinct disruptive voltages for any air-gap between 
^)5 mm. and 160 mm. For a gap of 150 mm. the 
voltage approximately are 57,000 volts and 
^2,500 volts. When the knobs are arranged 
horizontally, the law is represented by a single 
curve with irregularities. This furnishes tis 
with the clue to the proper arrangement of the 
li.ills in the multiple spark-gap. 

The third matter that I consider deserving of 



April is, 1905] 



WRIGHT: HIGH FREQUENCY MACHINES. 



681 



notice is the results recorded in Warburg's paper' 
as to the action of ordinary daylight in producing 
an appreciable decrease in the lag. In spite of 
the volumes of very pretty talk about silent 
spark-boxes and of deadening noise by enclos- 
ing the spark-gap in a wooden box lined with 
felt, I ask you to remember that in preparation 
as you prevent external light from acting upon 
the spark-gap do you sacrifice efficiency. In 
commenting upon Warburg's paper. Prof. J. J. 
Thomson says, "In the dark the spark does not 
always pass even when the potential difference 
is nine times that required to produce a spark 
when the field is continuous ; in the arc light a 
potential difference, only a little greater than the 
minimum required to produce a spark, is always 
effective ; daylight also produces a very percep- 
tible diminution of the lag. Now, if you use the 
multiple spark-gap, you will not have inuch rea- 
son to complain of noise, and in so doing you 
obtain relative silence without any sacrifice of 
efficiency. 

The fourth question that calls for an answer is 
"Of what size must the spheres be that form the 
knobs of the multiple spark-gap? Is it better to 
use large or small knobs? Now, the results of 
Bailie's - and Paschen's ^ experiments have been 
analyzed by Schuster, who has, by the aid of 
Kirchhoff's Theorem of Electrical Distribution 
over Spheres, shown that the more irregular the 
electric field (i.e., the smaller the spheres), the 
greater is its maximum electric intensity before 
the spark passes. It must, however, be remem- 
bered that inequalities in the electric field between 
small electrodes is reduced but not altogether 
annihilated by the process at work during the 
lag. 

The fifth proposition to be considered is "Have 
we any reliable guides that will help us to deter- 
mine the nature of the substances to be used to 
form the electrodes?" Now the experiments of 
De la Rue and Hugo Miiller * have shown that 
sparks pass more readily between aluminum 
or magnesium electrodes than between those 
formed of any other metal. The explanation of 
this phenomenon is that the spark potential, 
which has a very close relation to the cathode 
fall of potential, is to some extent determined by 
the absorption capacity of the metal for hydro- 
gen, and is inversely proportionate to the amount 
of disintegration produced in unit time by incan- 
descence. The advantages which aluminum 
electrodes offer as a source of very efficient 
ionizing spark-gap radiations must here be taken 
into account. 

The sixth point that demands our attention 
is Thomson and Mey's observations as to the 
abnormally small cathode fall of potential 
noticed when the electrodes are new, and the 
subsequent increasing drop with prolonged use. 
Warburg ascribes this effect to the presence upon 

1 Sitz. A Rad. der Wissenschaften. Berlin XII, \>. 22,!, 1R06. 

2 Annales de Chimie et de Physique (5), XXV, p. 486, 1882. 

3 Wied. Ann., xxxvii. p. 79. 1889. 

4 Phil. Trans., 139, Part I, p. 93, 1898. 



the new electrodes of a microscopically thin 
layer of oxide which is removed by the disin- 
tegration which goes on during use. Thomson 
has shown that there is very little disintegration 
of aluminium electrodes in nitrogen and air, but 
a large amount in monatomic gases, such as 
helium, argon, and mercury and cadmium vapor. 
Even a trace of oxygen present as a contamina- 
tion in nitrogen, seems to increase disintegration 
to an appreciable extent. This effect of oxygen 
is in some measure reduced by aquous vapor 
when present in minute quantities, but not alto- 
gether prevented. It is evident, therefore, that 
the current efficiency of the spark-gap can be 
maintained only by the periodic replacement of 
the old disintegrated knobs by freshly burnished 
spheres. 

The effects upon spark-potential of the nature 
of the gases in the spark-gap has long engaged 
the attention of physicists. Compound gases and 
the halogens in which dissociation can very read- 
ily be produced lower the spark-potential ; but 
their effects upon the electrodes have to be con- 
sidered. Natterer found that among elementary 
gases the spark-length was superlatively greater 
in monatomic vapors (for the same potential- 
voltage than in those of other valencies. The 
ratio of potential difference between the elec- 
trodes in air as compared with N, H and O are 
as follows: 34 : 25 : 20 : 32. Arons has 
observed that a variation results from the altera- 
tion of the metal used to form the electrodes. 
For aluminum terminals, the spark-potential in 
air as compared with nitrogen is as 13 : 9. The 
advantage of employing pure nitrogen is there- 
fore obvious. 

Faraday's experimental researches have shown 
that there is a distinct advantage in imprisoning 
the gas in the spark-gap and preventing its dif- 
fusion into the surrounding air. The electrical 
instability of a gas, ionized by the passage of a 
spark, is not in such a case entirely abolished 
till several minutes have elapsed. In an exposed 
spark-gap, on the other hand, diffusion rapidly 
takes place, and a fresh supply of unionized air 
obtrudes itself between the terminals of the dis- 
charger. I may incidentally refer to a question 
that may have engaged the attention of some here 
present. It is, whether there is any advantage 
in using a compressed air spark-gap. The 
answer must be a most emphatic negative. It 
is not the dielectric resistance of the air, for 
this only serves to increase its capacity for insu- 
lation, but the dissociation of the gaseous mole- 
cules produced by ionization which directly fav- 
ors conductivity, and by so doing increases the 
output of current. The only reasonable plea that 
has been brought forward for the compressed-air 
spark-gap is that it imprisons the gas already 
acted upon and rendered conductive by the spark, 
and prevents its diffusion. The same, however, 
can be done by imprisoned air at normal or 
slightly subnormal atmosphere pressure without 
any such sacrifice of efficiency. 



682 



WRIGHT: HIGH FREQUENCY MACHINES. 



[Medical News 



In summarizing the experiments which have 
a bearing on the proper construction of an 
efficient spark-gap, allow me to say : 

To obtain the maximum discharge it is nec- 
essary to employ a multiple spark-gap, whose 
discharging knobs are spheres of polished alum- 
inum arranged horizontally. A leak must also 
be provided between the adjacent spheres. This 
may be an electrolytic solution of high resist- 
ance, but it is more satisfactory to employ a coil 

Fig. I. 




of self-induction. To protect the knobs against 
rapid deterioration with use. the entire spark- 
gap may be hermetically sealed in a crystal globe 
or glass egg filled with absolutely pure anhy- 
drous nitrogen. Such a spark-gap is diagram- 
matically represented in Fig. i. 

Remember that if spark-potential determines 
the amperage of the derived current, it is the 
capacity of the condensers that influences its 
frequency. Tf you desire to vary the frequency 

Fig. 2. 




of the currents you must employ condensers of 
variable capacity. 

In the paper giving the results of my experi- 
ments to determine the effects of form and wind- 
ing on resonance phenomena, I incidentally men- 
tioned the fact that the capacity of a condenser 
could be varied by altering the relation of the ar- 
matures to each other. This can be done either by 
raising or lowering one armature so as to alter 
its position with respect to the other, or by rota- 
ting it through an arc, less than a semicircle. 



This principle applies both to the case of the flat 
condenser and that of the Leyden jar. Figs. 2 
and 3 w"ill show you how this is effected. In 
Fig. 2 the area of the electrically-opposed con- 
densatory interfaces is altered by raising or low- 
ering one armature while leaving the other unal- 
tered. In Fig. 3 the same result is arived at by 
the rotation of one armature with respect to the 
other. 

This procedure will allow you to produce a 
variation within very extensive limits — limits 
fixed only by the maximvmi capacity of the two 
armatures when in perfect electrical apposition 
to each other. 

It is not enough, however, to look to your 
spark-gap and condensers, while leaving the 
metallic connection between them a prey to the 
errant winds of fancy. You will remember that 
in proportion as the frequency of an alternating 
current becomes greater the more does the current 
tend to confine itself to the surface of the con- 
Fig. 3. 




ducting wire. In a current of very high frequency, 
like that generated by the oscillatory discharge 
of condensers, the so-called skin resistance has 
to be provided for. This necessitates the use of 
hollow metallic tubes to connect the internal 
armatures of the condensers with the spark-gap. 
You are thus able to conserve a maximum of the 
current and convey it by induction into the cir- 
cuit of utilization. 

One other point. See that the wires leading 
from the secondary of your transformer or 
induction coil are connected directly with the two 
outermost knobs of your multiple spark-gap, and 
not to the rod leading to the internal armatures 
of your condensers. As I am afraid I have 
already exceeded my space limit I will not go 
into the whys and wherefores of this question, 
which complete mv remarks on constitutional 
details of the circuit of generation ; I shall leave 
to some future occasion the consideration of 
improvements that can be made in the circuit of 
utilization. 



April 15, 1905] 



COAKLEY: STOVAINE. 



683 



REPORT ON THE USE OF STOVAINE.i 

BY C. G. COAKLEY, M.D., 

OF NEW YORK. 

Stuvai.m-; was discovered by M. Forneau of 
Paris, in studying the properties of the amino 
tertiary group. It is a hydrochloride of 
a-dimethylamine /3-benzoylpentonal. 

Chcutical Properties. — Stovaine crystallizes in 
small brilliant scales, melting at 175° C, and is 
extremely soluble in water, methyl alcohol and 
acetic ether. Absolute alcohol does not dissolve 
more than one-fifth of its own weight. It shows 
slightly acidic properties to litmus, but is neutral 
to methyl orange. 

Its aqueous solutions are precipitated by all al- 
kaloidal reagents, and are sterilizable by heat. 
On being toiled for a long time (say for an hour) 
the dissolved stovaine is not altered in any re- 
spect, and after evaporation is found to be intact. 
These solutions do not suffer decomposition at 
a temperature as great as 115° C, when boiled 
in a sterilizer for twenty minutes, but at 120° C. 
they slowly decompose. 

Briefly, the stability of stovaine is so superior 
to that of cocaine that no comparison exists be- 
tween the two products in this respect. 

The writer can attest to the fact that frequent 
boiling of a ten per cent, solution has not dimin- 
ished its local anesthetic properties. 

Five grams of stovaine were received on Janu- 
ary 12 of this year. The entire amount was dis- 
solved in 50 c.c. of sterile normal saline, thus 
making a ten per cent, solution. This was kept 
as a stock, some of which was applied to the nose 
or throat, where operative procedures were un- 
dertaken. From it also a 2 per cent, solution of 
stovaine was prepared for use as a spray in the 
nose and throat for diminishing the sensibility 
of the parts in the usual manipulations necessary 
for purposes of diagnosis. 

Two similar solutions of cocaine — one a ten 
per cent, and the other a 2 per cent. — were em- 
ployed for the purposes of comparison. 

Most of the minor operations common in of- 
fice practice occurring in our specialty have been 
performed under both cocaine and stovaine dur- 
ing the past six weeks. In all cases where two 
operations have been done on the same patient, 
stovaine was used in one and cocaine in the 
other, under as nearly as possible similar condi- 
tions. Careful questions were asked of each pa- 
tient to determine which was the better anesthetic 
and which gave the least disagreeable symptoms. 

My observations have led me to the following 
conclusions : 

1. That stovaine as a local anesthetic is ap- 
parently equal to cocaine. 

2. That the time necesary for acquiring local 
anesthesia is the same as that of cocaine. 

2. That it apparently does not contract the 
nasal mucous membrane to so great an extent as 

I Read before the Section on Laryngology, New York Acade- 
my of Medicine, February 22, 1905. 



do similar solutions of cocaine. This is at times 
a disadvantage when the nasal passages are de- 
sired to be widely opened for more thorough in- 
spection of the cavities; on the other hand, it is 
oftentimes an advantage, as in snaring of redund- 
ant tissue by not too greatly shrinking it, and 
therefore making it more easy to be removed. 

4. Stovaine does not produce nearly so great 
a sense of constriction in the pharynx as that 
which is produced by cocaine. In this respect 
it has a decided advantage over cocaine, especially 
in those patients to whom the symptoms of con- 
striction with constant desire to hawk and re- 
move a supposed foreign body are very distress- 
ing. 

5. Solutions of stovaine have a peculiar odor 
of stale fish, which has been annoying to some of 
the patients. 

6. Some of the patients have complained that 
solutions of stovaine are more bitter than similar 
solutions of cocaine. 

7. We have seen no toxic effects following the 
use of stovaine ; there have been no secondary 
headaches or feeling of lassitude after the local 
anesthetic effect of the drug has disappeared ; I 
am also of the opinion that the secondary swell- 
ing of the mucous membrane following the use 
of stovaine is less than that which occurs after 
cocainization. 

8. It is but fair to say that during this period 
when cocaine was employed we had no case of 
marked cocainism. 



ON THE TREATMENT OF CHRONIC OSTEOMY- 
ELITIS AND OF CHRONIC BONE CAVITIES 
BY THE IODOFORM WAX FILLING.^ 

BY CH.\RLES A. ELSBERG, M.D., 

OF NEW YORK; 
ADJUNCT ATTENDING SURGEON, MOUNT SINAI HOSPITAL, NEW YORK. 

It is a basic principle in surgical technic never 
to leave cavities or dead spaces in a wound if it 
can be avoided. In most cases where we leave 
behind cavities, these have collapsible walls, so 
that, after a short time, the walls come into con- 
tact with each other and the space becomes ob- 
literated. As examples of cavities of this kind 
may be mentioned the bed from which a tumor 
has been removed or the dead space left after the 
evacuation of the contents of an abscess. Some- 
times a part of the wall of the cavity is rigid, as 
in the chest after an empyema operation; we then 
seek to make the cavity smaller by causing the 
maximum of expansion of the lung, and if this 
does not suffice, we resect a number of ribs so as 
to collapse the soft parts of the chest wall and 
thus obliterate the space that has remained. 

It is far different, however, with cavities left 
ill the bones, and more especially in the long 
bones after operations for disease in those struc- 
tures. Bone cavities have rigid, unyielding walls, 
in which blood and secretions are only too apt 

I Read at the February Meeting of the Surgical Section of the 
New York Academy of Medicine. 



684 



ELSBERG: CHRONIC OSTEOMYELITIS. 



[Medical News 



to collect and stagnate and to serve as a nidus 
for bacterial growth. In deficiencies in the bony 
skull, osteoplastic methods are often successful, 
but in the case of the long bones, they are seldom 
feasible. In the majority of the cases, these cav- 
ities in the long bones have to heal by the slow and 
tedious process of granulation ; repeated opera- 
tions and months of treatment are often necessary 
to obtain healing. The best way to keep these 
cavities relatively aseptic and thus favor the 
growth of healthy granulations is to change the 
dressings as infrequently as possible. 

From the very earliest times, attempts have 
been made to obliterate these cavities by filling 
them with tissues from some other part of the 
patient's body, or by the introduction into them 
of foreign substances. Large pieces of bone or 
bone chips, muscle or fat were taken from one 
part of the patient's body and introduced into the 
cavity, but successes were few and failures many. 
Later, the moist blood clot method of Schede was 
highly recommended. The good results with the 
method were, however, rare and the procedure 
has been almost entirely abandoned. The skin 
flap method recommended by Neuber has occa- 
sionally yielded good results, but in many cases 
there is not sufficient skin for the formation of 
satisfactory flaps. Bone derived from animals 
and prepared in a number of ways was next tried 
but without success. Attempts were made to fill 
the cavities with a variety of foreign substances 
such as glass, ivory, rubber, cork, lead, sponge, 
celluloid, plaster-of-Paris, gold-foil, copper amal- 
gam, gelatin, etc., but satisfactory results were 
obtained in only exceptional cases. The mate- 
rials introduced almost always acted as foreign 
bodies, caused increased secretion and suppura- 
tion, and were either extruded or had to be re- 
moved. 

During the last three years, Mosetig-Moorhof, 
of Vienna, and his assistants have published the 
results that they have obtained with an iodoform 
wax filling for bone cavities. Impressed by the 
claims of these authors, the writer determined to 
give the method a trial. 

The steps of the procedure as described by 
Mosetig-Moorhof, are the following: The limb 
is prepared in the usual manner and rendered 
bloodless by the Esmarch constrictor. The bone 
is exposed, the periosteum turned back, and all 
diseased bone removed with the chisel, spoon, etc., 
until the walls of the cavity are formed by healthv 
bone. The cavity is tlicn thoroughly washed out 
with sterile salt solution, and its walls rubbed 
with sponges wet with two per cent, formalin so- 
lution. The bleeding from the bone is next 
stopped by hot irrigation, the insufflation of ster- 
ilized hot air, and tight packing with gauze. The 
soft parts are now carefully examined, all dis- 
eased skin, sinuses, etc., excised, until the wound 
in the soft parts is formed by healthy tissue. As 
soon as the bleeding from the bone has entirely 
ceased the filling is introduced. This filling con- 
sists of a mixture of 60 parts of iodoform, 40 



parts of spermaceti and 40 parts of sesame oil. 
The mixture is prepared by heating the sper- 
maceti and the oil of sesame over a water bath 
for one-half hour, then adding the iodoform to 
it, and preserving the mixture in a sterilized bot- 
tle or special retainer. When the filling is to be 
introduced, the mixture is melted by immersing 
the bottle in hot water , and while still fluid is 
poured into the cavity, until the latter is entirely 
filled. Within a few minutes the mixture 
solidifies. The periosteum, or, if this is im- 
possible, the soft parts are closed over it, 
the skin wound closed with or without drain- 
age, and a dry compression bandage applied. 
The Esmarch constrictor is then removed. The 
wound is dressed after seven to ten days and 
in the majority of the cases will be found to have 
healed by primary union. If the wound has been 
drained, which is advisable in most cases, the 
sinus left will heal in the course of a few weeks. 
In a certain number of the cases, the wax mix- 
ture is slowly extruded in the course of several 
weeks by the active growth of new tissue around 
it, and the mixture seems to act as a powerful 
stimulus to this growth. Iodoform poisoning was 
never seen, in spite of the large percentage of 
that substance in the mixture, as the iodoform is 
very slowly absorbed out of the filling, but traces 
of iodine were sometimes to be found in the urine 
for the first two or three days after the operation. 
Healing usually occurred without much elevation 
of temperature or pulse, although occasionally 
there was observed a marked rise of both temper- 
ature and pulse for one or two days. 

As a result of his investigations and experi- 
ments on animals, Mosetig-Moorhof was able to 
determine that the wax mixture slowly disappears 
as new tissue grows into it from the bone, and the 
gradual disappearance of the mixture could be 
nicely followed in X-ray pictures. 

Mosetig-Moorhof declares that his method is 
applicable to all forms of chronic bone disease in- 
clusive of the tuberculous variety, and also to 
chronic tuberculous affections of the joints, but 
the method is not applicable to acute bone disease 
in which the cavity cannot be rendered aseptic. 
In order to insure successful results, great care 
must be observed that the walls of the cavity shall 
consist of healthy bone, and that the soft parts 
of the wound shall bo thoroughly freshened ; the 
oozing from the bone must be very carefully 
stopped before the wax mixture is inserted, so 
that no blood shall collect between the wax mix- 
ture and the walls of the bone cavity. 

During the past year, the writer has used 
this method on the surgical service of Dr. 
Lilienthal at the Mount Sinai Hospital in three 
cases of chronic osteomyelitis of the hip; four of 
chronic osteomyelitis of the femur, one of tuber- 
culous disease of the tibia, one of chronic disease 
of the ulna, and one of chronic tuberculosis of the 
bones of the elbow-joint. All of the patients had 
been repeatedly operated upon in various hospi- 
tals, including our own, without permanent cure. 



April is, 1905] 



ELSBERG: CHRONIC OSTEOMYELITIS. 



685 



The results that I have obtained with the 
method of Mosetig-Moorhof, although not as 
good as those of this author, have shown much 
improvement over former methods of treatment, 
so that I feel warranted in recommending the 
method for further trial. I think it probable that 
with increasing experience the various steps of 
the method may be much improved upon. 

It is better to remove the Esmarch constrictor 
from the limb before the wax mixture is intro- 
duced so that the hemostasis in the bone cavity 
may be more perfect and the oozing from the 
bone be perfectly controlled when the normal cir- 
culation is established. In the second place, 
I have not made use of dry hot sterilized air in 
controlling the oozing from the bone cavity be- 
cause this required more complicated apparatus 
than I had at hand. The bleeding has been en- 
tirely controlled in our cases by irrigation with 
hot saline solution, irrigation with peroxide of 
hydrogen, and packing of adrenalin and dry ster- 
ile gauze. In our cases the wax mixture often 
did not harden as quickly as claimed by Mosetig- 
Moorhof, and considerable time was often lost 
in waiting for the mixture to become firm. Dur- 
ing this time slight oozing was apt to occur from 
the bone and to leak through the mixture while 
it was still semi-fluid. Even if the filling seemed 
fairly hard, the central portions were still soft, so 
that considerable of the softer portions of the 
filling were squeezed out when the soft parts of 
the wound were being closed, and the solidity of 
the filling was thus rendered imperfect. I now 
pour the melted mixture into a basin of sterilized 
cold water and mold it with the hands until it has 
about the consistency of putty. I then press bits 
of the mass into the walls of the cavity and thus 
stop the very slightest oozing from the bone and 
fill up all small spaces (in the same way that we 
use Horsley's bone wax in cranial surgery). 
When this has been done, the cavity is lined by a 
thin layer of wax and is absolutely dry. Then 
the cavity is tightly packed with the filling in the 
same way that the dentist fills a cavity in a tooth. 

I have never used more than 20 per cent, of 
iodoform in the wax mixture because in my ear- 
liest cases I had one of well-marked iodoform 
poisoning. I have tried also to use a mixture of 
iodoform and spermaceti without the oil, and a 
mixture of iodoform and paraffin without the oil, 
but the results have not been as good as those 
obtained with the mixture of equal parts of sper- 
maceti and oil containing 20 per cent, of iodo- 
form. 

In three of the cases here reported there was 
a considerable rise in the temperature and pulse, 
after the operation, which lasted for from two to 
four days. All but two of the patients had small 
quantities of iodine in their urine for one or two 
days after the insertion of the filling ; in one case 
there were marked symptoms of iodoform poison- 
ing for twenty-four hours. The patients almost 
uniformly complained of a burning sensation in 
their wounds for a few days but thereafter de- 



clared that they felt better than after any one of 

their previous operations. 

In six patients, the wounds healed by primary 
union except for the drainage opening. In four 
of these cases, the filling remained in situ ; in one, 
a small part of the wax was extruded and the 
wound then healed up ; in the sixth case, all of 
the filling was extruded in the course of two 
weeks and the wound then rapidly closed. 

In a patient who had a large cavity occupying 
almost tlie entire tibia, the result of a tuberculous 
osteomyelitis and numerous operations, I intro- 
duced the filling, but was able to close only about 
two-thirds of the wound in the soft parts. The 
wax filling remained in place for about two 
weeks and was then gradually pushed out of its 
bed by the active growth of granulations around 
it. The shell of bone that was left was very thin 
and during the manipulations incident upon the 
last operation a fracture had occurred. At the 
end of four weeks the fracture was firmly healed, 
and six weeks later, the large wound was entirely 
healed and the cavity was filled with new tissue 
so that the scar was hardly depressed. During 
the healing, the discharge was serous or sero- 
purulent in character and small in amount. This 
case demonstrated the powerful stimulating ef- 
fect of the mixture, and the rapidity of growth 
of new granulation tissue. I have observed this 
same effect in other cases. In three of the cases 
that I operated upon the method resulted in fail- 
ure. One patient had a large cavity in the lower 
end of the femur after several operations for 
osteomyelitis two years before. In spite of three 
operations, I never succeeded in rendering the 
cavity aseptic; after each operation the wound 
reopened and the wax was extruded. At the 
present time, the filling inserted at the third op- 
eration is being gradually extruded with consid- 
erable purulent discharge. In a case of chronic 
disease of the ulna, the filling remained in place 
for a number of weeks, but on reopening the 
wound, at a second operation, it was found that 
a sequestrum had been left behind. After the 
last operation a sinus has persisted for four 
weeks and although no bare bone is to be felt and 
there is very little discharge, the operative pro- 
cedure must be considered a failure.^ In a third 
case, one of sinuses of the hip- joint of many 
years' duration, the wax filling gradually escaped 
and a sinus still persists. 

In the case of a child of six years, who had 
several sinuses left after resection of the hip- 
joint for suppurating tuberculous arthritis (the 
sinuses had persisted for two years in spite of 
repeated operations, so that the patient was con- 
sidered incurable), the wound was entirely 
healed three weeks after, the filling had been in- 
troduced. Owing to a misunderstanding, the lit- 
tle patient was allowed to walk around without a 
hip-splint, so that direct pressure was made upon 

I After the above was written the wound closed rapidly. It 
was healed in three weeks, and has remained healed up to the 
present time. 



(.86 



POND: EPIGASTRIC PAIN. 



[Medical News 



the wax filling. Some months later a sinus re- 
formed from which the wax is being extruded at 
the present time, but there is little discharge. 
The general condition of the child, which was 
very poor when she was operated upon, is now 
excellent, and I have little doubt that the sinus 
will soon close. This case must, however, be in- 
cluded among those in which the operation was 
not or was onl)- a partial success. 

With the exception of the cases just mentioned, 
all of the other patients have remained well up 
to the present time, the most recent case was 
operated upon two months ago and the first case 
more than three years ago. 

A careful consideration of the results that 1 
have obtained in the cases I have operated upon, 
has convinced me that the method of Mosetig- 
Moorhof is worthy of a more extended trial than 
it has received up to the present time. It must 
be remembered that the cases in which this oper- 
ation was tried were cases in which all other 
methods of treatment had failed. The general 
condition of the patients is very much improved 
because the long-standing and continual suppura- 
tion is stopped. If the operation is successful, the 
patient's stay in the hospital is much shortened. 
I'lven if the filling is extruded, the healing process 
will be much hastened. 

Success will depend to a great extent upon the 
thoroughness with which the operation is done. 
The procedure is a slow and painstaking one, and 
it is not unusual for the operation to take one to 
two hours. If the patient's condition does not 
allow of so prolonged an anesthesia, the opera- 
tion may have to be done in two stages. The 
greater the care that is taken in the preparation 
of the bone cavity for the filling, the better will 
be the results that will be obtained. I believe that 
with increasing experience, the cures obtained by 
this method of operation will become more and 
more frequent. A more detailed account of my 
experiences is reserved for a future publication. 



THE SIGNIFICANCE OF EPIGASTRIC PAIN. 



liV A. M. PONI). M.I)., 

UF WEBSTKR CITV. IOWA. 



The epigastric space is, for convenience, 
divided into right and left epigastric, or right 
upper and left upper quadrants. 

Permit me, for just a moment, to refresh your 
memory as to the anatomy of these regions, be- 
fore proceeding further. The left epigastric 
spacl' contains the largest portion of the stomach ; 
the spleen, the greater portion of the pancreas, and 
a portion of the upper lobe of the liver : the right 
epigastric region is particularly rich in anatom- 
ical considerations, containing, as it does, the 
pyloric end of the stomach, the duodenum, the 
greater jKirtion of the liver, the gall-bladder, 
the cystic, the hepatic and the common bile ducts ; 
a yiortion ni tlie ascending and transverse colon ; 
and the head of the pancreas with the opening of 
its chief duct: the duct of Wirsung. 



We can readily observe, then, by this brief 
summary, that by far the chief causes of pain 
in the epigastrium are inciilent to the diseases of 
the liver, stomach, and the gall-bladder and its 
ducts. 

So much greater are the possible sources of 
epigastric pain due to the diseases of these 
organs, that we will consider the subject chiefly 
from such standpoints ; and, first of all. I will 
consider the methods of examining patients com- 
plaining of epigastric pain. 

1 regret to note the carelessness and indiffer- 
ence shown to such patients by their medical 
attendants. When a person enters your office, 
you have every reason to believe two very im- 
portant propositions. First: He is ill, or thinks 
he is ill, and needs medical advice and attention. 
Second: He honors you by coming to your office, 
and, by so doing, he carries the inference that he 
has confidence in your medical ability, and desires 
your advice, else he wotild have applied to an- 
other on exactly the same premise. 

If, then, you give that patient the privilege of 
a thorough examination, you are not only in 
position to proceed to treat and advise him more 
intelligently, but you have substantiated and 
strengthened his confidence, which first brought 
him to you, by your careful interest in his con- 
dition, to say nothing of the benefit you have 
derived yourself by improving a clinical oppor- 
tunity, since every case, properly treated, after 
a thorough examination, presents some very in- 
teresting and instructive clinical points, which 
increase your own usefulness. 

You cannot, intelligently, tell a person the 
cause of pain in the stomach, or the epigastric 
region, by looking on the outside clothing, or 
by examining his pulse or tongue. Request the 
opportunity to see the surface of the body ; it 
may tell you much. You can note, then, if 
there are distentions or depressions, whether any 
prominences move with respiration, as in large 
gall-bladder involvements. You can note epi- 
gastric pulsation, if present ; \ou can detect 
jaundice in the portion of the body covered by 
the clothing more readily than on the face. 

Palpation reveals fully as much. It deter- 
mines whether the prominences noted are hard, 
suggesting tumors ; or soft, indicating distention 
by gas or fluid. You can usually feel the free 
border of the liver, beneath the right costal arch. 
You can. with a little practice, find the kidneys 
on either side, and it might be well to note in 
passing that the left kidney lies one-half inch 
liighcr than the right, and that the position of 
the latter is directly back of the .gall-l)ladder. 
Not infrequently, .some pathological condition 
of the kidney gives rise to epigastric pain. and. 
pressure on the .gall-bladder increasing it, one 
thinks he has a gall-bladder involvement, when, 
in fact, the trouble lies behind. 

I-"pigastric pulsation used to be considered 
pathognomonic of carcinoma or pyloric ulcer, but 
to-day we know that in spare subjects, where 



Apkil 15, 1905] 



POND: EPIGASTRIC PAIN. 



687 



the abdominal walls are thin and free from fat, 
and where the chest wall is flat, we can see, not 
infrequentl_v, epigastric pulsation when there 
is no pathological condition in the upper ab- 
domen. 

I will merely mention auscultation and per- 
cussion in passing. By auscultation we can often 
determine the metallic note of gaseous disten- 
tion of the stomach, suggesting a fermentative 
process, due to faulty evacuation of gastric con- 
tents, and we immediately think of duodenal or 
pyloric stenosis, due to the cicatrices of a former 
ulcer : or of a motor insufficiency that allows the 
stomach to sag below the point at which it can be 
emptied by its impaired contractions. Percussion 
only emphasizes and confirms tlie conditions 
found by auscultation. After a little practice. 
one can readily detect the percussion note of a 
distended stomach from a dilatation of the trans- 
verse colon, and can also recognize a normal 
area of hepatic dulness, and quickly note any in- 
creasing or diminishing of this area. 

To the laity, the teriu " stomach " includes all 
the space from the borders of the ribs to the brim 
of the pelvis, so that when one comes to you com- 
plaining of a pain in the stomach, it may be wise, 
perhaps, to ask him to put his hand on the point 
of pain. You may be surprised at his knowledge 
of anatomy, both from the standpoint of igno- 
rance, as well as intelligence, and it requires no 
small amount of nice discrimination, sometimes. 
to get any information regarding the character, 
location, duration and degree of discomfort. 

So much. then, for introduction and generali- 
ties. 

By far the commonest complaint that the phy- 
sician will hear from patients is, that they have 
" indigestion."' This expression is extremely 
vague and indefinite, for nearly all conditions of 
the stomach or biliary apparatus are associated 
with some form of indigestion, so we must draw 
out our information piecemeal, as it were. 

Much information can be assumed from the 
social and physical surroundings of patients. For 
instance: If the patient is an anemic woman in 
the first three decades of life, and is nervous, we 
are reminded of a gastric ulcer. The pain, in the 
typical case of gastric ulcer, is an acute, sharp. 
" sore " pain, which has increased on taking any- 
thing of an acid or saccharine nature into the 
stomach, is sometimes associated with vomiting, 
and occasionally with the emesis of blood or 
bloody material. The pain is occasionally (in 
about one-third of the cases) referred to a cor- 
responding point in the back, and the history will 
bring out the fact that the patient is extremely 
nervous, irritable, impatient, and altogether pet- 
ulant. The history will also show that her trouble 
is of long duration. The stools are often of a 
tarry consistency, and, upon being dissolved in 
cold water, hemoglobin can be freed. There are, 
usually, intervals (especially between meals) 
when the pain is constant and of a boring nature, 
accompanied by eructations of gas, and, at times. 



the intensely acid fluid contents of the stomach. 
They will tell you that at such times, the taking 
of some bland food, of the drinking of considera- 
ble water, will aflFord relief. The total acidity 
of the stomach contents, if examined, will be 
found to be greatly increased, some two or three 
times the normal amount. 

This condition is to be differentiated from im- 
paired motility of the gastric walls, cholecystitis, 
and carcinoma. In the first, the analogy is ex- 
tremely close. Men suffer more commonly, how- 
ever, than women, and the condition has been 
noted in all ages above twenty years. The main 
difference is in the character of the pain, the time 
it occurs, and the absence of bloody vomit or 
black stools. Impaired muscular motility, or gas- 
tric atony, is due to an innervation of the gastric 
muscle, is common in the aggressive, intense, en- 
ergetic type of people, and is the result, directly, 
of an exhaustive and bankrupt nervous system. 
The voluntary muscles and the brain have had 
more than their share, and the passive, easily im- 
posed upon stomach, has been slighted. 

The pain is more a sense of weight or oppres- 
sion, but may become a dull ache, and, at times, 
even an acute boring pain. It usually occurs mid- 
way between meals, and is more common among 
those who drink large amounts of water with 
their meals. Vomiting is rare. Patients will 
tell you that they scarcely ever vomit. Drowsi- 
ness and mental dulness is common, and also, 
not infrequently, are periodic attacks of terrific 
headaches, which are the direct result of dis- 
turbed metabolism. 

Impaired motility and gastric dilatation quite 
naturally divides itself into three general classes 
of degree and gravity : 

1. Simple atony, where the motility is les- 
sened without any corresponding dilatation, and 
where digestion is normally performed. This 
condition is accompanied by a feeling of discom- 
fort, but is not attended with nausea or vomit- 
ing, and is usually readily overcome by a tonic 
treatment aided by judicious eating, and lessened 
nervous activity. 

2. Atonic dilatation follows closely on the 
heels of simple atony. It is due to the atrophy 
of the gastric muscle, and the tone is impaired 
or lost, so that the impaired stomach is unable 
to empty itself, and sags away down into the 
abdomen, sometimes descending as far as the 
brim of the pelvis. The normal contents are in- 
creased from about three pints to four quarts or 
more. Digestion is impaired ; a lavage early in 
the morning will bring up particles of food in- 
gested the night before. This material lies in a 
line below the point of evacuation, and ferments, 
giving rise to gaseous formation which, in turn, 
(lilates the weakened muscle wall, and the dila- 
tation drags on the nerve endings, thus produc- 
ing the pain. The contents of the stomach in 
this condition is typical. Should lavage be per- 
formed, the surprise is great at the enormous 
quantities of fluid that these stomachs can hold. 



688 



POND: EPIGASTRIC PAIN. 



IMeuical News 



On emptying it, by inverting the tube, the con- 
tents form in three layers ; first, a thick, frothy 
layer, composed chiefly of yeast ferments, one 
of a dark brown hquid, and one of undigested 
detritus, sometimes containing particles of food, 
and again assuming more the form of an insolu- 
ble powder in solution. 

3. The third class is known as a secondary 
dilatation due to pyloric stenosis, contracted 
sphincter, cicatrices of old ulcers, or from in- 
flammatory adhesions, often found in associa- 
tion with the acute gall-bladder troubles. The 
symptoms are very much the same as outlined 
in the foregoing class, but are relatively in- 
creased. 

I know of no condition more common, and 
none more worthy of careful study and intelli- 
gent effort to cure. 

In the simple atony cases, the simple tonic 
treatment, as has been suggested above, com- 
bined with caution regarding diet and lessened 
nerve expenditure, will not infrequently be fol- 
lowed by gratifying results. But if a physical 
examination reveals a largely dilated and dis- 
tended stomach, the condition passes from a sim- 
ple case to an exceedingly perplexing one. 

As we have noted above, in atonic dilatation, 
there is a pathological condition in the gastric 
muscles, atrophy has robbed the muscle of its 
tonicity, and it would be foolish indeed to pre- 
sume that we can restore that tone wholly by 
medical treatment. Let us. for a moment, con- 
sider this phase of treatment. 

The capacity of the normal stomach is about 
three pints : the most dependent position of the 
stomach, after a meal, is about three inches be- 
low the pyloric opening: the contour of the 
greater curve is a gradual incline, which favors 
the emptying of the gastric contents into the 
duodenum, wlien stimulated by the contractions 
during digestion. This is easily accomplished in 
the healthy organ, because the tone of the muscle 
is sufficient to bring the most dependent position 
of the filled stomach to a point of drainage into 
the duodenum. 

In the stomach where there is an atrophic 
change in the muscle fiber, the muculattuT of the 
stomach is greatly thinned, sometimes no thicker 
than the serous or peritoneal covering; it is incom- 
petent to bring the greater curve to a point of duo- 
denal drainage, even if there were no sagging 
of the greater curve, but the lower border of the 
stomacli in this condition, instead of being three 
inches below the pyloric opening, is sometimes 
six, eight, or even ten inches helow any pos.sihle 
point of evacuation or drainage. What, then, is 
the natural result? A portion of the meal — the 
upper portion — is brought up to the level of tine 
duodenum during the active contractions of the 
stomach, which have been stimulated by the tak- 
ing of food and by mastication : at first, these 
contractions are firm and good, and a part of the 
meal is emptied into the intestine. As digestion 
goes on, however, the weakened gastric muscle 



fails to respond to the stimulus, and each suc- 
ceeding contraction becomes shallower and shal- 
lower, finally ceasing altogether. The presence 
of the unemptied contents sags the stomach to its 
lowest possible point ; this is made possible, first, 
because the impaired muscle fibers are exhausted, 
and, second, the food remaining acts as a weight, 
carrying the lower border to the limit of its lax- 
ity ; and after a time fermentation begins, by 
reason of the absence of the bile. The meal has 
been treated to the gastric ferments, but has not 
been passed on to be acted upon by the other 
juices of digestion, so that digestion, which was 
well begun, is interrupted, the fermentation gives 
rise to gas, the gas continues the process of dis- 
tention, and, by dragging on the nerve endings, 
causes pain. There is a layer of fermenting, 
gas-producing material at this time, in the bot- 
tom of the stomach. What, then, could possibly 
be the result of medicine put into that fermenting 
mass? Would it not become a part of it? If it 
stopped the fermentation, could we hope that it 
would stinuilate tone to that impaired stomach 
wall to the point of emptying itself? If we can 
reasonably hope to accomplish this by medicine, 
I can readily see a hope for these unfortimatcs 
by medicinal treatment. But, so far, in my ex- 
perience I have failed to get the results, and I 
feel that I have found the cause of my failure. 

Carcinoma of the stomach occurs in about the 
equal ratio in men and women. The age of on- 
set is usually above forty-five years, is announced 
by a rapid loss of weight, and an acute pain in 
the epigastrium ; the symptoms usually precede 
the vomiting of bloody material. The usual site 
of the carcinomas is at the pyloris, and, by recall- 
ing your anatomy, you will remember that there 
are from three to five lymphatic glands in that 
region, and we know that the cancerous process 
manifests itself either in or about the lym])hatic 
supply of a part, or develops directly in the lym- 
])hatic area. The rapid loss of weight in a per- 
son over forty-five years, with progressive ane- 
mia and symptoms of pain in the stomach, of a 
boring acute nature, with or without vomiting 
of blood, is sufficient to warrant a suspicion of 
carcinoma. 

A test meal is very valuable to eliminate the 
" guess " of your diagnosis. If you find hydro- 
chloric acid absent, with lactic acid present in 
quantities of from three per cent, to six per cent., 
and if the microscope shows muscle fibers with 
l)lood cells and the Boas-Oppler bacilli, the case 
can safely be regarded as malignant. 

We have come to regard carcinoma of the 
stomach a curable disease under certain condi- 
tions. When the test meal reveals absence of 
hydrochloric acid, the presence of lactic acid with 
hiood-cells and the Boas-Oppler bacillus, but 
where there is no tumor definable, or the tumor, 
if present, is small, an exploratory operation is 
Ihe thing to advise. If after opening the abdo- 
men, the condition be found in the early stages, 
or even in the more advanced stages, if meta- 



April 15, 1905] 



POND: EPIGASTRIC PAIN. 



689 



stasis has not occurred, much benefit and com- 
fort, and sometimes cure, apparently, follow re- 
moval of the pylorus. 

W. J. JMayo states that the average length of 
life after carcinoma can be diagnosed, is about 
205 days. The length of life after his operation 
for removal of the pylorus, is from two to five 
years of a very comfortable existence, and not in- 
frequently does death occur from some other cause 
aside from carcinoma, or the immediate results 
of its removal ; and I feel safe in prophesying 
that in the next ten years, pylorectomy, or some 
better surgical procedure, will be the recognized 
treatment for carcinoma. 

One thing is certain, if we would obtain the 
best results, we must improve our diagnosis, so 
that we can intelligently detect a carcinoma of 
the stomach before tumor formation, and if we 
can do this and confirm it by exploration, it is 
comparatively easy to convert the exploratory 
opening into an operative one, and do some sur- 
gery on the stomach. In these cases, as noted 
above, they live about 205 days, without opera- 
tion after carcinoma has been diagnosed, and 
with operation, they live from two to five years, 
so that it would appear that they have nothing 
to lose and everything to gain. 

I will not take your time here to describe the 
gastric contents examination : you can find it ac- 
curately described in the works on diagnosis. 
Suffice it to say, it is very simple. 

To summarize a few of the pains we have con- 
sidered in the foregoing: 

The pain of ulcer gives a history of long dura- 
tion, is usually in women under thirty, is fre- 
quently associated with vomiting of blood, or the 
passage of blood in the stools : the pain can be 
located by pressure, and the nervous symptoms 
are pronounced. The pain is almost continuous, 
and extends over a long period of time, is in- 
creased by taking anything acid or saccharine 
into the stomach, and is relieved by taking bland 
food, or sometimes water, during the pain occur- 
ring between meals. 

In disturbances of impaired motility, the age 
is not so conspicuous a symptom. The pain is 
not so constant, there being intervals when com- 
parative good health is enjoyed ; it is dull and op- 
pressive, more than acute. There is no history 
of nausea, in fact, vomiting is very hard to ac- 
complish. The vomitus never contains blood or 
bloody streaks, but consists of yeasty ferments, a 
large amount of dark fluid, and undigested ma- 
terial. 

In carcinoma the pain is continuous ; there is 
a rapid loss of weight, early cachexia, vomiting 
of bloody discharge, presence of a tumor, and 
rapid decline. 

Gall-bladder disease presents as many phases 
as a kaleidoscope, but there are certain points 
that serve to keep us right. The pain is of a se- 
vere colicky nature, and, as a rule, is spasmodic. 
It is not long ago w^hen we were inclined to call 
every spasmodic pain in the epigastrium, gastral- 



gia. I wish to say that by far the commonest 
cause of spasmodic pain in the epigastrium is 
gall-bladder disease. We have neuralgia only 
in the nerves exposed to trauma or to the ele- 
ments ; it is not rational to expect neuralgia to 
occur in any other locality. The pathology of 
neuralgia is wholly concerning the neurilemma; 
the outer sheath of the nerve is exposed to a low 
temperature, and when warmed the vasomotor 
apparatus is unbalanced, and a consequent hy- 
peremia occurs which congests the membrane, 
making it more dense ; this lessens the lumen of 
the nerve canal and causes pressure of the neu- 
rilla on the nerve center, and we have pain. The 
same operation occurs in trauma of a nerve, but 
this does not explain, pathologically, the occur- 
rence of gastralgia. 

I will admit the involvement of the nerves of 
the stomach from an extension of some peri- 
gastric or gastric inflammation but not simple 
neuralgia, as is commonly accepted, and I would 
advise a change in the nomenclature of stom- 
ach pains, and, in the future, spell gastral- 
gias so that they are pronounced gall-bladder 
diseases. Then, find out just what condition 
exists but do not be deluded by the gastralgia idea 
any longer. 

I have had enough surgical experience with this 
region, and I have seen enough of these condi- 
tions to convince me that the foregoing state- 
ment is, in the main, truth. 

The majority of medical men have been taught 
that there can be no liver or gall-bladder disease 
where there has been no jaundice. They put all 
their clinical significance on jaundice. This is 
faulty; jaundice occurs in about 28 per cent, only 
of all cases of gall-bladder disease, and when it 
is present, you have an obstruction of the flow 
of the bile from some cause mechanical, as in the 
case of a gall-stone, or pathological, caused by 
the closure of the lumen of the common duct by 
inflammatory process, and that clears up only 28 
per cent., or, at most, one-third of these vague 
stomach cases. Jaundice is not a necessary symp- 
tom of gall-stone disease. I consider the pain the 
most significant, and I will present it to you 
under head-lines, to endeavor to make it more 
lucid and clear. 

It occurs spasmodically at first, and is of a 
boring, twisting character. This is produced by 
an extension of inflammatory condition to the 
lining of ducts, or by the passage of a gall-stone 
through the ducts. This pain is often referred 
to the right shoulder as a tender spot ; some- 
times this spot is easily covered by a silver dollar. 
The pain is exaggerated during digestion, since 
contraction of the gall-bladder occurs synchron- 
ously with the contractions of the stomach. It 
mav completely subside and not return for many 
months, and many are carrying slumbering gall- 
stones in their gall-bladders to-day without their 
knowledge, but as long as they don't know it the 
gall-stones cannot hurt them. 

In the inflammatory conditions, especially if 



690 



MCLAUGHLIN: EPILEPSY. 



[Medical News 



associated with, or caused by. the impaction of a 
stone in one of these ducts, there will be chills 
and fever, perhaps occurring so regularly that 
you will diagnose your case malaria. I recently 
saw a patient with a very prominent man. This 
patient gave history of acute colicky spasmodic pain 
in the epigastrium, followed by chills and fever 
quite periodically. The doctor said to me, in all 
seriousness, " I guess I'll give this man some 
quinine." He added, " His cellar is full of 
water," as if to carry conviction. I will venture 
the opinion that the quinine did not relieve the 
chills and fever, nor reduce the water in the 
man's cellar, because I am sure there was a gall- 
bladder disease which was responsible for all that 
the man had complained. 

Headache, loss of weight and periodic attacks 
of these acute, colicky cramps, point strongly to 
the presence of gall-stone. If they come to 
operation, you may find, as I did a short time 
ago, the gall-bladder distended and full of black, 
ropy, mucobile, the ducts open and no calculi 
of the biliary apparatus. The lining of the gall- 
bladder and ducts was congested and thickened 
sufficiently to impede the flow of bile, but not 
enough to prevent its current entirely. At first 
thought, one would feel that operation was not 
indicated. But the stomach w'as adherent to the 
parietal abdominal wall by bonds of plastic exu- 
date which had been poured out during some 
previous inflammatory condition, and every 
meal was followed by intense pain caused 
by the dragging on the adhesion with every 
contraction. It was this case, perhaps, more 
than any other that I have ever operated, 
that has convinced me of the increasing field of 
surgery in diseases of the stomach. No one could 
hope to relieve these adhesions, only to dull the 
sensibilities by morphine, and the danger of cul- 
tivating the habit is great, since every meal must 
cause ])ain. and the morphine could not be so fre- 
quently administered for a long period of time, 
without danger. 

Now, about the medical trcatnicnt of these 
conditions after a positive diagnosis has been 
reached. 

In looking over the newer W'orks on materia 
and therapeutics, I note more conservatism ex- 
pressed in the efficiency of drugs for the treat- 
ment of these diseases, and I consider it is a sign 
of the times. .Anyone who has seen a gastric 
ulcer, with its area of dense induration and hy- 
peremia and stasis, incident to the process, will 
be slow to believe that the wisest treatment would 
be the combination of bismuth, soda or anti- 
septics; the latter are most ridiculous of all. for 
how can you adminster an antiseptic of real value 
to a portion of I he stomach, by giving it inter- 
nally? 

The logical treatment of gastric ulcer is pro- 
tection against irritation, by drainage. Just as 
long as the food must pass that ulcerated area, 
just so long is it going to keep painful. 

In motor disturbances of the stomach, much 



can be done by rest and tonic treatment, provid- 
ing there is not a stenosis of the pyloris, or atro- 
phy of the gastric muscle : and if cases applying 
to you with these conditions are not benefited by 
a thorough treatment of from four to six months, 
and I think it is wise to be frank with these 
people and tell them that they cannot hope to be 
benefited in less time — if, as I say, after a thor- 
ough treatment of from four to six months, which 
has included rest, tonic, and, perhaps, electricity, 
they do not get better, it is time to give surgery 
its opportunity. 

Carcinoma is clearly a surgical condition from 
its very beginning, and when we get the co- 
operation of the conservative medical men to 
observe that the end of their conservatism in gas- 
tric carcinoma is always death in about two hun- 
dred days, then can we hope to have them listen 
to the pleadings for exploration — simple explora- 
tion. If one can look, see, handle, and know the 
pathology of these cases for a series, then can 
we, with reason, look for some definite light on 
the subject: until then we must be content to 
grope until some daring spirit essays to lead us 
out on the highway of treatment, illuminated by 
that great searchlight that should determine all 
efforts for relief or cure, the greatest phase of 
all medical science — Pathology. 

.Ml theory, speculation or experiment that has 
not pathology for its foundation must, and de- 
serves to fail. 

GASTRO-INTESTINAL CONDITIONS IN EPILEPSY. 

I'.'i J. w. MCLArcwii.ix, M.n., 

OF C.\LVESTON, TEXAS; 

PROFESSOR OF MEDICINE, UNIVERSITY OF TEXAS. 

The purposes sought in calling attention to the 
anatomical and functional conditions which I 
found in all the cases of epilepsy — six in number 
— in which I looked for them, is to invite addi- 
tional investigations, and by other observers, along 
the lines suggested in this paper. Conclusions 
which are based u])on insufficient clinical observa- 
tions are. as a rule, untrustworthy, but in the 
present instance attention is directed more to the 
stomach and intestinal conditions than to con- 
clusions suggested. 

As the cases under my observation were only 
six in number it would be rash to say that the 
stomach and intestinal conditions in these will 
likewise be found in other cases of epilepsy, or 
that such conditions occupy a definite etiological 
relation to the disease. And, further, the six 
cases under observation were all genuine — idio- 
pathic — epilepsy, hence it would be premature to 
say that similar conditions will obtain in other 
types of the disease. 

The term genuine e|5ilepsy is used to desig- 
nate cases which are not caused by indiscovcrable 
lesions: as traumatism, syphilis, or new growths, 
involving the central nervous system. 

.\uthorities on epilepsy usually recognize as 
factors of the genuine type of the disease, first, 
an instability, perhaps of a special order, of the 



April 15, 1905] 



McLaughlin : epilepsy. 



6gi 



nervous system, that has been transmitted from 
an ancestor or ancestors by inheritance ; second, 
a center or centers of irritation in the organism 
which are capable of influencing certain brain 
areas in a special way. A special predisposition 
to epilepsy may or may not be inherited, but in 
any case there has been transmitted a local or gen- 
eral instability of the nervous system. The exact 
site of the center of irritation in the organism, or 
the nature of this, whether mechanical or toxic, is 
apparently of no great concern, as it may be 
trivial in character, and situated in almost any 
part of the body. The sites of irritation have 
been referred to the genitalia, the stomach, intes- 
tines, nose, eye, ear and to the cutaneous and 
mucous surfaces. The irritation may be that 
caused by an elongated, adherent or tight pre- 
puce ; by an irritable clitoris, vagina, uterus, 
tube or ovary; by intestinal irritations, tox- 
emias, parasites or constipation, by nasal polypi- 
inflammations or deformities ; by error of refrac- 
tion and muscular dystrophies of the eye. 

Most writers on epilepsy mention in a general 
way the association of dyspeptic troubles, and 
some of them attach much importance to a real or 
supposed associated intestinal toxemia. Vari- 
ous dietaries more or less conflicting in character 
and composition have been advised, but so far as 
I can ascertain there have been found no definite 
conditions of the digestive organs, either func- 
tional or organic. 

In all the cases of epilepsy which came under 
my observation there was found a myasthenic 
stomach ; the organ was dilated, flabby and dis- 
placed. The food ingested was not delivered to 
the intestine in due time or in proper condition. 
There was a stagnation of gastric food in all the 
cases, and at times there was found a retention of 
the contents with fermentation, and quite often 
with a production of butyric acid. In these cases 
the contents withdrawn with the tube were ex- 
cessive in quantity and foul smelling in character. 
In a majority of the cases there was found an ex- 
cessive production of mucus, which appeared in 
the wash water in large, heavy transparent masses. 
Starch digestion was defective in all the cases, 
and was totally inhibited in the majority. The 
age of patient was not above twenty-five years, 
and the disease began in early life in all : three 
of the cases came under the care of myself or of 
my son. J. W. McLaughlin, Jr., in Austin. The 
remainder were treated by me in Galveston. 

The association of excessive mucous produc- 
tion with an excessive hydrochloric acidity, which 
occurred in two of the cases, is contrary to the 
accepted rule that these secretions are usually 
found in inverse proportions, that is, there is a 
hypoacidity with a hypermucous secretion. The 
probability that the mucous secretion in these 
cases is not catarrhal, but that both it and the 
excessive secretion of hydrochloric acid are ex- 
pressions of a secretory gastric neurosis has 
occurred to me. 

It is often quite impossible to determine whicli 



of the two disorders, that of the stomach and 
intestines or that of the nervous system, is pri- 
mary in cases of so-called gastric neurosis. For- 
tunately this knowledge is not absolutely essen- 
tial to correct treatment, as the two disorders, 
gastric and nervous, form a vicious circle and 
react injuriously one upon the other, so that each 
one must, therefore, receive proper treatment. 
In a somewhat extensive experience in diseases 
of the stomach I have quite often met with these, 
especially secretory and motor disorders of the 
stomach, in association with neurasthenia, and 
have found the neurasthenic symptoms to disap- 
pear pari passu with those of the stomach, under 
proper treatment. 

Treatment has been local, dietetic and general. 
Lavage, to rid the stomach of stagnated food, 
particularly when it is in a condition of fermen- 
tation or is foul-smelling and putrid, always 
affords temporary relief, and is important in 
affording permanent improvement of health. 
Sodium bicarbonate or chloride, in the proportion 
of a teaspoonful to each pint of water, may be 
used to wash out the stomach. The washing 
should be continued at each seance until the wash 
water comes away clear, and this should be re- 
peated daily until gastric stagnation is overcome. 
I have followed this cleansing lavage, in cases of 
fermentation, with solutions of silver nitrate 
1/4,000, or moderately strong solutions of argy- 
rol, allowing the latter to remain in the stomach 
five or ten minutes before withdrawing it and 
washing out any remaining portion with clear 
water. 

Electricity is valuable as a means of restoring 
the myasthenic gastric muscles. The Faradic 
current is recommended, one electrode intragas- 
trically and the other applied over the dorsal 
spine. Massage, cold morning baths, followed by 
vigorous rubbings, and properly regulated exer- 
cise, accomplish the same purpose. 

Diet. — The digestive capacity in individual 
cases should be determined by modern methods 
of investigation and the information thus ob- 
tained should guide the physician in the selection 
of diet for epileptics. Starchy foods, for example, 
are badly digestecl and favor gastric fermenta- 
tion, at least in the cases which I examined. 
Sweets are contraindicated during gastric fer- 
mentation, but may be moderately used when the 
condition is not present. Proteids are unobjec- 
tionable if used moderately, the appearance of a 
pathological indicanuria should be a signal that 
proteids are often in excess. Vegetables are 
unobjectionable if properly cooked. But any 
form of food will be harmful if eaten in excess. 
The digestive capacity must nbt be exceeded. 

Strychnine, quinine, nux vomica, the bitter 
tonics and iron, are advised to overcome gastric 
myasthenia. Believing that the protective func- 
tion of the liver is impaired in neurasthenic con- 
ditions arising from intestinal intoxications, I 
have used with apparent benefit iris versicolor, 
cuonymus, rhubarb and the preparations of mer- 



692 



MEDICAL PROGRESS: SURGERY. 



[Medical News 



cury, to restore this function. The bromides, 
belladonna and preparations of zinc, may be re- 
quired in the neurasthenic habit. 

Results. — The results have been uniformly 
good. The patients under treatment are brighter 
and stronger : are less nervous and more cheer- 
ful. There has been no attack in over two years 
in one case, and over one year in another. In 
the other cases the attacks have been milder and 
less frequent. 

MEDICAL PROGRESS. 



SURGERY. 

Comparison of the Abdominal and Vaginal 
Routes for the Removal of Uterine Fibroids. — 

Comparing the relative merits of the two routes for the 
removal of uterine fibroids, Bvford (Chic. Med. Reg.. 
March, 1905) gives very clearly the advantages and dis- 
advantages of each method. He states that generally 
these factors should be considered, viz., the relative dan- 
ger to the patient, the possibility of completing the op- 
eration in a satisfactory manner, and the surgical train- 
ing of the operator. The advantages of the abdominal 
route are cited as follows : the possibility of working 
under the direction of the sight, the short time required 
for performing the operation, the ability 10 control all 
hemorrhage, the possibility of conservative surgery es- 
pecially in subperitoneal tumors and the increased 
room possible which is of decided advantage to opera- 
tors of moderate experience. The disadvantages of the 
abdominal route are enumerated as follows : The dan- 
ger of surgical shock and intestinal traumatism, and of 
infection of the peritoneal cavity with following intes- 
tinal paralysis or obstruction and the objection of many 
patients to the abdominal incision. The advantages of 
the vaginal route are given as follows : The insignifi- 
cance of shock, the minimum of disturbance of the ab- 
dominal viscera and the comparatively localized nature 
of any untoward conditions that might result from pos- 
sible imperfection of sepsis and manual skill. 

The author gives the disadvantages of the vaginal 
route as follows : The impossibility of having the guid- 
ance of sight, the difficulty of securing a thoroughly dis- 
infected field and the liability of encountering unex- 
pected or unappreciated difficuUies as hemorrhage, in- 
jury to the ureters, etc. 

The author considers that the vaginal route should 
be selected in cases in which the tumor is of such a size 
as not to hinder the pulling forward of the cervix to 
the vulva, so as to allow the operator to secure without 
delay the uterine arterjes on either side of the cervix 
as well as the middle hemorrhoidal arteries behind. By 
this method one is able to remove subperitoneal nitra- 
mural and submucous fibroids if the mass can be brought 
down into view. The abdominal route should he se- 
lected in all cases when adhesions to the neighboring 
viscera are present, for all large fibroids for small ones 
that cannot be pulled down toward the vulva and in 
cases in which there is a small vaginal entrance and 
narrow vagina. 

Prevention and Reduction of Deformity in Pott's 
Disease. — In calling attention to the very evident 
fact that the treatment of Pott's disease is not as 
successful as it should he, C. F. Eikenuarv (Chic. Med. 
Rec, March 3, 1905) states that no case taken in the 
early stage before there is any deformity, or before tlie 
deformity is marked, need recover with anything but a 
perfectly normal spine, so far as contour is concerned. 



and many cases, probably 50 per cent., who come in the 
later stages of the disease — that is, the sub-acute stage, 
when the deformity is quite marked, can have the de- 
formity reduced one-half or nearly. In most cases the 
aim and expectation should be no deformity. No single 
line of treatment is applicable to all cases. So far as 
known, there is no medical treatment in any way, shape 
or form that has proven of the slightest benefit. The 
treatment is essentially mechanical, in addition to keep- 
ing up the general tone of the system all cases should 
wear a support, no matter whether the patient be con- 
fined to bed or not. Cases under three years, or in 
undersized children under four years, are best treated 
by being placed securely on a canvas-covered rectangu- 
lar gas-pipe frame, and having a suitable number of 
buckles and straps to hold the child firmly. At the point 
opposite the kyphosis the frame should be bent, the con- 
vexity of the bend being toward the kyphosis. The child 
should be securely fastened until all acute symptoms 
subside, or, preferably, until the cure is complete. If 
deemed advisable, after the acute symptoms have sub- 
sided and the deformity is practically nil, plaster jackets 
may be applied, and if properly applied and kept on 
without the slightest intermission until the cure is com- 
plete, no deformity will ever result. In cases past' four 
years of age there is no brace so universally successful 
as the plaster-of-Paris jacket properly applied. Ever>' 
jacket should be so carefully and smoothly applied that 
no pressure, sore or other complication is going to arise 
that would necessitate its removal for a few days. The 
jacket should be applied as high a« possible, while the 
patient is in the horizontal position, so as to secure as 
much hyperextension as possible. The important thing in 
whatever method is used is to produce the maximum 
amount of e-xtension at the seat of disease, and having 
obtained such extension to apply the jacket high enough 
and low enough that you will lose nothing that has been 
gained, and to apply it so smoothly and so strong that a 
change under four months will be unnecessary. 

Urethral Structure with False Prostatic Passage. 
— that the very great progress which has been 
made in the art of passing sounds is largely due to the 
teachings of Gouley cannot be doubted. He always in- 
sisted that it should be done with the utmost gentleness 
and his teachings are at last bearing fruit. Neverthe- 
less, as recorded by Reginald Harrison (Lancet, Feb- 
ruary 18, 1905) it is still possible to find victims of the 
older methods of instrumentation who have actually had 
sounds passed directly through their prostates and thence 
into the posterior portion of the bladder. The sound 
usually leaves the urethra about an inch and a half be- 
fore its entrance into the bladder, passes backward near 
to the rectum and thus breaking through prostatic cap- 
sule and retrovesical wall, establishes an absolutely new 
passage. These pasages not infrequently fimctionate 
moderately well, although it has been observed that 
many of the patients die from nephritis. The treatment 
should obviously be directed toward making good the 
old path and rendering the false passage uimecessary. 

Acute Hemorrhagic Pancreatitis. — It is refresh- 
ing to find that an occasional case of acute pancreatic 
disease is being recognized in time to operate upon it 
and save the patient. T. C. Litler Hones (Lancet, 
February 18. 1905) reports the case of a married woman, 
twenty-six years of age, who was admitted to the hos- 
pital after seven days of obstipation. The abdomen was 
distended. She vomited. The epigastrium was tender 
and there was a localized swelling. The pulse was 128, 
temperature 96.2° F. Tlie abdomen was opened and on 
dividing the peritoneum, bright blood gushed out. Three 
pints of free fluid were in the cavity. It suggested extra- 



April is, 1905] 



MEDICAL PROGRESS: MEDICINE. 



693 



uterine rupture. At the entrance of the lesser sac a 
well-marked fat necrosis was noted. The pancreas was 
three times its normal size, di.5coIored, edematous and 
hemorrhagic. There was no bleeding at the time of 
operation from the pancreas. This organ was packed 
off and in size longitudinally. No obstruction could be 
found, but the examining finger seemed to enter a dilated 
space. This was packed with gauze. The hemorrhage 
was at no time severe. The packing was removed in 
thirty-six hours, when the discharge became clear and 
continuous. It was pancreatic juice. It began to digest 
the margin of the wound, but gradually closed without 
serious trouble. For three weeks after operation, no fat 
containing food was given. Her urine was most care- 
fully examined and nothing in the nature of the crystals 
described by Cammidge could be found. Although Mayo 
Robson and Barling emphasize the association of this 
condition with gall-stones, nothing was noted in this 
case. Opie's well-known experiments attest Halsted's 
opinion that obstruction at the duodenal orifice at the 
gut of Wirsung might be responsible for acute pan- 
creatitis are well known. He concluded that the necrosis 
of the parenchymatous cells and hemorrhage represent 
the primary action of the bile and that inflammatory 
reaction rapidly follows. In the Heaton case, the ducts 
were patent and the microscopical sections showed acute 
inflammatory changes in the gland and the areas of 
blood extravasation. Beaver strongly advises an early 
operation with free drainage as the best means of check- 
ing progressive necrosis of the pancreatic cells and says 
that a tense edematous condition without marked involve- 
ment of the peripancreatic tissue calls for an incision in 
its long axis. 

Traumatic Lumbago. — By traumatic lumbago is 
understood a condition in which pain and stiffness in 
the lumbar region caused by injury persist long after 
the immediate and acute effect has passed away. Frank 
RoMER {Lancet, February 18, 1905) states that while no 
pathological proof was forthcoming of the assumption 
that these distressing conditions are brought about by 
adhesions in the muscular or tendinous structure of the 
lumbar region, the results of operation based upon this 
supposition are confirmatory in nature. The history of 
these case^ generally records some strain of tlie back, 
necessitating perhaps a few days' rest. Most of such 
cases go on to recovery. But occasionally one is found 
in which the pain does not entirely disappear. Lumbar, 
stiffness increases so that it eventually simulates chronic 
lumbago. The treatment of ordinary lumbago is in these 
cases obviously futile because of the absolute difference 
in the pathology. They resemble each other only in 
name. An anesthetic should be given both for the pre- 
vention of pain and for the insurance of complete re- 
laxation. The patient is placed on his back. The leg 
on the sound side is flexed at the knee. The thigh is 
flexed on the body till the knee touches the chest wall. 
It is then brought back to the extended position. The 
leg on the affected side is now put through the same 
movements and comparison can then be made as to the 
difference in resistance. Both legs are now brought 
up together and both knees should be kept pressed 
against the chest for about a minute. The legs are now 
brought down again flat on the bed. and the patient 
raised to a sitting posture. The operator places one 
hand firmly over the affected lumbar region, while with 
the other he thrusts the patient back toward the bed. 
The hand on the small of the back causes the part to be 
extended. By this procedure the lumbar portion of the 
column is put through flexion and extension as the pa- 
tient is pressed forward and backward. There is little 
pain after these manipulations. The after-treatment con- 



sists in rest, massage and graduated exercise. The au- 
thor reports six cases which were cured by this treat' 
ment. 
Surgery of the Gall-bladder and Bile-Duct. — In no 

department of surgery has the .'\merican mind left its 
impress in a more forceful manner than in the develop- 
ment of the surgery of these parts. Cholecystotomy 
was first performed by Bobbs, of Indianapolis, in 1867. 
In 1878, this operation was established as a definite sur- 
gical procedure by Marion Sims and thus the way was 
paved for the first cholecystectomy done by Langenback 
in 1880. D. A. K. Steele (Annals of Surgery, February 
19. 1905) in an address upon this department of surgery 
before the Chicago Surgical Society, congratulated the 
members upon the fact that the society had probably 
more than any other kindred organization contributed 
to the sum of our knowledge upon the subject. In 
speaking of the symptoms, he said that it had been 
shown that the formation of a stone requires several 
months and is invariably preceded by gastro-intestinal 
catarrh, constipation, flatulence, epigastric discomfort, 
sallowness, slight icterus, scant high-colored urine, sour 
stomach, tenderness over the gall-bladder, so-called 
bilious colic and sick headache. Gradually from this 
condition there may be evoluted a typical attack of gall- 
stone colic. Many of these cases are treated for years 
by medication, by diet, massage, baths, exercise, olive oil, 
Carlsbad and other resorts. The delay occasioned by 
this error often causes serious complications, peritonitis, 
dilatation and infection of the gall-bladder, circumscribed 
abscess formation, empyema and universal adhesions. 
These lead to the obliteration of the normal landmark 
and this immensely increases the difficulties of operation 
and add to its mortality. The condition is in nowise 
seriously different from that found in recurrent appen- 
dicitis. For this reason, the old dictum of three months' 
medical and dietetic treatment, is seen in the new light 
to be altogether too long, for while uncomplicated cases 
of cholecystitis and cholelithiasis, give practically no 
mortality, the same operation in cases generally ex- 
hausted and with local conditions rendered abnormal as 
a result of chronic inflammation and infection, the mor- 
tality is discouragingly high. The author gives the fol- 
lowing indications taken from Waring for operation : 
(i) The presence of a tumor in the abdomen appears to 
be an abnormally distended and large gall-bladder. (2) 
The existence of jaundice, which is persistent, together 
with other signs and symptoms which point to complete 
destruction of the common bile duct or the common 
hepatic duct. (3) The recurrence of successive par- 
oxysmal attacks of biliary colic with short intervals be- 
tween the attacks and a general lowering of the health. 
(4) Symptoms of localized inflammation in the region 
of the gall-bladder, associated with bilian,' colic. (5) 
The occurrence peritonitis due to perforation of the 
gall-bladder. 

MEDICINE. 

A Case of Anchylostomiasis. — The case reported 
by Karshin (Roussky I'ralch, February 25, 1905) is in- 
teresting inasmuch as, besides the principal parasite, the 
patient seemed to harbor also Tania iaginata and 
Trichocephahis dispar. The boy, eleven years of age, 
began some three years ago to show signs of impaired 
health, grew pale and very weak, complaining of gas- 
tric pain, at times vomiting, dyspnea, palpitation of the 
h^art, dizziness, tinnitus aurium. headache, and so on. 
He was a playful child, who formerly spent much of 
his time playing in sand. He presented all the symp- 
toms of progressive pernicious anemia, except that the 
great percentage of eosinophiles in the blood, namely. 



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[Medical News 



41/^ per cent, suggested the possible presence of in- 
testinal parasites ; appropriate medication caused the 
expulsion of taenia with the consequent dropping in the 
percentage of eosinophiles to 17.2 per cent. But as the 
condition of the patient did not seem to improve much 
(he had marked edema of the legs, heart murmurs, di- 
lated pupils, a tender liver and subfebrile temperature), 
and an examination of the feces elicited the presence of 
an enonnous number of the eggs of Anchylostoma 
duodcnalc ; treatment was instituted (chiefly the ethereal 
extract of male fern and cautious doses of thymol), and 
the author succeeded in the course of some days in 
expelling 200 live worms. There ensued at once general 
improvement in all the symptoms, the patient recovered 
rapidly and remained so. It would seem that between 
the two theories — infection by the worm per os, or per 
cutem, the latter finds more favor with most of the 
investigators. The symptoms produced in the host are 
evidently due not only to mechanical causes alone, but 
also to the presence of some as yet unknown poison 
which seems to be the biological product of the parasite 
in the human body. Moreover, the presence of the par- 
asite in the intestine tends to increase the number of 
the intestinal bacteria, thus enhancing the various putre- 
factive processes therein, and also deprives the host of 
so much nutrition, besides acting reflexly by irritating 
the peripheral nerve-endings. The parasite is taken 
up chiefly and directly from the soil, and since attention 
had been called to the serious consequences caused by 
it the number of those affected with it increased from 
113 in 1897 to almost 2.000 in 1903. With their accus- 
tomed care the Germans have since the last few years 
required that every miner, clay worker, etc., applying 
for work present a certificate of never having suffered 
from anchylostomiasis. The author calls special atten- 
tion to the fact that the child having become infected 
while living at Port Arthur, the army now in Man- 
churia, living as they do under extremely unhygienic 
conditions, and being constantly occupied in digging up 
the ground for various military purposes, are sure to 
become the disseminators of the disease on their return 
home to Russia, and urges special precautions to limit 
the spread of the disease. 

Duodenal Ulcer. — The ulceration of the funnel- 
shaped area comprising the pyloric end of the stomach, 
the pylorus and the first portion of the duodenum has 
in the past fifteen years attracted very great attention. 
B. G. A. MoYNiH.\N (.Lancet, February 11, 1905) states 
that since 1900, the date of his first operation on duode- 
nal ulcer, to September, 1904, he had operated on 51 
cases. There were seven cases of perforating duodenal 
ulcer with five recoveries, 22 operations for duodenal 
ulcer associated with gastric ulcer with one death and 
23 operations for duodenal ulcer alone with one death. 
It is well known that almost all writers remark upon 
the rarity of ulcer in duodenum, that this is a fallacy 
there can be no reasonable doubt. The author has made 
his observations and has established the frequency of 
the condition from the study of the living, whereas 
text-book authorities obtain their data from autopsy re- 
ports. The symptoms of duodenal ulcer in many cases 
arc characteristic and in the writer's opinion it is a mis- 
take to believe the oft-repeated statement that a differ- 
ential diagnosis between an ulcer of the strnnach and 
one of the duodenum is difficult, he having in most 
cases been able to establish it either upon the physical 
signs or upon the history. Ulceration is ten times more 
common in the first portion of the duodenum than in 
the second. Duodenal ulcer may occur at any age. Op- 
penhcimer has collected the records of 15 cases of me- 
lena neonatorum resulting from ulcerated duodenum. 



Duodenal ulcer is said to be more common in the male 
than in the female. Weir has stated it as being six to 
one. Mayo 2.5 to one. In the author's reports there 
were 32 males and 19 females. The symptoms naturally 
are kin to those of gastric ulcer, namely hematemesis 
and melena neonatoruin. The complications are (i) 
hemorrhage; (2) perforation, acute, subacute and 
chronic; (3) cicatricial contraction and induration, 
causing narrowing at the ampulla of vater and obstruc- 
tion to the outflow of bile and pancreatic juice; (s) 
periduodenitis; (6) cancer; (7) compression of the por- 
tal vein from cicatrization of a deeply placed ulcer 
(French) ; (8) diseases of the gall-bladder or bile ducts; 
and (9) diseases of the pancreas. The association of 
diseased gall-bladder and bile ducts with pancreatic dis- 
ease is interesting. In ten of the author's series there 
was obvious evidence of disease in the gall-bladder with 
or without stones. Duodenal ulcer unquestionably may 
predispose to the formation of stones by giving rise 
to peritonitis. As a result of this there is stasis of bile 
and perhaps infection. The two conditions best known 
to be necessary for the formation of concretions. The 
relation of pancreatic disease to duodenal ulcer has 
not yet received attention. It was present in three of 
the 51 cases. A localized chronic pancreatitis may re- 
sult from a gradual deepening of the duodenal ulcer. 
It may further be caused or at least aggravated by the 
same conditions which give rise to the ulcer, viz., alco- 
hol or syphilis. 

On the Influence of Copious Water Drinking. — 
Notwithstanding the fact that a large number of in- 
vestigations have been made on the influence of copious 
water drinking, yet there does not seem to be recorded 
any set of data from a carefully conducted series of ex- 
periments of this sort upon human subjects, having for 
its object the study of the course of the nitrogen, sul- 
phate and phosphate elimination. An extensive series 
of experiments have now been made by P. B. Hawk 
(Univ. Pa. Med. Bull., March, 1905) in which the sub- 
jects were placed on a constant diet, and by means of 
preliminary periods of sufficient length, brought to a 
condition of approximate nitrogen, sulphur and phos- 
phorus equilibrium. At this point, the regular constant 
diet was supplemented during a period of two days by 
a large volume of water taken daily at stated intervals. 
.■\fter this the normal conditions were again maintained. 
Food, urine and feces were all subjected to most care- 
ful analysis. The writer concludes that water drinking 
causes an increased excretion of nitrogen and phos- 
phorus by the urine. The increase in the amount of 
nitrogen eliminated is due primarily, to the washing out 
of the tissues of the urea previously formed, but which 
has not been removed in the normal processes, and sec- 
ondarily, to a stimulation of proteid catabolism. The 
increase in the excretion of phosphorus is due to an 
increased cellular activity and the accompanying catab- 
olism of nucleins, lecithins and other phosphorus- 
containing bodies. There was nothing which would 
lead to the inference that there was anything detri- 
mental in the consumption of large quantities of water. 
The ingestion of 9,000 c.c. of water in forty-eight hours 
caused an increase of 2.17 grams of nitrogen during that 
period in the urine. The excretion of the sulphates was 
along similar lines. 

Early Diagnosis of Cancer of the Stomach, — The 
special points of value which are of aid in the early 
recognition of malignant disease of the stomach are 
reviewed by M. le Dr. J. Noever (Jour. Med. de Brux., 
March 2. 1905). He calls attention to the statements of 
Finckelnburg who in 1894 noted the increasing fre- 
quency of this affection, and to the statistics of W. 



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MEDICAL PROGRESS: MEDICINE. 



695 



Roger Williams showing that this increase is real, and 
that men are more frequently affected and present vis- 
ceral lesions. The early diagnosis depends upon the fol- 
lowing points: (l) Examination of stools for blood by 
the Boas method. In 67 cases he was able to detect 
blood in 65 cases. Method, (a) Triturate part of stools 
with distilled water; (6) add to one part of mixture 
one-third volume of glacial acetic acid; (c) extract 
with ether; (d) stir etherial extract with a mixture of 
30 drops of oil of turpentine and 10 drops of tincture of 
guaiac. The blue color resulting is made more distinct 
by adding distilled water and chloroform. (2) Exam- 
ination of gastric fluid. Hydrochloric acid is present 
in II to 13 per cent, of cases and is more frequent in 
cases of carcinoma of the pylorus than of the lesser 
curvature. Hyperacidity also is present in cases of 
carcinoma with an old ulcer, or following nervous 
hyperacidity. Lactic acid is not pathognomic of car- 
cinoma, but it is not produced in so great a quantity in 
other affections, nor is stasis necesary for its presence. 
In cases of stasis fasting with absence of lactic acid and 
presence of hydrochloric, the difference between ulcer 
and carcinoma is distinguished as follows : The gastric 
juice should be examined three times the same day. 
The first fasting; the second after a test meal of egg 
albumin ; the third after a test meal of beefsteak. In 
cases of ulcer he finds hydrochloric acid in all three 
trials. The absence or presence of a small quantity of 
hydrochloric acid in one or several of the three exam- 
inations indicates mucous catarrh of the stomach. 
Mucous catarrh with other symptoms is in favor of car- 
cinoma. The transudation of albumin into the stomach 
is determined by allowing no albuminous food after 
midday. In the evening the stomach is washed with 
water. Next morning, while fasting, the stomach is 
washed with 400 c.c. of normal salt solution. If the 
liquid contains more than 20 mg. of nitrogen, or more 
than Vij to 'A in 1,000 albumin, the presumption is in 
favor of carcinoma. (4) The bacillus of Boas-Oppler is 
in itself not diagnostic but the presence of this bacillus 
on small brownish coagula mixed with chyme after 
certain test meals in the presence of hydrochloric acid 
points toward probable carcinoma. Albumoses are 
found in the urine by the biuret reaction in two-thirds 
of the cases of carcinoma but are also demonstraable in 
the urine of cases of appendicitis, abscess of groin, em- 
pyema, meningitis and other purulent processes, but is 
distinguished from these latter by the presence of other 
symptoms. It has been shown that the lack of diges- 
tion leucocytosis which was supposed to occur only in 
carcinoma may be present in simple gastric catarrh. 
The author considers that sometimes an early diagnosis 
of cancer can be made, but for the most part we remain 
ignorant of its malignancy and its extension. He does 
not agree with some authorities that an early diagnosis 
is impossible without exploration, yet considers that an 
early exploratory laparotomy should be done when a 
sufficient number of symptoms point to beginning car- 
cinoma. 

Extensive Carcinoma of Tongue and Neck, Pre- 
senting Points Special Interest. — Dr. Wii.li.^m Sea- 
M.-\N' B.MXBRinGE (.Am. Med.. March 25, 1905) reports 
the case of a man of forty-nine, an inveterate smoker 
for twenty years, who was first aware of his trouble in 
May, 1902, when a small pimple appeared half-way 
back on the dorsum of the left half of the tongue. This 
would disappear under local applications, with discon- 
tinuance of smoking, only to return when smoking was 
resumed. The pimple finally persisted, growing rap- 
idly, and in December, 1903, the author took charge of 
the case. The patient was somewhat cachectic and had 



lost considerable flesh and strength. The anterior third 
of the tongue, except the tip, was involved by a hard, 
crater-like ulcer. No glands were palpable at this time. 
Microscopic examination confirmed the diagnosis of 
vascular epithelioma. On March 11, 1904, the patient 
was operated upon. The first incision extended from 
the tip of the left mastoid process to that of the right, 
and below as far as the thyroid cartilage. The second 
incision extended along the anterior border of the left 
sternocleidomastoid muscle to within an inch of the 
clavicle. The two lingual arteries were tied in situ, 
the submaxillary and the sublingual glands on either 
side removed, and the salivary ducts extirpated clear 
into the mouth. Many cancerous glands were removed 
from the region of the tonsil on either side. The lym- 
phatic glands with their vessels were removed en masse 
as far as possible, and with them the connective tissue 
and fascia of all the contiguous muscles. The wound 
was completely closed except for a small drain at the 
lower part. The mouth was next forced open and the 
growth on the tongue cut down with Paquelin cautery. 
Whitehead's shellac being applied as a coating to the 
cauterized surface. The wound healed by primary 
union. On March 28 the left corner of the mouth was 
incised to the edge of the masseter muscle, the mouth 
forced open, the tongue drawn out and elliptic in- 
cision made on the floor of the mouth, encircling the 
tongue, this organ being completely removed. A bridge 
of tissue was made across the fauces in front of the 
epiglottis by a small flap of mucous membrane dissected 
away from the right glosso-epiglottic fold. The wound 
in the floor of the mouth was partially closed by 
chromicized catgut, the wound in the cheek closed in 
the usual way and shellac applied over each. Within 
a few hours the patient could swallow fluids, and on 
.April 21 was discharged cured. Since that time he has 
steadily gained in flesh, is apparently perfectly well, is 
able to masticate even solid food, to taste, to talk in- 
telligibly, and even to sing. 

Nature of Scleroderma. — L. Huism.^ns (Munch. 
Med. IVoch., March 7, 1905) draws attention to the 
fact that in most cases of scleroderma there are symp- 
toms pointing to involvement of some or all of the 
ductless of glands. Thus in his own case, there was 
amenorrhea (ovaries), pigmentation and dryness of the 
skin with vomiting and general lassitude (adrenals), 
atrophy of the thyroid, falling out of the hair, absence 
of perspiration (thyroid) and dystrophy with weak- 
ness of the muscles (liypophysis). The disease is cer- 
tainly not a pure neurosis but is probably the result 
of an infection, secondary to a functional disturbance 
of the sympathetic nerve following trauma, preg- 
nancy, etc. If the functional disturbance is slight, com- 
plete recovery may follow, if severe, a degenerative in- 
flammation will develop in the ductless glands and 
skin. The localization of the disease is solely due to 
tlic peculiar distribution of the sympathetic nerve. 

Chemistry of Chronic Nephritis. — Chemical exam- 
ination of the blood, kidneys and various other organs, 
particularly with reference to the chlorides, led T. 
RuMPF (Miineh. med. Woch., February 28, 1905) to 
conclude as follows : In health, the amount of chloride 
of sodium in the kidneys, generally exceeds that in the 
blood and the other organs. In a large number of 
cases of nephritis, the difference is still more marked. 
but exceptions are common, especially in the early 
stages. The amount of salt in the blood and tissues in 
nephritis is usually above normal, yet there are many 
cases where the opposite holds, despite the presence of 
edema, albuminuric retinitis and uremia. The per- 
ccnta.ge of chlorides found in the pericardial. ple\iral 



696 



MEDICAL PROGRESS: THERAPEUTICS. 



[Medical News 



and peritoneal fluids of nephritis is not constant. Since 
higher figures were often obtained with the transudates 
of other conditions, it is improper to conclude that 
transudation in nephritis is a result of retention of salt. 
There can be no question, however, that there is a de- 
cided retention in the kidney of chlorides, sodium, 
potassium, calcium and magnesium. In the early stages 
of nephritis the blood and tissues contain less water 
and more solid residue, but in the later stages this is 
no longer constant. 

Roentgen Rajrs in Leucemia. — A typical case of 
myelogenous leucemia was subjected by K. Schleip 
and W. HiLDEBRANDT (Miinch. med. Woch., February 
28, 1905) to a thorough course of treatment with the 
Roentgen rays. All in all, the spleen was exposed 648 
minutes, and the bone-marrow of the sterum and 
femur, 130 minutes, over a period of nearly three 
montlis. The following changes were observed during 
this period. The fever, which before treatment was 
very slight and absent altogether on some days, became 
more pronounced and of decidedly intermittent type; 
despite this the patient increased in weight three kilo- 
grams. The number of leucocytes increased from 280,- 
000 to 350,000 until the duration of the exposure had 
reached 500 minutes; after this there was a rather sud- 
den drop to 53,000. Each single exposure diminished 
the number, sometimes as much as 100,000, but usually 
there was a secondary rise soon after. There can be 
no doubt that the effect of the rays is a specific one 
upon the white cells, since the reds never fluctuated to 
such an extent. It seems that not only the neutro- 
philes, but all the different types of leucocytes found 
in leucemic blood, are affected. Degeneration, cell- 
division, etc., were never seen so that it is not probable 
that the cells are actually destroyed, but that their dis- 
tribution within the body is altered. A final disin- 
tegration does, however, occur after the cells have once 
accumulated within the internal organs. The objective 
symptoms did not improve, and the spleen retained its 
original size. It is impossible to say at this date, if the 
improvement brought about by the Roentgen rays is 
parmancnt or only transient, but it is unquestionable 
that prolonged exposures (600 minutes and over) are 
followed by pronounced improvement. 

The Tuberculous Predisposition. — Most of the 
investigators of and writers on tuberculosis incline to 
the view that the predisposition to tuberculosis is of 
greater importance in the etiology of the disease than 
the infection with the bacillus ; for if it were otherwise 
we should have a much greater number of those sick 
with the disease than there are at present; according 
to Naegeli's statistics, almost every human being carries 
within him the bacillus by the time he gets to be eight- 
een years old. On the other hand, it is assumed by 
KossEL, Weber and Unterbercer (Prakt. Vrach., Jan- 
uary 8, 1905) that there exists a certain gradation in 
the degrees of virulence of the infectious principle. The 
latent and the lethal cases of tuberculous infection differ 
from each other not by the nature of the infection, but 
simply by its degree. The individual predispositon, 
as well as the excitng causes are of an inconstant and 
changeable nature. In accordance with the relation be- 
tween these two, wc get the tuberculous infection in a 
light, or serious form, or the attacked person may show 
no clinical signs of the infection at all. The bacilli 
expectorated with the sputum contain in the majority 
of cases infectious spores, which may possibly be of 
saprophytic nature. It is the hereditary predisposition 
that plays the most important role in the etiology of 
the disease As based on these postulates phthisiopho- 
bia is not justifiable and should be vigorously com- 



bated, and it becomes evident that all our efforts should 
be directed toward the creation of such sanitary and 
economic conditions by the aid of legislative measures 
as to minimize any possible tuberculous predisposition 
in the family. The author thinks that the time has at 
last arrived when the treatment of tuberculosis through 
the destruction of the bacilli is no longer feasible, and 
that hygienic and dietetic measures are of much greater 
importance. 

IJiphtheria Infection in Minnesota. — F. F. Wes- 
BROOK (Journal A. M. A., March 25), describes the 
methods of handling diphtheria epidemics in that state. 
The principal points insisted on are the needs of thor 
ough laboratory examinations, repeated frequently if 
necessary where suspicious bacilli are found, isolation 
of cases and of hitherto unaffected individuals with 
simple sore throat and prompt executive action based 
on laboratory findings and initiated by one of the lab- 
oratory experts. After the system is well started, com- 
petent local medical authorities can be relied on, if suf- 
ficiently impressed with its importance. The experience 
in Minnesota has shown that this is perfectly practica- 
ble under most varying conditions, and this is proved 
by the history of the management of epidemics given 
in the paper. The experience of Minnesota seems to 
point to the conclusion that diphtheria infection is usu- 
ally transmitted by almost direct exchange of the flora 
of the nose and throat. In institutional and school life 
the more independent the individual and the easier 
the individual isolation, the less is the diphtheria in- 
fection and the easier is its eradication. 

THERAPEUTICS. 

The Use of Atropine in Puerperal Fever. — In 
spite of its well-known property of putting to rest 
plain muscle, atropine has hitherto played no im- 
portant rc")le in gynecology, according to Dr. Drenk- 
H.\HN {Therap. Monatsheft., February, 1905). The 
author treated successfully two cases of puerperal sep- 
ticemia with atropine. The first case received in the 
course of nine days .06 grams of atropine, about .006 
grams daily, that is about double the maximal daily 
dose. The second case received likewise large doses. 
The author defends his practice upon the following 
observations and conclusions: Puerperal fever is, 
above all, a wound-infection of the uterus with a pure 
tissue-mycosis. With complete rest of the uterus and 
neighboring organs it remains a tissue-mycosis which 
heals spontaneously without douching or other manip- 
ulations. Atropine is the ideal drug for producing 
rest of the uterus. Contractions of the uterus lead 
10 toxemia and bacteremia. The bacteria circulating 
in the blood and lymph streams may lead to tissue 
mycosis in other organs. If the latter have already 
been infected, atropine still favorably influences the 
course of the uterine disease, and may even at times 
arrest the progress of the toxemia by inhibiting the 
absorption of the toxic material from the extensive 
surface of the uterus. It has no effect upon the sec- 
ondary tissue mycoses. If menstrual colic be, accord- 
ing to Theilhaber, the result of a spasm of the circular 
muscle of the inner os, then atropine would be indicated 
for the relief of pain. One should not be afraid to give 
relatively large doses of atropine. There is no danger of 
producing uterine hemorrhage during the first few days 
following delivery. Frequently one mg. has but slight 
effect. Prolonged atropinization of the uterus has no 
effect on involvement. The only disadvantages that 
sometimes accompany the use of atropine in puerperal 
patients are disturbance of accommodation and vesical 
paralysis. 



April is, 1905] 



PATHOLOGY AND BACTERIOLOGY. 



697 



Clinical Notes on Digalen. — Some time ago Clo- 
etta introduced a new soluble modification of digitoxin, 
to which he applied the name digalen. In a recent 
article K. Kottmann (Zeitsch. f. klin. Med., Vol. 56, 
Nos. I and 2) gives an account of his clinical exper- 
ience with this drug. Injected subcutancously in doses 
of 0.25 to 0.3 milligrams two or ■three times daily a 
prompt digitalis action is generally obtained within 
twenty-four hours. Owing to its ready solubility there 
is very little danger of a cumulative action and the 
subcutaneous application avoids gastro-intestinal dis- 
turbances. The only disadvantage is a local reaction 
which sets in within half an hour and may persist 
over night. It generally shows itself in moderate pain 
and some swelling, but fever was seen in only two cases 
of Basedow's disease. If an immediate result is de- 
sired, the drug may be injected directly into the vein, 
preferably at the bend of the elbow. For this purpose 
the arm is constricted with a rubber bandage and the 
needle then introduced into the vein which is steadied 
with the fingers. As soon as a column of blood rises 
in the syringe, the bandage is loosened and the solu- 
tion injected very slowly. After doses of 1.5 to 3 milli- 
grams a rise of blood-pressure was observed in two to 
five minutes ; it reached its maximum in one and one- 
half hours and persisted for twenty-four hours. The 
frequency of the pulse was influenced but little, but 
diuresis was marked. Intravenous injections of diga- 
len are indicated especially in acute cardiac weakness, 
cardiac asthma, and in the imminent collapse of typhoid, 
pneumonia and other acute diseases. For chronic endo- 
carditis, on the other hand, the subcutaneous applica- 
tion is preferable. Great care should be exercised to 
avoid intoxication, since this cannot be combated with 
any known remedy. 

Food Preservatives V. C. Vaughn (Journal A. 

M. A., March 11) states that a true food preservative 
must keep the substance to which it is added in a whole- 
some condition so that it can be consumed without 
impairment of health. It must be a real preservative, 
keeping the food in a wholesome condition and not 
merely preserving the ' appearance of freshness while 
permitting bacterial changes to continue. It must not 
materially impair any of the digestive processes even 
in the largest quantities used, and should not be a cell 
poison, or if such to any extent, it must be added to 
foods only by persons qualified by special training and 
oflScially authorized. Foods containing these substances 
must be plainly labeled and the kind and amount of the 
preservative used must be made known, not only to 
the buyer, but to each consumer. A cell poison is de- 
fined as an agent that destroys or impairs cell functions 
by its chemical action. 

PATHOLOGY AND BACTERIOLOGY. 

Physiological Mechanism of Natural Immunity. — 

It has been found by R. TuRRO and A. Pi v Suner 
(Jour, de Physiol., January 15, 1905) that the injection 
of large doses of saline solution into rabbits increases 
their resistance to the infections of malignant edema 
and streptococcus. This effect is attributed to the 
fact that the saline solution dissolves a large amount 
of alexines out of the protoplasm of the cells, and 
thus adds it to the bodily fluids, thus increasing their 
bactericidal power. This conclusion is supported 
by the observation that the splenic or renal pulp, if 
macerated with salt water acquires a bacteriolytic 
energy which is greater than if the zymotic prin- 
ciples had not been dissolved out. The guinea-pig 
does not behave toward the virus of charbon like 
a culture tube; it opposes certain resistances to the 
proliferation of the microbe, which are, however, 



feeble. This natural resistance increases in the fol- 
lowing order: sheep, cow, man and dog. The de- 
gree of immunity depends principally upon the 
bacteriolytic power of the cells and humors, and 
this power is directly in proportion to the degree of 
solubility of the active substances. If a tissue con- 
tains enzymes that are but slightly soluble, its de- 
fensive power is diminished. If it is easily coag- 
ulated the defensive power is destroyed and the or- 
ganism is helpless. This explains how the procedure 
of artificially augmenting the solubility of the active 
bacteriolytic substances in the rabbit by means of 
saline solution, gives this animal for the time being 
a defence against charbon which is equal to that of 
the dog. To sum up, the organism is infected by 
virtue of the coagulability of its plasmas, and re- 
.sists infection by virtue of their solubility. 

The Agglutination of the Streptococcus by the 
Blood of Scarlatinal Patients. — That this actually oc- 
curs is positively shown by the experiments of MM. 
Detat et BouRCART (Rev. Mens, des Mai de L'Enfance, 
March, 1905). The phenomenon, however, is variable 
and inconstant. Normal serum as well as the serum 
obtained from infections other than these of scarlatina, 
can also agglutinate the streptococci isolated from the 
blood of cases of scarlatina, and to an equal degree. 
Analogous results were obtained by using streptococci 
obtained from patients sufi^ering from other diseases. 
These researches are admitted by the authors as having 
no practical application in diagnosis. 

The Presence of Soaps in the Organism in Certain 
Pathological Conditions. — That soaps are formed in 
the cells as precursors of calcareous degeneration, has 
been revealed by the researches of O. Klotz (Am. Jour. 
Physiol., February, 1905). The earliest change in cells, 
which later undergo calcareous degeneration, is one of 
cloudy swelling or coagulation necrosis. Following 
this, fatty changes are noticeable in the cells, and, now, 
by means of proper reagents, soaps with potassium, 
sodium, and presumably ammonium bases, can be de- 
tected. Such soaps and albumins form a combination 
which is insoluble in water or salt solution. Soaps and 
fatty acids have an affinity for the calcium salts in so- 
lution in the body-fluids, and form with them an in- 
soluble compound. Later, judging from the fact that 
phosphate and carbonate of lime are formed, and the 
deposits give no reaction for fats, the fatty acid moiety 
of the calcium soap is replaced by the more powerful 
carbonic and phosphoric acids. 

PEDIATRICS. 

Conditions Mistaken for Meningitis. — A report of 
a number of cases of simulated meningitis is made 
by E. P. Baumann (flnV. Jour, of Child. Dis., Feb- 
ruary, 1905). They include a case of typhoid fever 
believed to be one of typical tuberculous meningitis 
and demonstrated as such to students; a case of 
lobar pneumonia in which the tache cerebrale was 
marked; a case of bronchopneumonia with extreme 
head retraction, michal rigidity, strabismus and 
Kernig's sign; a case of influenza, with head re- 
traction, rigidity of both legs, Kernig's sign, tache 
cerebrale, increased tendon reflexes and strabismus; 
and cases of mastoid disease, middle-ear disease, sar- 
coma of the brain, renal disease, and gastro-intestinal 
disturbance. Other conditions that sometimes 
closely ape meningitis are the hydrencephaloid con- 
dition of infants suffering from acute gastro-en- 
teritis, roundworms, trichinosis, abscess of the brain, 
hysteria, retropharyngeal abscess, tonsillitis, teeth- 
ing, the exanthemata, particularly scarlet fever; and 
last of all, cases catalogued in hospital records as 



698 



PRESCRIPTION HINTS. 



[Medical News 



cases of " pseiidomeningitis," in which all the symp- 
toms of cerebral irritation are present, and every 
possible cause having been excluded, a diagnosis of 
meningitis is arrived at, — then, for some unknown 
reason, the temperature falls, and the child recovers 
completely. 

The Dangers of the Use of General Anesthetics in 
Operations for Adenoids. — A discussion of the regret- 
able consequences that may follow the employment of 
anesthetics in general and bromide of ethyl in partic- 
ular in these operations, is made by S. de Mendoza 
(Arch, de Med. ct de Chir. Spec, January, 1905). No 
one should be exposed to the danger of death for an 
operation which should not last more than fifteen sec- 
onds, and in which the pain is a negligible quantity. The 
dangers from ethyl bromide are as real as those from 
chloroform. Those who look upon anesthesia for sim- 
ple ablation of adenoid vegetations as a necessary ad- 
junct to the mise en scene, should remember that, as 
Dastre has said, " Anesthesia is nothing else than a lim- 
ited poisoning, the first step in a general intoxication; 
the mortal dose is far from the useful one, but fre- 
quently, it may be near ; occasionally the road is on 
the edge of a precipice." If one is determined to use 
an anesthetic, it is a crime to make the family of the 
patient an innocent accomplice by assuring them that the 
anesthetic is not accompanied by any danger whatsoever. 

Weaning. — An extract on this subject from Prof. 
A. Pinard's book in the care of the young child, is 
published in Rci'. Prat. d'Obstei., et de Pediat., Decem- 
ber, 1904). The child should be weaned when at least 
a year old. If the child is thriving and has already 
shown evidence of digesting cow's milk, it may be 
weaned at the tenth month, provided that this does not 
coincide with the warm months. Weaning should not 
occur either immediately before or after the warm 
months; hence it should not occur in May, June, July, 
August or September. Prolonged lactation is bad, re- 
sulting in delayed dentition and maldevelopment of the 
bones. Gradual weaning should be practised. During 
the first year the infant should receive nothing but 
milk. The addition of soups, legumes, wine, etc., to its 
diet is to expose it to the danger of rickets. At the 
period of weaning the mother should expose herself to 
fatigue as little as possible, the breasts should be in- 
cluded in a binder with cotton and may be gently rubbed, 
morning and evening, with warm sweet almond oil. The 
use of purgatives is not indispensable. The mother 
should diminish the quantity of fluids in her diet. Dur- 
ing the second year, until the appearance of the twentieth 
tooth, the best nourishment for the child is fotmd in 
milk, bread and eggs. Under bread is included bread in 
all its forms, as well as the cereals. Exceptionally, 
toward the end of the second year there may be given 
in small quantity some puree of potato. The proprietary 
cereal preparations are to be avoided. The food should 
be liquid or semi-liquid at first. The fundamental food 
is milk. The quantity of the latter to be taken by a 
child one yesr old is about a quart. During the second 
year this quantity will hardly be exceeded. Overfeeding 
should be avoided. Insufficient nourishment is more 
frequently the result of over- rather than under-alimen- 
tation. In the beginning, a simple gruel should be given, 
at first once, and later, twice daily. At first only sugar 
and salt should he added, but later a little butter may be 
added in addition. In due time egg may be given. One 
should begin by giving the yolk only, mixed with the 
milk or gruel. Later the entire egg should be used. A 
frequent result of the addition of eggs to the diet is 
constipation. Until the twentieth tooth has been cut, 
it is necessary to closely watch the child's diet during 
the hot months. 



Infectivity and Management of Scarlet Fever. — 

A good deal has recently been written on the pros and 
cons of desquamation as a factor in determining posi- 
tively the infectiousness of a case of scarlet fever. Mal- 
lory. of Boston, has presented indisputable evidence of 
the existence of certain forms of protozoan-like bodies 
capable of segmentation and in many ways resembling 
the malarial organisms which have been found in the 
skin and in the occasional vesicles which form under 
certain conditions in the surface of skins of persons 
suffering from scarlet fever. W. T. Gordon Pugh 
(Lancet, February 4, 1905) concludes as a result of his 
investigations that the evidence in favor of the belief 
that infectivity does not lie in the desquamating cuticle, 
but in the throat and nasal cavities. In scarlet fever, 
therefore, as in diphtheria, it must be impossible, he 
asserts, to ascertain definitely by clinical means when the 
patient has been freed from infection. It must not be 
assumed, however, that prolonged infectivity is the rule, 
it being probable that the majority of patients are free 
from infection at the end of the minimum periods of 
isolation. It would seem impossible to discover by clin- 
ical means the minority who retain infection longer and 
difficult even to differentiate those by whom transmis- 
sion of infection is likely. The impression derived from 
experience has been that such transmission is likely to 
occur from those who suffer from rhinitis at the time 
of their discharge or who have suffered from this com- 
plication during the period of their isolation. A nasal 
discharge then, while not necessarily to be looked upon 
as giving evidence that the patient continues to be in- 
fectious is to be viewed with suspicion, for if the source 
of contagion still happens to continue in the secretion, 
it will certainly act as a vehicle for distribution should 
the case be allowed to pass out. 



PRESCRIPTION HINTS. 

Urticaria in Children. — M. Dauchez recommends in 
the (Jour. Med. de Brux, March 9, 1905) in the treat- 
ment of urticaria in children the following treatment: 
(1) Give to the child, during two or three successive 
days, as a laxative, one or two teaspoonfuls of the fol- 
lowing mixture : 

B Magnesium sulphate ") 

Sulphur sublimate ! 

D . , . , ^ > aa gr. V 

Bitartratr of potassmm. ( 

White honey J 

(2) Restrict the child exclusively to a milk diet, and 
later omit the use of fi.sh and fruits, especially of the 
fresh variety. (3) Immer.se in a gelatine bath (100 to 
200 gr.) for twenty, thirty or forty minutes, avoid wip- 
ing and wait two hours at least before applying, pre- 
ferably in the evening, by a pencil brush the following 
liniment : 

IJ Chloroform pure gr. iv 

Tincture of aconiti gr. vi 

Oil of sweet almonds gr. xc 

M. and stir well. For external use. 

(4) In case of irritation at night, apply warm sola- 
tions of opium or the decoction of tobacco, followed 
abundantly by the use of the following powder : 

R Talc (finely pulverized) . . 1 

Oxide of zinc > aa 

Starch (chemically pure) ) 

The above treatment is supplemented advantageously 
by the internal use of some slightly alkaline water (Vals 
or Vichy .St. Yorre) pure or mixed with milk. 

To prevent the offensive return of the urticaria, con- 
tinue the use of laxatives, each week; omit the use of 
preserves, pork, shellfish, salt fi.sh, especially in summer, 
strawberries, etc. -Avoid carefully overfeeding. 



April 15. 1905 



EDITORIAL. 



699 



The Medical News. 

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SATURDAY, APRIL 15, 1905. 



MEDICAL ADVERTISING AND THE DAILY PRESS. 

The counsel for the Medical Society of the 
County of New York, Champe S. Andrews. Esq.. 
has done a very laudable thing in giving due 
publicity to his article read before that society 
on " A Century's Criminal Alliance between 
Quacks and Some Newspapers." Any one vi'ho 
knows anything about the nefarious trade of the 
quack and how he succeeds in working on the 
fears of his victims, often, indeed, groundlessly, 
in order to secure what is so frequently the hard- 
earned savings of a lifetime, will appreciate the 
sociological importance of Mr. Andrews' work. 

There seems to be no doubt that he has struck 
the keynote of the whole case in laying the 
blame directly for the success of modern quackery 
upon the rapacity of the advertising department 
of many newspapers. Ninety-nine per cent, of 
the victims of qiiacks are attracted to these men 
as the result of reading newspaper advertise- 
ments. Not only are the victims attracted from 
the cities, but also from distant parts of the 
country. 

It seems idle for the newspapers to claim that 
they are guiltless in the matter. Some of the 
contracts made with quacks show that the\ 
charge practically double the ordinary rates of 



advertising to these men confident that owing to 
the objectionable nature of the advertising ma- 
terial and the fact that they are sharing in the 
profits of the nefarious work, they will obtain 
their price. In some of the cases of quacks 
recently condemned for fraud and extortion in 
New York City, the advertising contracts with 
New York papers ran up to many thousands of 
dollars a year. If these unfortunate evidences 
of lack of the true ethical spirit were on the de- 
crease, the present condition would not be so 
pitiable. As a matter of fact, however, there is 
more medical advertising and it is of more re- 
prehensible character now than ever before in the 
history of the modern newspaper. While many 
respectable papers refuse to accept medical ad- 
vertisements of any kind, and this is indeed the 
only proper position to occupy in the matter, 
others in their most widely circulated editions, 
publish more medical than of almost any other 
class of advertising. 

Perhaps the saddest feature of all this unfor- 
tunate business, is the fact that the newspapers 
that are most ardent in their protestations of 
interest in the poor and of persistent effort to 
save the people from impositions of various kinds, 
are the most flagrant violators of the simple code 
of ethics which, if effectively maintained, would 
at once put an end to a whole mass of impositions 
and frauil and deceit mainly affecting the poorer 
classes. If after the present exposure, for it 
can be considered nothing less than this, by any 
one who reads without prejudice Mr. Andrews' 
arraignment of the newspapers, then legal reme- 
dies must be secured or such as are at present in 
existence must be enforced. There is no doubt 
at all that with regard to many of these adver- 
tisements fhe present laws forbidding the passage 
tlirough the mail of printed matter evidently 
intended to be an auxiliary of fraud, might very 
well be enforced. If the advertisements of " get 
rich quick " concerns are not to be admitted to 
the mails, then surely the advertisements of the 
" get well quick " concerns might very well be 
excluded for similar reasons. 

If this cannot be done, then Mr. Andrews' 
suggestion that State legislation shall be obtained, 
seems to be next in order. At least one State 
has furnished a valuable precedent in this matter. 
As the result of properly directed efforts on the 
part of the State Medical Society of Michigan, 
a law has recently been passed to prohibit the" 
publication of the virtues of patent and other sim- 
ple and compound medicines in the State of 



700 



EDITORIAL. 



[Medical Xf.ws 



Michigan in language of immoral tendency or of 
ambiguous character. This law expressly forbids. 
for instance, the advertising of drugs of any kind 
for private diseases, for the cure of chronic fe- 
male complaints or compounds that are designed 
to prevent conception, or produce miscarriage, or 
abortion. Besides this a special act forbids the 
advertisement of anything having reference to 
the production of criminal abortion. These laws 
indeed might very well be imitated by other 
States to the great benefit to the morals of the 
community and to the good riddance of a class 
of persons eminently undesirable in their influ- 
ence in their present occupation. 

Unfortunately there is an impression abroad 
that the members of the medical profession are 
engaged in this work of preventing the advertise- 
ment of quack remedies, mainly because it is a 
business proposition to them, as if indeed these 
advertisements did not rather, by exciting the 
morbid feelings, bring an added number of clients 
even to regular practitioners. On account of 
this unfortunate impression, however, there must, 
in most States, be a preliminary period of educa- 
tion during which physicians must use every 
effort to make it clear that the proper regulation 
of medical advertising will result in benefit to 
the community at large rather than to the physi- 
cian and will at the same time eradicate from 
our newspapers one of their most objectionable 
features. 

PROPHYLAXIS AND TREATMENT OF INTESTINAL 

AMEBIASIS (AMEBIC DYSENTERY) 

IN THE TROPICS. 

Intestinal amebiasis (amebic dysentery) is 
the most important disease of the Philippine 
Islands. It causes more disability and does more 
to cripple enterprise there than all the other in- 
fectious diseases combined. Heretofore a ra- 
tional prophylaxis and treatment has been im- 
possible, as knowledge concerning the exact 
role of the ameba in the disease and their dis- 
tribution in nature has been wanting. The 
methods of cultivating amebas, fully described 
by Musgrave and Clegg,' have now supplied this 
fundamental knowledge. 

According to Musgrave, ° who has done much 
important work on amebiasis, all ages, classes, 
and races are attacked. Children are less sus- 
ceptible to the disease than adults and are more 



1 Bulletin No. i8, Government Laboratories, Manila, Jour, of 
Infectious Diseases, 190^, 11, No. 2. 

2 Bulletin No. 18, rTovernment Laboratories and Jour. Am. 
Med. Ass'n., 1905, April 8. 



amenable to treatment. Recently arrived Cau- 
casians are the most liable to the disease. Nat- 
ural immunity apparently plays an important 
role in determining infection, as many foreigners 
who have been there for years, have taken no pre- 
cautions, but have not contracted the disease. 
This immunity probably depends on many con- 
ditions and unfortunately is often transient. 

Theoretically, amebic dysentery is a prevent- 
able disease. The ideal prophylaxis is to avoid 
taking anything into the alimentary tract that has 
not been sterilized by heat. This, however, is 
not always practicable, is always inconvenient, 
and is often unnecessary. The following state- 
ments suggest the main lines of practicable 
prophylaxis suitable for the tropics in general. 

{a^ ^^'ater : Practically all of the surface water 
of the Philippine Islands is infected. Cistern 
water is especially dangerous. Pathogenic atme- 
bas have repeatedly been isolated from the city 
water of Manila. For drinking purposes, distilled 
water and carbonated and imported waters arc 
the safest. The distilled water, however, is often 
contaminated by improper handling, either be- 
fore or after purchasing, and some of it on the 
market has never been distilled. The carbonated 
and imported waters, also, are occasionally con- 
taminated and sometimes fraudulent. 

For the preparation of food and the washing 
of dishes, unboiled tap-water should never be 
used. Every kitchen should be provided with a 
large hot-water tank, which should be the only 
source of water for such purposes. For the bath, 
tap-water is satisfactory, but its entrance or in- 
troduction into the rectum or vagina should be 
carefully avoided. Much of the ice-cream of 
commerce, especially the " sorbette " sold on the 
streets, contains encysted amebas, and in this 
stage the parasites are most dangerous. 

(b) Vegetables and Fruits: The surface of 
fruit and uncooked vegetables is probably one 
of the most fruitful sources of infection. Yet 
many people who are quite careful about drink- 
ing-water, eat these articles without special prep- 
aration, except, at most, the rinsing of them in 
distilled water. To test the efficiency of such 
cleansing, a head of lettuce, one of the most fre- 
quently infected vegetables, was washed four 
times in distilled water, each washing being more 
thorough than that given by the average house- 
wife, and the wash-waters then examined. 
Amebas were cultivated from all four wash- 
waters. These cultures proved pathogenic to 
monkevs. 



April 



:9CE] 



EDITORIAL. 



Such articles of diet can be rendered harmless 
by dipping them for a few seconds in boiling 
water. Few fruits and vegetables are materially 
damaged by such scalding if they are previously 
rendered ice-cold by being placed on ice. 

(c) Soil : This is the natural habitat of amebas. 
Especial care should be taken of the cleanliness 
of the hands. 

{d) Personal Factors: The normal acidity of 
the stomach is probably one of the preventives 
of amebiasis, but gastric derangements in warm 
countries are frequent. Diarrhea, constipation, 
abnormal conditions in the mouth, and indiges- 
tion predispose to the disease. Consequently, 
great care should be taken to keep the digestive 
system in good condition. To avoid amebiasis 
a carefully planned personal hygiene of living 
should be followed. It is to daily lapses in this 
hygiene rather than to the general plan of living 
that infection is generally traceable. 

(c) Public Factors: Public control of cases is 
neither necessary nor desirable, but regulations 
requiring the report of cases would be of value. 
Soldiers, on coming to this country, are carefully 
instructed how to avoid the disease. Statistics 
show that amebic dysentery is only one-tenth 
as common among them as among civil em- 
ployees. Provision for the proper instruction 
of those in civil life would be amply repaid by 
increased efficiency. 

Any routine treatment of the disease is unsatis- 
factory. Each case must be studied by itself, and 
the mode of infection, the duration of the disease, 
and the location of the lesion must be taken into 
account. A careful record of weight should be 
kept to determine the success of the treatment. 

Acute manifestations are rare early in the dis- 
ease, but are frequent as exacerbations. They 
should be treated like acute colitis from other 
causes : the patient is put to bed, kept perfectly 
quiet, and given a liquid diet. Pain may be con- 
trolled by local applications, opium, cathartics, 
and cold or sedative enemas. 

In the absence of acute manifestations, less 
severe measures are used. The patient is not con- 
fined to bed, and takes gentle exercise. Attempts 
are made to build up his general health. The 
following suggests the usual general line of treat- 
ment : 

(a) Diet : The appetite and digestion are often 
good, notwithstanding extensive ulceration of the 
intestines. A limited and selected diet should be 
used in cases in which the stomach and intestines 
are deranged or the rectum very irritable. In 



the ordinary type of case, however, a liberal diet 
is beneficial, irritating and fermentable foods only 
being avoided. If the cecum is involved, the pa- 
tient should be put on a liquid diet. 

(b) Change of Climate: While not a specific, 
this is valuable, especially in old, emaciated cases. 
Local treatment, however, must be kept up. If 
possible, the patient should be given a letter to 
a physician in the place to which he goes, ex- 
plaining the nature of his disease. 

(c) Drugs: No drug by mouth is specific. 
Bismuth may be useful, harmless, or harmful, 
according to the way it is used. It impregnates 
the edges of the ulcers and prevents the action 
of local remedies. Salines should be used only as 
active cathartics. Mineral acids are of most 
value if given in connection with pepsin. Strych- 
nine stinuilates the intestine and must be used 
with care. Quinine is valueless by mouth. Even 
when malaria is a complication it is best given 
as an enema. 

(d) Local Treatment: Enemas of benzoyl- 
acetyl-peroxide, succinic peroxide, hydrogen 
peroxide, and silver nitrate have been used. The 
quinine enema is the most satisfactory. The 
proper strength of this varies from i to 1,500 to 
I to 750. Hydrochloric acid is a better vehicle 
than sodium chloride. The latter has been shown 
to cause antiperistalsis and should be avoided, 
especially where nausea is a symptom. Injections 
shovdd be given from one to three times daily 
and the quality of fluid used should be the largest 
that can be retained from five to fifteen minutes. 
The enema should be approximate of body tem- 
perature. If too hot or too cold it causes encyst- 
ment of the amebas. 

Cold injections, however, have two advantages. 
After encystment the parasites are flushed from 
the bowel with greater ease. Tuttle has recently 
reported good results in amebic dysentery by the 
frequent administration of simple ice water ene- 
mas. Furthermore, although the introduction of 
an ice-cold enema is often quite painful, it is 
frequently followed by a rare sense of comfort. 
Where other methods fail, a tolerance for the 
quinine injection may sometimes be secured by 
rendering it ice-cold or by having it preceded 
by an ice-cold simple enema. Musgrave recently 
tried the cold quinine injections on twenty old 
and very resistant cases. The results, while en- 
couraging, have not been universally satisfactory. 

The injecting apparatus consists of a glass 
pressure bottle, connected with five or six feet 
of soft rubber tubing, a valve stopcock, and a 



EDITORIAL. 



[Medical News 



rectal tube lOO cm. long and from lo to 15 mm. 
in diameter. The end of the rectal tube contains 
a single round hole and is slightly contracted and 
hardened. Two openings are not so satisfactory, 
as buckling of the tube is not so easily detected. 

In giving the enema, the patient is put either 
in the Sims position with hips elevated, or in 
the knee-chest position, and, if possible, the foot 
of the bed is elevated 12 to 18 inches. The tube 
and anus are well lubricated and the tube freed 
from air. The end of the tube is introduced be- 
yond the sphincter, the flow turned on gently 
and controlled by the finger, after which the 
tube is introduced 40 to 100 cm. and the flow 
increased. One to three liters, and in some cases 
four liters, may be given. When all the fluid 
is in, the position of the patient is changed so 
that the fluid may be retained a longer time and 
reach all parts of the colon. 

To relieve bowel spasm, occurring usually dur- 
ing the entrance of the fluid, the rate of flow and 
the position of the patient are varied. If the 
bowel is very irritable, a preliminary enema con- 
taining a half grain of morphine may be given, 
half an hour before the quinine enema. A pre- 
liminary simple enema is often useful as a routine. 
An excessively irritable anus may be relieved by 
a cocaine suppository. This, however, sometimes 
interferes seriously with the action of the sphinc- 
ter during the injection. After each injection the 
exposed parts should be washed with soap and 
water and an antiseptic solution. 



THE RELATION BETWEEN THE FATTED CALF 
AND THE PRODIGAL SON. 
There is a new Richmond in the field and tlie 
" Ministerial Alliance." of Toledo, seems again 
to be up and doing. This in itself is nothing 
new, as the clerical finger is very apt to he thrust 
into the municipal pie when work is to be found 
for idle hands to do. But in this case the cloth 
seems to have impressed some of the medical 
fraternity into joining them in a purity crusade, 
the particular object of which is the abolition of 
the display of women's hosiery in shop windows. 
It seems that up to this time the proscribed 
stockings have been exhibited by the shopkeep- 
ers in flattened masses that were entirely unsug- 
gestive of the dainty curves that they were manu- 
factured to cover and yet to emphasize, or were 
so arranged that they presented simply formless 
mounds of variegated colors. Now this has been 
all changed, and thi' deft fingers of the " window 



dresser '" have, by the aid of what is technically 
known to the trade as " forms," produced a dis- 
play of shapely, well-dressed limbs that would 
put the ballet of the original Black Crook to 
shame and which, according to the local press, 
has drawn the youthful mind from all thoughts 
of the straight and austere lines of home and 
mother. In fact, these Toledo youths have been 
taught by these exhibitions that the line of beauty 
is a curve, and they have not only caught on to 
the curve itself, but have found out in ever-in- 
creasing numbers that the lines have truly fallen 
in pleasant places. 

Now' all this may be, and doubtless is, dis- 
tressing to the clergy, a good many of whom 
know from more or less practical experience, the 
dangers of a temptation that they are accustomed 
to handle both in the pulpit and out of it. But 
it is no excuse for the doctor to go from practis- 
ing to preaching, as he is the one man that should 
realize that nothing breeds contempt in the youth- 
ful mind so quickly as familiarity, and that cus- 
tom will stale any fictitious ardor that novelty 
can produce. Thus no one comments on the ab- 
breviated skirts on a bathing shore, or notices 
the bare arms and necks of the ballroom, but re- 
verse the order of things and there would be a 
riot on the dancing floor and a masculine mass 
meeting on the beach. 

Ten years ago, before the general adoption of 
athletic sports, with the concomitant costumes, 
women, and men, too, clad in these regalia, 
would have been followed in the streets by a 
jeering, scoffing crowd of abusive gamins. To- 
day not one of these urchins would turn his head 
or remove his ever alert faculties from the pen- 
sive contemplation of his half-smoked cigarette. 
At the present time a woman could walk the 
whole length of Broadway clad in a short tennis 
skirt without attracting the slightest attention. 
Sliould she, however, attempt a crowded cross- 
ing in a long dress lifted to the same degree of 
elevation, or should she be caught in a spring gale 
on the weather side of the Flat-iron Building, the 
price of " rubber " would rise as quickly as her 
skirts. 

The stocking itself, however, is generally 
deemed a necessity in all civilized communities, 
and is one of, if not the most, important articles 
of wearing apparel. Its manufacture by hand 
gave our mothers and grandmothers, infinite sat- 
isfaction, and the use of their busy needles killed 
the ennui of many a long winter evening. Now 
this has passed away, and the blue and gray yarn 



April 15. 1905] 



ECHOES AND NEWS: NEW YORK. 



703 



products of our ancestors have been supplanted 
by the looms of commerce, which, under the in- 
fluence of modern art, have blossomed out into 
an infinite number of lace, silk and lisle-thread 
varieties, the sight of which might well have 
dazzled more seasoned eyes than those of these 
young Toledo blades. 

Apart, too. from its legitimate and accustomed 
use, the stocking fills many otherwise vacant 
niches in our domestic economy. Thus it is in- 
separably connected with our youthful recollec- 
tions of Santa Claus. as no Christmas would have 
been complete without it hanging by the chimney. 
In France, and for that matter in this country, 
too, it is a favorite receptacle for hoarding 
money, the one difference being that the Gallic 
article is usually an old one belonging to an el- 
derly woman, while with us it is apt to be one 
of the newest fashions which adorns a leg that 
is seldom bent by age. As a weapon of offense, 
it has. when filled with sand, become a most dan- 
gerous and deadly factor in the hands of the 
thug, making no noise and leaving no scar, so 
that, taking one consideration with another, the 
stocking's lot is not an idle one. 

\\'e do not, however, consider that these prodi- 
gal sons of Toledo are in any danger, particular- 
ly if they become inured to these temptations at 
an early age. We have all heard of the woman 
who was able to carry the cow in her arms 
simply because she began in its infancy, and we 
do not believe that these wooden calves will grow- 
in weight as the years go by. Moreover, the 
average youth in a Western city who cannot tell 
the diiiference between these " artificial limbs " — 
no matter how temptingl\- they are arrayed in 
open-worked hose, bounded on the north by blue 
ribbon and on the south by a Louis Ouinze slip- 
per with its golden buckle — and nature's form 
divine, is painfully apt to die of starvation in the 
struggle of the survival of the fittest, and even if 
the means of subsistence had been inherited from 
a less impressionable father, his position in and 
his influence to the community would consist 
simply of being a purchaser of illusive and glit- 
tering gold bricks, from his more needy and 
worldly-wise competitors. 

As far as our sympathies are concerned in this 
matter, they lie entirely with the very reverend, 
the president of the Ministerial Alliance of To- 
ledo, Ohio. He is evidently sincere, and as evi- 
dently a wholesale reformer; one w^ho will not 
dally with the compromise-producing position of 
Mother Goose and her son John, with one stock- 



ing off and one stocking on, but who stands 
squarely, with both feet bare, on the straight-out- 
and-out platform of the " Sockless Jerry." We 
do not wish to impugn his motives, and far be it 
from us even to suggest that he has civic aspira- 
tions, but from his utterances we can imagine 
him as wearing brogans next his thickened skin, 
disdaining stockings with all the unconcern re- 
quired to fit him for a successful political career 



in bleeding Kansas. 



ECHOES AND NEWS. 



NEW YORK. 

Dr. Ball an Emeritus.— The trustees of Columbia 
Univer.sity have made Dr. Alonzo Brayton Ball emer- 
itus professor of clinical medicine, in recognition of his 
long years of teaching service at the College of Physi- 
cians and Surgeons. 

Voice Topics. — This is a new journal, a quarterly, 
edited by Dr. F. A. Bryant, of New York, devoted en- 
tirely to the subject of the voice, particularly to stam- 
mering and its, treatment, in which specialty Dr. Bryant 
has long held a prominent position. We wish it a 
hearty success. 

New Epileptic Home.— Private enterprise will fur- 
ther the efforts of tlie State in providing for epileptics 
at a new sanitarium, to be opened at Glenwood, Dans- 
ville. Livingston Co., N. Y., May 15, 1905. The site 
chosen is a dehghtful one, in the same general region as 
Craig Colony, which has shown such excellent results, 
and there is every reason to believe that the new epileptic 
colony will prove highly valuable. The terms are to 
be moderate and training is to constitute a desirable 
adjunct to hygienic measures. 

P. & S. Hospital Appointmentss. — Tlie following is 
the list from the College of Physicians and Surgeons 
for the curent week: Methodist Episcopal. Brooklyn, 
First, H. F. Graham, A. C. Hutcheson. St. Vincent's, 
First, W. J. O'Leary, J. S. Brady, C. M. Quinn, D. .A.. 
Corcoran. City, C. S. Boyd, H. S. Martland, P. C. 
Piuiiyea, J. D. Slack. Monmouth Memorial. Long 
Branch. X. J., J. Z. McDermott. Nexvark City, J. J. 
Smith ; Alternates, C. L. Allers, S. W. Dodd. German, 
Brooklyn, J. J. Valentine, German, N. V., First. R. M. 
Ottenberg. .\. H. Noehrcn. E.xternes, A. M. Hellman, 

D. J. Kaliski. Posl-Graduatc. 1. W. Voorhees. 
Cornell University Medical College. — The follow- 
ing members of the Graduating Class of Cornell Univer- 
sity Medical College have thus far obtained hospital ap- 
pointments ■.—Bellevue Hospital, Fourth 'Division, J. H. 
Richards, H. P. Groesbeck, A. A. Walker; N. Y. Post- 
Graduate Hospital. B, F. Drake; German Hospital. G. 
L. Rohdenburg, J. H. Cudmore ; Methodist Episcopal 
Hospital (Scney). W. B. Zimmer; City Hospital, H. A. 
Walker, J. M. MacKellar ; Brooklyn German Hospital, 

E. O. Darbois, H. B. .\very ; Babies' Hospital, Elizabeth 
M. Worts ; Rochester City Hospital, M. Chapman ; U'or- 
cester Memorial Hospital, L. E. Todd, A. L. Bedford; 
Robert Packer Hospital (Sayre. Pa.), H. I. Andrews, 
Jr: Rhode Island General, S. N. Smith, Jr ; St. I'in- 
cent's Hospital. A. M. Wright. 

Meningitis Decreasing. — Commissioner Darlington, 
of the Board of Health, last Tuesday made public figures 
showing that the death rate for last week was consid- 
erably less than it was the corresponding week last year 
and that the deaths due to cerebrospinal meningitis were 



704 



ECHOES AND NEWS: NEW YORK. 



[Medical News 



twenty-one less than the previous week. The death rate 
for the week ended Saturday at noon was 20.1 1 per 
thousand, while for the corresponding week of 1904 it 
was 25.76. Week before last there were no deaths due 
to cerebrospinal meningitis, while for the previous week 
the number was 131. In the corresponding week of 
last year the deaths resulting from the same ailment 
were 29. Pneumonia caused 232 deaths last week, 
against 427 for the same week last year. It is pretty 
"well recognized that if more autopsies could be made on 
so-called meningitis cases it would be found that from 
25 to 30 per cent, of the deaths accredited to that disease 
was due to other ailments. 

New York County Medical Association. — At the 
next regular meeting of the New York County Medical 
Association, to be held on April 17, 1905, at the New 
York Academy of Medicine, 17 West Forty-third 
Street, Dr. Francis Huber will read a paper on : 
"The Clinical Features and Treatment of Cerebro- 
spinal Meningitis." This paper is to be discussed by 
Dr. Abraham Jacobi, Dr. L. Emmett Holt, Dr. 
Thomas Darlington, Dr. Harlow Brooke, Dr. Hermann 
Biggs, and otlier distinguished authorities in the city. 
The second paper will be read by Dr. William B. 
Pritchard, on ; " Galvanism as a Curative Ageiit in the 
Treatment of Nervous Diseases : Its Equipment and 
Technic." This paper will be discussed by Dr. George 
W. Jacoby, Dr. William J. Morton, Dr. J. J. MacPhee, 
Dr. Milton Franklin. The Association has rarely pre- 
sented such an interesting program as the foregoing, 
and invites the medical profession to its meeting. 

Lunacy Budget Itemized. — A highly desirable curb 
has been put on the State Lunacy Commission, which a 
short time ago voted to buy the farm of I. V. Baker, 
of Washington County, as the site for an insane asylum. 
In years past the commission has been in the habit of 
getting large lump sums from the legislature without 
specifying objects. Last year, for instance, the com- 
mission received a lump sum of $1,203,000 for making 
improvements, etc., at the various institutions. Follow- 
ing the Baker site scandal and the, as yet unexplained, 
disclosure of a $455,000 deficiency, the board has had to 
make an itemized statement this year of the cost of pro- 
posed improvements and the items have gone iVito the 
form of a single bill. The Ways and Means Committee 
of the Assembly directed the Lunacy Board to do this. 
The $1,152,566 asked for is divided into 146 items rang- 
ing from $60,000 to $242,000. It is surmised in some cir- 
cles that the change is due to Governor Iliggins. Be- 
sides showing the public what the commission purposes 
to do this itemized method gives the Governor an op- 
portunity of cutting out appropriations intelligently. The 
bill, however, does not prohibit this board taking away 
from one item and adding to another. Among the items 
are the following: Reception hospital in New York, 
$150,000; two hospitals for acute insane, each to accom- 
modate not less than eighty patients, and to be located 
at such established State hospitals as the commission 
may determine, $144,000; construction and furnishing of 
a building to accommodate at least 440 patients of the 
chronic class at one of the established hospitals to be 
designated by the commission, $242,000. The anomalous 
appointments of three immigration inspectors, drawing 
salary, who are not allowed to inspect by the Federal 
authorities >.|ill pass without comment. Some more 
Odellisni. 

Deficient Children in the Schools. — Investigation 
has shown that there are thousands of children admitted 
to the public schools every year who are absolutely 
unfit mentally, morally and physically to cope with the 
conditions which they meet. Examinations are being 



conducted along these lines by Dr. Luther H. Gulick, 
director of physical training for the city's educational 
institutions, and his assistant. Dr. Asa R. Brown. 

" Fully ten per cent, of the pupils of the public 
schools," said Dr. Gulick last week, " should have spe- 
cial attention. I should say that from five to ten thou- 
sand of the two hundred and fifty thousand children in 
the schools of this city are so deficient that they should 
have special instruction in small classes in order to fit 
them for any part in life, and they should have the most 
tender care. With the funds now available," continued 
the Doctor, " it is not possible to conduct examinations 
on the scale which should be followed. Only the pupils 
whose appearance is such that the teachers are able to 
recognize that something is wrong with them are ex- 
amined. The time will come, though, when every child 
upon entering .school will be inspected by physicians 
so that it may be determined at the outset if he has any- 
thing the matter with him which would interfere with 
the prosecution of his studies. If a boy has weak eyes 
the authorities will see that he is provided by his par- 
ents with glasses, and instructions could he given that 
he be placed in a front seat. If a child is partially deaf 
every care should be taken to make sure that he if so 
placed that he can hear all that is said. Many children 
come to our schools who are beginning to develop curva- 
ture of the spine. A minute of such a fact could be 
made and the teacher could be advised of the condition 
so that the boy could be urged to sit correctly. Such 
care as that might result in the pupil gradually overcom- 
ing a tendency toward deformity." 

With reference to the widely circulated state- 
ment that seventy thousand children go to school 
hungry, Dr. Gulick said " that there are very 
few such cases as that. Nevertheless if children are 
sent to school hungry it should be the duty of the teacher 
to find out that fact and by conference with the parents 
or in some other way make an arrangement by which the 
child shall live under better conditions. It is manifestly 
not the best plan to keep these deficient children in the 
regular classes. By so doing the progress of the other 
pupils is retarded and the backward ones do not get the 
instruction which they should have. You ask me as 
to the mental state of the two per cent, of the school 
children which I have mentioned. They are of course 
considerably in advance of children who are usually 
cared for in institutions and asylums provided by the 
.State, yet they are incapable of keeping up to the grades 
in the public schools. Thoy cannot be made to conform 
to the regular courses of instruction, yet by special care 
they can be made useful and self-supporting members 
of society. They should be taught first of all to labor 
with their hands, for by that means they will be able 
to earn their living. They can of course learn to read 
and write and to cipher a little. They can at least ac- 
quire enough arithmetic to enable them to count their 
money. It is impossible for teachers in regular classes 
which consist of about fifty pupils to do any work along 
these lines. Not more than fifteen of such pupils should 
lie assigned to one teacher, for each one should have in- 
dividual instruction and study. At the present time 
there arc in all eighteen of these classes, averaging 
fifteen each, or, in other words, there are facilities for 
taking care of two hundred and seventy backward pu- 
pils, although I estimate that there are from five thou- 
sand to ten thousand children who require special train- 
ing and attention." To substantiate the conclusions 
which he had reached Dr. Gulick called attention to the 
investigations conducted by his associate. Examinations 
of 2,084 children were made by Dr. Brown, which are 
used as a basis for the policy advocated with regard to 
the needs of the schools. 



iyo5| 



ECHOES AND NEWS: PHILADELPHIA. 



705 



PHILADELPHIA, 

Meningitis Reaches Pittsburg. — Pasquale de Costa, 
a boy, aged fifteen ycar.-i, who had recently come from 
New York, introduced this disease into Pittsburg. Kis 
case was reported to the Board of Health and he was 
at once removed to the Municipal Hospital, where he 
died. 

Dr. Osier will Address Students. — Under the aus- 
pices of the Stille Medical Society of the University, Dr. 
Osier will deliver a lecture to the students of the Uni- 
versity of Pennsylvania, upon the " Student Life," on 
April 19, 1905. Nelson W. Janney is chairman of the 
committee appointed to receive Dr. Osier. 

College of Physicians. — The society met April 
5, 1905. The members listened to the reminiscences of 
the earlier experiences of Drs. S. Weir Mitchell. W. W. 
Keen and John S. Billings. lAfter the meeting the mem- 
bers went to the University Club, where the evening's 
entertainment was concluded with a smoker. 

Obstetrical Society. — This society met April 6, 
1905. The scientific program was opened by Dr. G. E. 
Schoemaker with a paper on " Some Operative Re- 
sults." It was discussed by Dr. Noble, Dr. Norris and 
Dr. Hirst. Dr. B. C. Hirst read the next paper which 
was entitled " A Contribution to the Efficiency of Plas- 
tic Operation in the Genital Canal." 

Woman's Medical College of Pennsylvania. — 
Gertrude .\. Walker, clinical Professor of Ophthalmol- 
ogy, has resigned her position and .\nina C. Rondi- 
nella has resigned as Demonstrator of Ophthalmology 
and Assistant Demonstrator of Pathology. The ap- 
propriation received from the State has apparently 
wiped out the ill feeling that existed between the hos- 
pital and tlie college departments of the institution. 

Smallpox Infests a Town. — Mount Union, a town 
of 1,000 inhabitants in Huntington County, has quaran- 
tined nearly lOO cases of smallpox. The epidemic broke 
out some time ago and it was at first diagnosed as be- 
ing chickenpox. Its spread caused the State Board of 
Health to send the quarantine officer to make an exam- 
ination. The inspector reported the disease as smallpox 
and the infected houses were at once isolated. Before 
the visit of the inspector the affected individuals were 
permitted to mingle with the non-diseased persons, so 
that trouble is anticipated in stamping out the epidemic. 

New Buildings for the Municipal Hospital. — Bids 
will soon be advertised lor the construction of two new 
buildings on the new Municipal Hospital grounds. Each 
structure will be built of brick, will be two stories high 
and will contain two wards, and accommodating 300 
patients. One building will be reserved for scarlet fever 
patients and the other for diphtheria, .\rrangements 
will be made to disinfect every person or article that 
enters or leaves the building. There is available for the 
construction of these buildings $900,000. The smallpox 
ward, which has been building for nearly a year, is now 
complete. 

Mayor's Message Refers to the Work Done by 
the New Bureau. — In his message to the council the 
Mayor calls attention to the fact that the Department of 
Public Health and Charities has been in existence since 
1903 only, and in that time the Department has wiped 
out smallpox and has lowered the death-rate of other 
diseases. He points out to the council that something 
should be done so soon as possible to relieve the con- 
gestion at the Philadelphia General Hospital for the In- 
sane and the Hospital for the Indigent. He informs 
the council that plans and specifications have been drawn 
for the construction of an administration building for 
the insane and one for the indigent, but, he is of the 
opinion that all the insane cannot be quartered there. 



A Free Bed for Each $5,000 State Aid.— The 

Senate Appropriation Committee has inserted a pro- 
vision in the bill for several Allegheny County Hospi- 
tals which provides as follows : That in consideration 
of the appropriation there shall be maintained a free 
bed for each $5,000 appropriated. The Mayor or the Di- 
rector of the Department of Public Safety or the Direc- 
tor of the Department of Charities of the proper city 
will issue a certificate to the applicant to occupy these 
beds. The certificates are then to be presented to the 
hospitals' officer who will pass upon the propriety of 
such patients. 

Conference of Anatomists. — The first session of 
the Conference of American .Anatomists was held April 
1 1 in Wistar Institute. Anatomists from all parts of the 
country were present. The subject considered at the 
meeting was the advisability of selecting a central insti- 
tute for cooperative research, the board of managers of 
the Wistar Institute offering that institution for the pur- 
pose. Those in attendance were : Dr. Llewellyn F. Bar- 
ker and Dr. Henry H. Donaldson, Chicago University; 
Dr. Simon H. Gage, Cornell University; Dr. G. Carl Hu- 
her and Dr. J. P. McMurrich, University of Michigan; 
Dr. George S. Huntingdon, Columbia University; Dr. 
Franklin P. Mall, Johns Hopkins University; Dr. 
Charles S. Minot, Harvard University ; Dr. George A. 
Piersol and Dr. Edwin G. Conklin, University of Penn- 



sylvania, 



Houses in Which Meningitis Exists to be Pla- 
carded. — Dr. Benjamin Lee, secretary of the State 
Board of Health, has ordered that physicians report all 
cases of this disease to the health authorities and that 
the houses in which the malady exists shall be placarded. 
The sign shall contain a warning to the public asking 
them not to enter except by the permission of the Board 
of Health, Upon the placard will be written in large 
letters " Epidemic Cerebrospinal Fever ; Spotted Fever— 
an Infectious and Communicable Disease." The pres- 
ence of the poster on the house will not establish a 
quarantine of the inmates of the premises but merely a 
warning to the public not to enter. After the removal 
or the death of the patient the place shall remain 
placarded for at least one week. 

Cerebrospinal Meningitis Discussed. — In a paper 
read before the .■\mericaii Philosophical Society, Dr. 
A. C. Abbott said that the present so-called epidemic 
began about September 8, 1904, and since that time 51 
cases had been reported, but this figure includes the 
tuberculous meningitis also. From the widely separated 
foci in which the disease developed he inclines to be- 
lieve that it is not contagious. In only four instances 
did he find that more than one case existed in the same 
house. The death-rate is about 35 per cent, in this epi- 
demic. In discussing this paper Dr. Tyson said he has 
been trying to collect data with the view of drawing out 
a similarity between the meteorological conditions of the 
winter of 1864-65 and the present. They were remark- 
ably cold. Dr. Cleeman said in Russia where it is very 
cold they have never had an epidemic of meningitis. 

Governor Vetoes Consumptive Camp Appropria- 
tion. — In giving his reasons for the veto, he said, 
the bill opened a new field for establishment of chari- 
ties for whose maintenance the State would be held re- 
sponsible. " If we are to provide for consumptives be- 
cause they are likely to be fatal and because they are 
likely to injure others we may some time be called upon 
to take care of individuals suffering with smallpox, 
leprosy, yellow fever, bubonic plague, typhoid fever or 
pneumonia." The bill makes no distinction between the 
class of cases treated. He is of the opinion that it 
should be confined to the poor. The commission which. 



7o6 



ECHOES AND NEWS: CHICAGO. 



[Medical News 



according to the bill, shall contain two practising phy- 
sicians, he believes should be made up of experienced 
business men and artisans rather than of men with 
professional experience. To create a commission would 
take away important matter from a department recently 
formed by the passage of a bill. 

CHICAGO. 

Cerebrospinal Meningitis, — Only one or two cases 
of malignant spinal meningitis have come to the atten- 
tion of the City Health Departinent up to this writing. 
It is said there were several suspicious cases, but these 
turned out to be not of the contagious form. There is 
no danger of an epidemic. 

Fire at the Illinois Southern Hospital for the 
Insane. — .\ lire broke (lul at this institution, damag- 
ing the pow-er house to the extent of $5,000. Xo casual- 
ties occurred. The patients were taken from their rooms 
and marshaled in halls in case it proved necessary to 
remove them from the building. 

Inspection of Joliet Penitentiary, — It is said that 
tuberculosis has spread so rapidly among the prisoners 
in this institution, being attended by a largely increased 
mortality, that the State Board of Health has under- 
taken an investigation. It is thought that a crisis has 
been reached in the efforts of the prison authorities to 
combat the disease under present conditions, and that 
unless better sanitation is established, it will be prac- 
tically impossible to prevent the spread of the disease 
to the prisoners now there, and to others who may be 
sentenced to Joliet in the future. Among those who 
will conduct the investigation are the President of the 
State Board of Health, Dr. George \V. Webster; Dr. 
J. H. Long, Professor of Chemistry in Northwestern 
University Medical School ; the Secretary of the State 
Board of Health, Dr. J. A. Egan, and Mr. J. .\. Harmon, 
of Peoria, the Sanitary Engineer of the Board. Dr. 
Webster is quoted as saying, " We have no accurate 
knowledge of sanitary conditions at Joliet as yet, but 
we know they are far from perfect. In instituting an 
investigation, we are acting on the belief that the State 
of Illinois has no more right carelessly to infect a con- 
vict with tuberculosis than it has to take him out and 
hang him." Professor Long will make an analysis of 
the air in different parts of the prison, where it seems 
that lack of ventilation promotes the spread of infection. 

When Shall We Be Chloroformed?— .^t a recent 
meeting nf the Plixsicians' Club this subject was dis- 
cussed both by laymen and physicians. Franklin Mac- 
Veagh replied to the question, " When Shall the Busi- 
ness Man Shuffle Off?" He said he is willing to feed 
out the 95 per cent, of incompetents to the Osier wolves 
in order to save the five per cent. wJio are fitted to 
survive. Only five per cent, of men who embark in 
business succeed ; the 95 per cent. fail. They cannot 
meet the competition, but perhaps they could have done 
well as college professors, some of them. Prof. Geo. E. 
Vincent, of the University of Chicago, replying to the 
query, "When Shall the Professor be Doped?" intro- 
duced his graver remarks by an anecdote. A Scotch 
exhorter asked his congregation how many wanted to 
go to Heaven. All responded except one canny old fel- 
low. "Don't you want to go, Sandy?" demanded the 
exhorter. " .\ye," responded Sandy, " only I don't care 
to be personally conducted." He declared tliat the older 
a professor got, the better fitted he was for his business, 
since the ideal of the college professor is to be perma- 
nently dogmatic. Bishop Samuel Fallows considered 
the point, " When Shall We Administer Cliloroform to 
the Clergyman ? " He believes in persons getting out of 
the world when it is a decent time; but the days of 



man are not the proverbial three score and ten, but 120 
years. This is scriptural, and he is glad to see it is 
also the present scientific idea. The subject w-as fur- 
ther discussed by Dr. Wm. Allen Pusey, Mr. I. K. Pond, 
Mr. Joseph W. Errant, Mr. \\'. D. Nesbitt, and Joseph 
L. McMahon. 

GENERAL. 

Meningitis in Silesia, — There is an epidemic of 
cerebrospinal meningitis at Kattowitz, Prussian Sile- 
sia. There have been 236 cases, of which 133 have 
proved fatal. 

Ireland Physicians Honor Dr, Osier. — Dr. Wil- 
liam Osier. Regius Professor of Medicine at Oxford 
I'niversity, has been elected an Honorary Fellow of the 
Royal College of Physicians of Ireland. 

Meeting of Texas State Board of Medical Ex- 
aminers. — The Board of Medical Examiners for the 
State of Texas (Regular) will hold its next meeting 
in .\ustin, Texas, May 2. 3, 4 and 5, 1905, for the 
examination of applicants, 

A Congress of Midwives. — The midwives of Italy 
:irc shortly to meet in a national congress to be held 
;it Milan. Intimations of adhesion have been re- 
ceived from the midwives' societies of Turin, Ge^oa, 
Milan, Bologna, Florence, Rome, and Cremona. 
The municipality of the city and the council of the 
province of Naples have promised their support. 
-Xddresses wilj be delivered by Professors A. Guz- 
zoni. of !Messiiia, E. Pestalozza, of Florence, and L, 
Bossi. of Genoa. 

Lepers in Canada. — The annual report presented 
to the Federal Parliament of the Dominion of Can- 
ada by Dr. Smith, Medical Superintendent of the 
Leper Hospital, at Tracadie, New Brunswick, shows 
that there are now fifteen residents in the institu- 
tion. Of these ten are males and five females, the 
youngest patient being ten years and the oldest 
sixty-two years. Chaulmoogra oil has been used 
during the last two years with some success. Dr. 
Smith, who has carefully examined the question, 
expresses the conviction that leprosy is communi- 
cable through contagion. 

The Medical Profession in Italy,— In 1861 the 
total number of medical practitioners in Italy was 18,947, 
the proportion to poptili-tion being 8.8 per 10,000. In 
1861 the number had fallen to 18,420, a proportion of 
6.6 per 10.000 inhabitants. In 1881 it w-as 18,950, or 
6.6 per 10,000. In 1901 it was 22,168, or 6.8 per 10,000. 
The distribution of practitioners is somewhat unequal, 
the proportion being higher in the south (7.7 per 10,000) 
than in the north (6.1 per 10,000). In the province of 
Udinc the i)roportion is lower than anywhere else in 
Italy, there being only one practitioner to 2,831 inhabi- 
tants ; in that of Naples it is highest, there being tw-o 
doctors to 732 inhabitants. 

The West Virginia State Medical Association, — 
This association will hold its thirty-eighth annual 
meeting at Wheeling, W, Va., May 24, 25 and 26, 
1905. The committees are unsparing in their eflforts 
to make this meeting a memorable one for scientific 
interest. The social features will be fully equal 
to the facilities of the metropolis and the well known 
zeal and liberality of the members residing therein. 
Members who are in possession of interesting 
anatomical and pathological specimens are particu- 
larly requested to bring them along. If unable to 
come, please send them to Dr. S. L. Jcpson, chair- 
man of the committee on arrangements. They will 
be well taken care of and returned in safety. Titles 
of papers to appear on the official program must be 



April 15, 1905] 



ECHOES AND NEWS: GENERAL. 



707 



in the hands of the secretary not later than May 3, 
1905. The usual arrangements for special railroad 
and hotel rates will be made. 

The Missouri Valley Medical. — The excursion to 
the Portland meeting of the American Medical Asso- 
ciation will leave Kansas City, St. Joseph and 
Omaha on June 27, via the Burlington and Northern 
Pacific Railways. A week will be spent in Yellow- 
stone Park and one or two days in Seattle and 
Tacoma. A cordial invitation is extended to all 
medical men and their friends to join a congenial 
party and make this the most delightful trip of the 
season. The entertainment in Portland promises to 
excel all previous events, and the Lewis and Clark 
Exposition will be in progress at the same time. 
Rate for the round trip to Portland, $45. Yellow- 
stone Park trip, hotels and all expenses, $49.50. 
Pullman, berth for two, $11.50 to Portland, allowing 
stop-over at the Park. A second special train will 
leave Kansas City on July 6 for the accommodation 
of those who do not care to visit Yellowstone Park. 
Full information and berth reservations may be ob- 
tained by addressing the secretary. Dr. Chas. Wood 
Fassett, St. Joseph, Mo. 

Boston Medical Library Meetings in Conjunction 
with the Suffolk District Branch of the Massachu- 
setts Medical Society. — The last meeting was held 
at the Library, Wednesday, April 5, 1905. Dr. F. B. 
Harrington was in the chair. The subject for dis- 
cussion was Results in Non-Traumatic Surgery of 
the Brain and Spinal Cord. This included explora- 
tory, palliative and radical operations for intra- 
cranial and intraspinal lesions, either objective or 
functional. Operations for the immediate results of 
trauma, for meningitis, for hydrocephalus and en- 
cephaloceles, etc., were excluded. Drs. James J. 
Putnam and E. A. Codman reported observations 
on actual results obtained at the Massachusetts Gen- 
eral Hospital up to the present time; Drs. William 
N. Bullard and F. B. Lund reported results at the 
Boston City Hospital. Dr. Walter B. Odiorne de- 
scribed three very interesting cases of intraspinal 
tumors operated on by Dr. John C. Warren. Dr. 
G. L. Walton spoke of the findings at autopsy in 
cases of brain tumor and their bearing on the se- 
lection of operable cases. Dr. T. C. Munro and 
others took part in the discussion that followed. 

Post Graduate Instruction in Cologne. — The 
Akademie fiir praktische Mediziu. in Cologne, is 
founded to give post-graduate instruction to medical 
practitioners who have the advantage of following 
the practice of the Burger Hospital, 510 beds; the 
Augusta Hospital, 480 beds; the Lindenbnrg Hos- 
pital, 480 beds: the Children's Hospital, 100 beds; 
the Ophthalmic Institute, 50 beds; and the Mid- 
wifery Training Institute, 70 beds (with 2,500 con- 
finements annually). We are informed that during 
the first winter term which commenced in October 
last, 150 German medical practitioners were regis- 
tered, and that at the end of January a special course 
for military medical men was attended by 30 staff 
district officers, and 5 district assistant medical offi- 
cers sent by the ministry. On May 15 a fortnight's 
course for foreign practitioners will begin. Lectures 
will be given on medicine, children's diseases, patho- 
logical anatomy, surgery, orthopedics, gynecology 
■And obstetrics, dermatology and syphilis, laryngology 
and otology, ophthalmology, psychiatry, hygiene and 
biology, and social medicine. Further particulars 
can be obtained on application to the secretary of 
the Cologne Academy, Portalgasse 2, Cologne. 



French Congress of Climatotherapy. — As has al- 
ready been announced in the British Medical Journal. 
the French Congress of Climatotherapy and Urban 
Hygiene, will hold its second meeting at Arcachon, 
.•\pril 24 to 28, under the presidency of Professor 
Renaut, of Lyons. The closing meeting will be held 
at Pan on April 29. In the Section of Climatother- 
apy the following questions will be discussed: The 
climatology of the French Atlantic littoral; pretu- 
berculous and tuberculous cases in relation to forest 
and marine treatment; sanatoriums and seaside hos- 
pitals of the French Atlantic littoral; indications and 
contra-indications of the climate of Pau. In the Sec- 
tion of Urban Hygiene the questions to be discussed 
are mainly of local interest. Excursions will be 
made to the forest around Arcachon, Biarritz, 
Hendaye (Sanatorium) and Fontarabia, Bayonne 
and Cambo. A reduction of 50 per cent, is granted 
by all the French railways to titular members (sub- 
scription 20 francs) and to their wives and children 
registered as associate members (subscription 10 
francs). The latest date for inscription is April 5. 
All applications for membership should be addressed 
with the amount of the subscription, to the general 
treasurer, Dr. Dechamp, Villa Tibor, Arcachon. For 
information relative to railway fares, tickets, hotel 
accommodation, etc., application should be made to 
the general secretary. Dr. A. Festan, Villa David, 
.\rcachon. 

National Association for Study and Prevention of 
Tuberculosis to Meet in May. The most important 
meeting of tuberculosis specialists ever held in this 
country will take place in Washington on May 18 
and 19, when the National Association for the Study 
and Prevention of Tuberculosis will convene and 
plan a great campaign to rid the United States of 
the most terrible scourge that now besets humanity 
— consumption. This meeting means much for the 
future of the country. Here and there local societies 
have undertaken to grapple with the tuberculosis 
problem, State and city health boards have fought 
the devastating plague with more or less vigor, and 
private philanthropy has assisted in the battle in no 
small measure, but not until now has there been 
an authoritative national body, composed of Amer- 
ica's most distinguished experts — such men as Drs. 
Osier, Trudeau, Biggs, Bowditch, Sternberg, Flick, 
Knopf, and others. These leaders, with scores of 
other physicians and laymen of exceptional training 
and influence, have joined forces to take up the tuber- 
culosis problem in all its aspects — sociological, path- 
ological and bacteriological, clinical and climatologi- 
cal. Pulmonary tuberculosis, or consumption of the 
lungs, now costs more than one hundred thousand 
lives and a money loss of millions of dollars every 
year in the United States, and the leaders of the 
national movement for its eradication realize that 
their task is no small one. Yet the most conserva- 
tive among them agree that the disease can be con- 
trolled and in the course of time virtually stamped 
out. This is their aim. 

Nebraska Medical Legislation. — The medical pro- 
fession of Nebraska has again passed through the 
throes of its biennial labor, and medical legislation 
for this year is over. The McMullen Bill is a clear, 
legal definition of what constitutes a physician and 
how one shall be recognized as such. It provides 
that any one shall be considered a legal physician, 
and required to apply for and receive a license, after 
a successful examination, who holds himself out to 
the public as being able to diagnose human disease. 



7o8 



ECHOES AND NEWS: GENERAL. 



[Medicai. News 



who prescribes any form of treatment for the pallia- 
tion, relief or cure of any physical or mental ailment, 
with the intention of receiving compensation there- 
for, or one who uses any title to indicate that he 
treats human diseases, or one who maintains an 
office for the diagnosis or treatment of disease. It 
also provides that any one who thus holds himself 
out as a physician and who does not possess a 
license shall be fined, on conviction, $50 to $300 and 
costs. This bill was passed by the House without 
amendment. It covers every phase of medical prac- 
tice and was modeled upon the ideal medical bill, 
first suggested by Dr. Van Meter, of Colorado. The 
Nebraska Senate amended the Bill so that the 
Osteopaths were to be exempted from examination 
in all questions relating to the administration of 
drugs and the treatment of disease. This amend- 
ment was concurred in by the House and the 
amended Bill has been sent to the Governor for his 
signature. The profession has every reason to be- 
lieve that he will sign the Bill. If he does, Nebraska 
will have an ideal law. The Osteopaths are already 
compelled by law to pass an examination upon 
physical diagnosis and the practice of medicine, ex- 
empt only from examination on materia medica. 

P.S. The Governor vetoed the Bill. 

Mississippi Medical and Surgical Association 
(Colored). — The following is the official program 
of next meeting, April 26 and 27, 1905: " President's 
Address," by Dr. J. M. May, of Westside; "'Remin- 
iscences of Twenty Years of Practice," by Dr. J. 
B. Banks, of Natchez; "Address in Medicine," by 
Dr. A. J. Lopez, of Lake Providence, La.; "Treat- 
ment of Diseases of Eye, Ear, Nose and Throat by 
General Practitioner," by Dr. A. W. Dumas, of 
Natchez; " Syphilis in Negro Children," by Dr. H. 
H. Procter, of Vicksburg; "Obstetric Complica 
tions," by Dr. T. V. James, of Columbus; " Genito- 
urinary Diseases of a Surgical Nature, case Re- 
ports," by Dr. L. T. Miller, Yazoo; "Pulmonary 
Tuberculosis in the Negro and its Alarming Mor- 
tality," by Dr. S. D. Redmond, of Jackson; "Maras- 
mus and Rachitis," by Dr. J. B. Banks, of Natchez; 
Address in Surgery, " Suppurative Appendicitis," by 
Dr. A. W. Newman, of New Orleans; "Address," 
by Dr. Jno. F. Hunter, Secretary, State Board of 
Health of Mississippi; "Gunshot Wound of Abdo- 
men and Thorax — Operation; Enormous Hydro- 
thorax, Paracentesis and Subsequent Empyema — 
Operation, Recovery, Presentation of Patient," by 
Dr. H. E. Connor, of Brookhaven; "Advances in 
Therapeutics," by Dr. C. Henri Woode, of Vicks- 
burg; "Advances in Surgery," by Dr. C. W. Raines, 
of Clarksdale; "Points of Diagnosis in Diseases of 
the Brain and Nervous System," by Dr. D. W. Sher- 
rod, of Macon; "Respiratory Diseases," by Dr. J. 
A. Miller, of Vicksburg; " Malaria and Malarial Dis- 
eases," Treatment, by Dr. J. H. Miller, of Greenville; 
" Enucleation of Large Tumors of the Abdomen," 
by Dr. B. F. Fulton, Greenville; "Venereal Diseases 
in the Negro," by Dr. C. S. Waters, of Moss Point; 
" Local Treatment of Gynecological Cases," by Dr. 
L. F. Miller, of Canton; "Syphilitic Manifestations 
in the Skin," by Dr. E. W. Moore, of Jackson; 
" Bronchopneumonia in Children," by Dr. Georgia 
Procter, of Vicksburg; "Traumatic Disease of 
Joints," by Dr. S. A. Miller, of Canton; "Chronic 
Interstitial Nephritis," by Dr. J. E. Beale, of Jack- 
son. 

American Proctologic Society. — The seventh an- 
nual meeting will be held at Pittsburg, Pa., May 



5 and 6, 1905, at the Hotel Henry, Fifth Avenue and 
Smithfield Street. The profession is cordially in- 
vited to attend all meetings, at which the following 
papers will be read: "Malignant Disease of the 
Rectum and Its Treatment," by Dr. G. B. Evans, of 
Dayton; "The Ambulant Treatment of Internal 
Hemorrhoids," by Dr. C. F. Martin, of Philadelphia; 
" Is Fissure of the Os Uteri analagous to Anal Fis- 
sure? The Symptomatology, etc., of the Former, 
with a Consideration of it as a Cause of Sterility," 
by Dr. William Bodenhamer, of New Rochelle, N. 
Y.; " Instrumental Massage in the Treatment of 
Acquired Valvular Hypertrophy (Obstipation)," by 
Dr. T. C. Martin, of Cleveland, O.; "A Report of 
Cases," by Dr. Leon Straus, of St. Louis; " Urethro- 
rectal Fistula, with Report of a Case," by Dr. W. 
M. Beach, of Pittsburg; "Tuberculous Fistulas of the 
Rectum, and the Repair of Extensive Injuries of the 
Bowel following Same," by Dr. Howard A. Kelly, 
of Baltimore; " The Operative Treatment of Tuber- 
culous Fistulas in Tuberculous Subjects; with Report 
of a Case," by Dr. J. Coles Brick, of Philadelphia; 
" Formalin in the Treatment of Diseases of the Rec- 
tum, Sigmoid, and Colon," by Dr. John L. Jelks, 
of Memphis; "A Further Contribution to the Study 
of Pruritus Ani, with Special Reference to Local 
Treatment," by Dr. Lewis H. Adler, Jr., of Phila- 
delphia; " Profound Secondary Anemia Due to Rec- 
tal Diseases: Report of Six Cases," by Dr. D. H. 
Murray, of Syracuse; " Personal Experience in the 
Employment of Mechanical Vibration in the Treat- 
ment of Rectal Diseases," by Dr. William L. Dickin- 
son, of Saginaw; " The Office Treatment of Rectal 
Diseases and its Limitations," by Dr. James P. Tut- 
tle, of New York; " Two Cases of Imperforate 
Anus," by Dr. T. L. Hazzard, of Pittsburg; "Amebic 
Dysentery: Report of Recent Investigations in Its 
Treatment," by Dr. Samuel T. Earle, of Baltimore; 
"Artificial Anus: Practical Suggestions Regarding 
its Making and Closing," by Dr. S. G. Gant, of New 
York; "The Pathology of External Hemorrhoids," 
by Dr. Louis J. Krouse, of Cincinnati; "The Treat- 
ment of Rectal Prolapse," by Dr. A. Tierlinck, of 
Gand, Belgium; " A Summary of Twenty Radical 
Operations upon the Rectum under Local (Sterile- 
water) Anesthesia," by Dr. A. B. Cooke, of Nash- 
ville. 

American Medico-Psychological Association. — The 
sixty-first annual meeting of the American Medico- 
Psychological Association, will be held at San An- 
tonio, Texas, April 18, 19, 20 and 21, 1905, in the 
Menger Hotel. The program is as follows : " The 
Unity of the Manifestations of Insanity," by Dr. H. 
.\. Tomlinson, St. Peter, Minn.; " Perils of Psy- 
chiatry," by Dr. W. A. Gordon, of Winnebago, Wis.; 
" Neuropsychic Asthenia and its Psychiatric As- 
pects," Chas. H. Hughes, M.D., St. Louis, Mo. 
" The Prevention of Insanity in its Incubation by 
the General Practitioner," by Dr. J. T. W. Rowe, of 
Ward's Island, N. Y.; "Final Report upon the Re- 
lation of Insanity to Cardiac Diseases," by Dr. 
Arthur McGugan, of Denver, Col.; "Expert Testi- 
mony on the Doctor in Court," by Dr. D. R. Wal- 
lace, of Waco, Texas; " Korsakoff's Psychosis," by 
Dr. A. W. Hurd, of Buffalo, N. Y.; "The Therapeu- 
tic and Medico-Legal Features of Drug Addictions," 
by Dr. George P. Sprague, of Lexington, Ky.; 
" Melancholia, The Psychical Expression of Organic 
Fear," by Dr. J. W. Wherry, of Clarinda, la.; "Psy- 
choses of Anemia," by Dr. Frank P. Norbury, of 
Jacksonville, 111.; " Mysophobia, with Report of 



April 15, 1905] 



ECHOES AND NEWS; GENERAL. 



709 



Case," by Dr. John Punton, of Kansas City, Mo.; 
" Cholemia; Its Relations to Insanity," by Dr. R. 
J. Preston, of Marion, Va. ; "'A Case of Hunting- 
ton's Chorea," by Dr. Harry W. Miller, of Taunton, 
Mass.; "Nature of Practice in Neurology," by Dr. 
Arthur McGugan, of Denver, Col.; "The Liver and 
its Relations to Mental and Nervous Diseases," by 
Dr. Charles G. Hill, of Baltimore, Md.; "As to Sur- 
gery for the Relief of the Insane Condition," by Dr. 
M. E. Witte, of Clarinda, la.; "Observations on 
Some Recent Surgical Cases in the Manhattan State 
Hospital, East," by Dr. John R. Knapp, of Ward's 
Island, N. Y.; "A Preliminary Report of the Gyneco- 
logical Surgery in the Manhattan State Hospital, 
West," by Dr. LeRoy Broun, of New York City; 
" Some Observations on the Relations of the Gastro- 
intestinal Tract to Nervous and Mental Diseases," 
by Dr. Robert C. Kemp, of New York City; "Tuber- 
culosis Among the Insane," by Dr. C. Floyd Havi- 
land, of Ward's Island, N. Y. : "Masked Epilepsy," 
by Dr. Gershom H. Hill, of Des Moines, la.: "Epi- 
lepsy as a Symptom," by Dr. Everett Flood, of Pal- 
mer, Mass.; "Clinical Notes on Dementia Paraly- 
tica." by Dr. E. C. Dent, of Ward's Island, N. Y. , 

Kansas Medical Society. — The thirty-ninth annual 
meeting of this society will be held in Hartman's 
New Dancing Hall, Wichita, Kansas. Wednesday. 
Thursday and Friday, May 3, 4, and 5, 1905, with the 
following program: Surgical Clinic at Wichita and 
.St. Francis Hospital at 9 a.m. and 12 M. " Psychics 
in Practice of Medicine," by Dr. P. S. Mitchell, 
of Tola; "Exophthalmic Goiter." by Dr. S. 
S. Glasscock, of Kansas City: " Report of De- 
tached Retina," by Dr. G. W. Mascr, of Parsons: 
" The Physical Basis for Fatigue," bv Dr. J. M. Latta. 
of Wichita; "Paper," by Dr. H. O'Donnell, of Ells- 
worth. President's Address; Medical Clinic and 
Demonstration of Cases; "Preventative Medicine," 
by Dr. S. J. Crumbine, of Topeka; "Treatment of 
Deformities," by Dr. J. Naismith, of Lawrence; 
" Surgical Diseases of the Gall Bladder." by Dr. G. 
C. Purdue, of Wichita: " Paper,'' by Dr. Frank L. 
.Abbey, of Newton: "The Country Practitioner as a 
Surgeon, by Dr. B. R. Riley, of Coyville; "Intes- 
tinal Obstruction," by Dr. C. A. .Smith, of Yale; 
" Some Therapeutic .A.xioms," by Dr. G. H. Hoxie, 
of Lawrence: "Medical Education," by Chancellor 
Frank Strong, of Lawrence: " Hyper- Acute Mania," 
by Dr. T. C. Biddle, Topeka: "Report of a Case 
Resulting from Railway Injurj'. by Dr. L. H. Munn. 
of Topeka: "Practical Experience With the Use of 
.Mkaloids," by Dr. H. Humfreville. of Waterville: 
"Traumatic Neurosis." by Dr. W. S. Lindsay, of 
Topeka: ".Address, Hypertrophied Prostate," by Dr. 
Chas. E. Bowers, of Wichita: "What Every Doctor 
Ought to Know About the Eye," by Dr. J. R. Scott, 
of Garnett; "Paper." by Dr. A. L. Cludas, of Min- 
neapolis; "Esophageal Stricture," by Dr. D. W. 
Basham. of Wichita: "Paper." by Dr. H. H. Brook- 
hart, of Scammon; "The Border Land in Nervous 
and Mental Phychosis," by Dr. C. C. Goddard, 
Leavenworth: "My First Fractures," by Dr. J. D. 
Clark, of Wichita; " Paper." by Dr. H. L. Clark, of 
La Cygne: "The Scientific Basis of Medicine." by 
Dr. J. F. Axtell, of Newton: "Disease of the Pan- 
creas," by Dr. Longenecker. of Kansas City. 

Medical Association of the State of Alabama. — 
The Medical Association of the State of .Alabama 
will hold its next annual meeting in the city of 
Montgomery, commencing on Tuesday, April 18, at 
12 o'clock noon, and will continue in session for 



four days. The following program has been ar- 
ranged: "Jerome Cochrane Lecture," by Dr. Robert 
-Abbe, of New York, N. Y.; "Monitor's Address," 
by Dr. William G. Somerville, of Tuscaloosa; " The 
Responsibilities of the Physician in Obstetrical 
Work, and How to Meet Them," by Dr. J. G. Palmer, 
of Opelika; "Iritis," by Dr. L. G. Goodson, of Bir- 
mingham; "Surgery of the Kidney, and Its Appli- 
cation to the Cure of Disease," by Dr. Harry T. 
Inge, of Mobile; "Lobar Pneumonia and Its Treat- 
ment," by Dr. W. S. Britt, of Eufaula; " Surgery of 
the Arteries," by Dr. Rudolph Matas, of New Or- 
leans, La.; "Cystoscopy and Ureteral Catheterization 
in Gynecology," by Dr. H. Dawson Furniss. of 
New York, N. Y.; "The Non-Surgical Treatment of 
Uterine Displacements," by W. P. Mc.A.dory, M.D., of 
Birmingham; "The Choice of Methods m Removing 
Uterine Fibro-Myomata," by Dr. LeRoy Broun, 
of New York, N. Y.; "Electric and Radiant Energy 
as Therapeutic Agents," by Dr. E. T. Camp, of Gads- 
den; "Varicose Veins, and Their Surgical Treat- 
ment," by Dr. S. G. Gay, of Selma; "Modern Thera- 
peutics," by Dr. Henry A. Moody, of Florence: 
" Therapeutics," by Dr. Henry N. Rosser, of Bir- 
mingham; "Tuberculosis," by Dr. Edgar A. Jones, 
of Raton, N. M.; "Recent Developments in the 
Study of Diarrheal Diseases of Infancy and Child- 
hood," by Dr. S. W. Welch, of Talladega; "The 
Present Status of Gail-Bladder Surgery," by Dr. 
Robert N. Pitts, of Montgomery; "Cystitis," by 
Dr. W. D. Gaines, of LaFayette; "Some Observa- 
tions as to the Causes and Treatment of Puerperal 
Infection," by E. M. Prince, of Coleanor; " Heart 
Treatment," by J. D. Heacock, of Birmingham: 
" Hip-Joint Complications of Typhoid Fever," by 
Dr. McLean Pitts, of Selma; "Syphilis," by Dr. A. 
G. Douglas, of Birmingham ; " Tuberculous Peritoni- 
tis," by Dr. N. G. Clark, of Ensley; The Contract 
Doctor," by Dr. George A. Hogan, of Bessemer: 
■' Alcohol as a Medicine," by Dr. E. H. Sholl, of 
Birmingham: " Puerperal Eclampsia," by Edgar G. 
Givhan, of Montevallo; "Spinal Cocainization," by 
Dr. George H. Searcy, of Mt. Vernon; " Recording 
Cases in Private Practice," by William C. Williams, 
of Shelby. 

Tennessee State Medical Association. — The seven- 
ty-second annual meeting was held in the Watkins 
Institute Building, Tuesday, Wednesday and Thurs- 
day, April II, 12 and 13, 1905. The following papers 
were read: " President's Annual Address," by Dr. 
Paul F. Eve, of Nashville, special order for evening 
session of first day; " Food Adulterations in Ten- 
nessee, by Dr. Lucius Brown, .A.B., A.M.; "Dys- 
tocia," by Dr. D. M. Hall, of Memphis; "Melan- 
cholia," by Dr. S. T. Rucker, of Memphis; "Psychic 
Phenomena, or Hlpnotism as it should be in Medi- 
cine," by Dr. J. D. Hopper, of Jackson; " Diagnosis of 
Kidney Diseases," by Dr. Louis LeRoy, of Nash- 
ville; " Perinephritic Abscess," by Dr. W. A. Bryan, of 
Nashville; " Treatment of Hypertrophied Tonsils," by 
Dr. J. F. Hill, of Memphis: "Treatment of Hyper- 
trophied Tonsils," by Dr. J. T. Herron, of Jackson; 
" .A.cute Middle Ear Inflammation," by Dr. N. C. 
Steele, of Chattanooga: "The Association of Serous 
Meningitis with Mastoid Inflammation," by Dr. E. 
C. EUet, of Memphis; "Tuberculosis of the Skin," 
by Dr. J. M. King, of Nashville; "Keratosis Follicu- 
laris," by Dr. G. P. Edwards, of Nashville; "Gastro- 
intestinal Diseases of Children in Summer," by Dr. 
Zeb. L. Shipley, of Cookeville; "Amyloid Degen- 
eration: A Warning to the Physician; A Plea to the 



710 



CORRESPONDENCE: ARMY TRANSPORT SERVICE. 



[Medical News 



Surgeon," by Dr. C. P. McNabb, of Knoxville; "'The 
Clinical Significance of Ascites, " by Dr. Raymond 
Wallace, of Chattanooga; " How Shall We Feed and 
Treat the Baby?" by Dr. Hermon Hawkins, of 
Jackson; "The More Serious and Unusual Com- 
plications of La Grippe or Influenza," by Dr. E. 
A. Cobleigh, of Chattanooga; " Biliary Concretions 
in the Common Duct," by Dr. W. D. Haggard, of 
Nashville; "Bone Surgery," by Dr. R. A, Barr, of 
Nashville; "Septicemia, with Report of a Most In- 
teresting Case," by Dr. R. J. McFall, of Cumberland 
City; "Circumcision: Its Technic, Anesthesia, Oper- 
ation, and After-Treatment, ' by Dr. E. A. Tim- 
mons, of Columbia; "Some Anomalous Cases of 
Appendicitis," Is^' Dr. Jno. A. Gaines, of Nashville: 
"Appendicitis: Its Etiology and Pathology, with a 
Report of Laboratory Findings in Twelve Cases," 
by Dr. Walter Lenehan. of Nashville; "Amputations 
of the Thigh," by Dr. J. B. Murfree, of Murfreesboro; 
" Laryngeal Diphtheria," by Dr. O. H. Wilson, of 
Nashville; " Osteo-Myelitis," by Dr. Jere L. Crook, 
of Jackson; "Locomotor Ataxia," by Dr. G. P. Ed- 
wards, of Nashville: "Alcoholic Inebriety," by Dr. 
I. A. McSwan, of Paris: "The Importance of More 
Perfect Teaching of Physical Diagnosis in Our Medi- 
cal Schools," by Dr. Hazle Padgett, of Columbia: 
"Treatment of Diffuse Peritonitis," by Dr. M. C. 
McGannon, of Nashville: "Unprofessional or Dis- 
honorable Conduct," to which reference is made in 
Section 3 of the Medical Practice Act. by Dr. T. J. 
Happel, of Trenton. 



CORRESPONDENCE. 



ARMY TRANSPORT SERVICE. 

To the Editor of the Medic.\l News : 

Dear Sir : — The last time I wrote you from a trans- 
port the letter was headed " On the Way to Port 
Tampa." I use the designation " Transport " for the 
miserable ship we were on, simply because that was the 
name given that particular boat and many others, equally 
unfitted for the carrying of troops by the then higlily 
ornamental Secretary of War. The memory of Algers' 
fleet makes one most deeply appreciate the comfort and 
perfection (one might almost say) of " The Sheridan." 
In this letter I desire to set down, as plainly as may be 
for the delectation of your readers, what the Govern- 
ment is doing and has done for the better care of Army 
Officers and men at sea. It may serve to help them for- 
get the Alger disgrace. 

This ship may be taken as a type of the ships which 
Uncle Sam now has in his transport service. Slie is 
one of the Atlantic Transport Line and built originally 
with special strength and staunchness. She was later 
entirely refitted at the Fulton Iron Works. San Fran- 
cisco, and, as I said, she stands to-day a model of what 
a troopship should be. To begin at the stern. Here we 
find a large, roomy hospital ward, capable of accom- 
modating patients. A companion way in the very cen- 
ter leads to an isolation ward on the upper deck (the 
hospital itself being on the main deck) which is airy 
and flooded with sunshine ; a better place for the treat- 
ment of contagious diseases could not be found on a 
ship. Aft of the hospital proper are the closets and bath 
tubs — excellently well placed since the foul odors are 
carried out the rear port holes by natural draughts 
caused by the forward motion of the ship. 

There is, just off the main ward, an excellently 
equipped operating room and in immediate proximity 
are the dispensary, kitchen and the rooms of hospital 



corps tiien (nurses). The troopdeck is fitted with iron 
stands, three beds to each, for the accommodation of sol- 
diers. Mattresses are not used; the ordinary wire spring 
being supplanted by canvass. This is removed at each 
port and thoroughly scrubbed and disinfected. Sixteen 
hundred to two thousand men can be comfortably cared 
for on this deck. The quarters occupied by the soldiers 
are marvels of cleanliness. I neglected to mention the 
system of ventilation with which the Sheridan is fitted. 
This extends to every part of the ship and the air of the 
troopdeck may not only be renewed at will but can be 
kept at any temperature desired ; the temperature being 
taken every hour, night and day. Electrical fans are to 
be found in every stateroom and are placed wherever 
they may be desired, on every deck and in any nook 
and corner. 

The soldiers eat on the main deck forward and the 
grub provided for them simply could not be improved. 
(What a contrast to the commissariat of those Heavenly 
Twins, Alger and Eagan.) The food in the cabin is de- 
licious. I have never eaten as well on any Atlantic 
liner ; not only that which is put before a passenger, but 
the way it is served — so appetizing; hot plates and all 
the rest of it and leaves nothing to be desired by the 
most fastidious. The Government buys only the" best 
of stufif, and this is kept in the best condition in the cold 
storage plant which is maintained on the ship. Fresh 
bread is served daily and delicious are the rolls and 
cakes as well. There is fresh fruit in profusion ; also 
part of the daily ration, so to speak. 

As the best of everything is served to officers and 
passengers so is it to the enlisted man. Gentlemen who 
have seen the transports of the English, French, Ger- 
man, Russian and other armies tell me that there is 
nothing in any of them to compare to our American 
ships, which a thoughtful Government has prepared for 
the comfort and care of those ofiicers and men who go 
forth to carry our flag to the uttermost ends of the 
earth. 

And now comes the question which is causing much 
an-xiety among those who have the good of the oflScers 
and men of the army at heart. Shall this magnificent 
service, established at so much labor and cost be done 
away with, at the behest, not to say the order of those 
men who control our railroads and who would get their 
unholy grip upon the sea-carrving of the Government as 
well? 

It is devoutly to be wished that the Government will 
not give up this service. It goes without saying that 
J. J. Hill et id genus are not going into the transport 
business for their health and God knows not for the 
health of the officers and men of the American army. 
The change cannot be advised on the ground of economy, 
for the last report showed a very large saving to the 
Government in the last year from having run its own 
fleet of transports. 

Another consideration — your business man would 
characterize this as " sentimentality." The one comfort 
which an officer has in his exile in the Philippines is in 
the fact that as matters are to-day he is enabled to have 
his wife and children with him. For a nominal sum 
the Government transports them to his station here and 
back to America in case of sickness or change in his 
orders. Now the powers of the trans-Pacific lines say 
this is really cruel injustice to them, taking all this trade 
and so making them poorer and in their " rarity of Chris- 
tian charity," tell a listening Congress that they will take 
officers and their families for the moderate (sic) sum 
nf %\2$ "per head." He who runs may read; the result 
would be that officers would have to get along as best 
they could without the love and companionsliip of those 



April 15, 1905] 



NEW YORK ACADEMY OF MEDICINE. 



711 



nearest and dearest to them. Their very moderate sal- 
ary could bear no such demand. 

These unselfish and eminently altruistic capitalists say, 
" The Government should not be in the sea-carrying 
trade; they are hurting the ^American merchant marine 
which we and other apostles of purity and light are en- 
deavoring to build up." One is tempted to irreverently 
remark. Bunkum. I am reminded of the answer found 
in a civil service paper : 

Question. What is the purpose of Life Insurance? 

Answer. It is to provide ample funds for those who 
are born in a state of impecuniosity. 

This exactly fits this particular case. The purpose, 
the end of our Government, for in the opinion of these 
capitalists, is not to provide properly and generously 
for those officers and men who are daily giving up all 
they hold dear and their very lives that our nation may 
live, but to furnish more and more pabulum for them, 
who with all their riches consider themselves poor and 
to whose overwhelming greed there is no limit. 

Another pertinent objection to turning the soldiers 
over to the tender mercies of the mercantile lines ; our 
Government has found that both officers and men who 
have been stationed for any length of time in these 
islands are particularly liable to develop pneumonia, if 
subjected to the low temperatures which a ship en- 
counters, returning by the great circle or northern route ; 
indeed, as I understand it, 'twas this fact which led the 
returning ships to take the more southern course via 
Honolulu. 

Again, the best of discipline can be and is preserved 
on the Government boats and the soldiers are exercised 
and drilled daily; there is no objection on the part of 
passengers to this, for whether they be ainiy folk or not, 
it is perfectly well understood that these ships are first 
and foremost for the army, its comfort and improve- 
ment. Such practices could not be maintained on board 
a passenger boat. People who pay a high passenger 
tariff simply would not put up with them and one or the 
other would have to go. Drinking is kept at its min- 
imum on the Government transports. They rank as 
Government reservations and no Canteen is allowed, and 
so long as there is no such sensible control as a Can- 
teen gives, the officers are wise in keeping whisky away 
from the men as much as possible. 

Finally, it is to be most sincerely hoped that the in- 
fluence of the President and those who have the good 
of the army at heart will successfully resist any attempt 
to do away with the Army Transport Service, as it is 
now organized. 

Frank Donaldson, B..\., M.D. 

U. S. Transport Sheridan, Manila, March i, 1905. 



SOCIETY PROCEEDINGS. 

NEW YORK ACADEMY OF MEDICINE. 

Section on Medicine. 

Regular Monthly Meeting, held December so, 100 j. 
The President, Charles H. Lewis, M.D., in the Chair. 

Pneumothorax. — Dr. Mannheimer presented a pa- 
tient suffering from pneumothorax. The patient was 
thirty-seven years of age, and suffered from the 
affection for some four months without any effusion 
of liquid into the pleural cavity. His mother had 
died of tuberculosis at the age of forty-two, and the 
man himself had suffered with symptoms of the 
same disease. He had been ailing since August 
when, after a few weeks of cough and malaise, there 
was a sudden onset of difficulty of breathing, with 



great oppression and pain in the chest. Not long 
after the signs of pneumothorax were recognized by 
the attending physicians, the right side of the chest 
was slightly enlarged to inspection and mensura- 
tion. There was very loud resonance reaching to 
the eight and ninth ribs. The diseased side does not 
stand still, but moves less than the other side, in 
respiration. The patient can lie on his left side, 
showing that his other lung is capable of doing con- 
siderable work. On percussion there is no change 
of note on opening or closing the mouth. The 
breathing is distant and amphoric over the entire 
side except in the interscapular region, and in the 
fourth interspace in front, where there is probably 
an adhesion. A distinct coin sound can be heard. 
Tactile fremitus is greatly diminished. The left 
lung is somewhat emphysematous. The heart is 
slightly displaced to the left and the liver is mark- 
edly displaced downward. This condition has con- 
tinued to remain stationary for six weeks now, and 
it is a question whether aspiration of the air for 
the relief of the patient should not be attempted. 

Acromegaly. — Dr. Mannheimer also presented a 
case of acromegaly in the person of the wife of 
the preceding patient. This patient is about forty 
years of age, and has suffered from the affection 
for the last three years. There has been distinctly 
progressive enlargement of the face, hands and feet, 
until now the picture of acromegaly is a very char- 
acteristic one. There are the prominent cheek 
bones, the prominent chin, the lower teeth protrud- 
ing, the thick lips and thick nose, with the spade- 
like hands and the clumsy feet, and the large toe 
being particularly broad and the skin around the 
heel being much thickened. 

Pachyacria. — The enlargement in this case is much 
more in width than in length, and justifies the term 
suggested by Recklinghausen some years ago be- 
cause of this characteristic feature. The heart is 
somewhat enlarged, and the apex beat is heaving 
and found to (he left of the nipple. The first sound 
of the heart is booming, and the second a pulmon- 
ary sound is distinctly accentuated. There is an 
acceleration of the pulse, which is also of rather 
high tension. A slight amount of albuminuria has 
been noticed, but this is not constantly present. 
The abdomen is quite pendulous. There is a dis- 
tinct separation of the recti muscles, in fact, a 
typical diastasia. Menstruation ceases early in most 
cases of acromegaly, but is profuse in this case, 
occurring every three weeks and being much more 
abundant than normal. This is due to the fact that 
there are fibroid tumors present in the uterus caus- 
ing the menorrhagia. This is atrophic rhinitis. 
The patient says that her voice has become coarser 
and deeper during the progress of the disease, and 
this observation is confirmed by her husband. The 
fungus and feels of vision are normal. There is 
slight myopia. The patient complains of weakness 
and pain in the left side and of headache, though 
not to the severe extent so often seen. No heredi- 
tary can be traced in the case, either direct or indi- 
rect. There is one child, aged six years, which 
looks perfectly normal and has always been healthy. 

The Blind and Massage. — Dr. M. B. Potter then 
read a paper on the employment of the blind to 
give massage. He said that his attention had been 
called to the subject, particularly, 'by hearing that 
for several centuries the Japanese had employed 
blind persons to give massage and with great suc- 
cess. The result of this system is that massage is 



712 



NEW YORK ACADEMY OF MEDICINE. 



[Medical News 



very well done at a comparatively cheap rate in 
Japan, and, as a consequence, even the poor have 
the opportunity to take advantage of its curative 
effects. The government protects the blind in their 
avocation from being imposed on, and thus a class 
of people that otherwise would be a charge on the 
community becomes a very useful and self-support- 
ing element. It is easy to understand that a blind 
masseur or masseuse would be more acceptable for 
people of delicate sensibilities than a seeing one. 
As a rule, the blind themselves enjoy better health 
as the result of the exercise they obtain, and as a 
consequence of the interest in life aroused by a 
constant money-making occupation. 

Massage in Europe. — The only place in Europe in 
which massage is extensively carried out by the 
blind is in St. Petersburg. The first teacher of it 
was a medical student, who became blind just be- 
fore graduating. There the experience is that the 
blind learn rapidly, especially if the pupils are se- 
lected with the definite idea of taking only those 
who show special talent. It is considered that two 
years are needed for the proper study of anatomy 
and physiology in connection with massage. After 
graduation the students are able to find a reason- 
able amount of work and make a successful living. 
In Sweden, the home of massage, an attempt to 
teach the blind failed. The reason for this was said 
to be the absence of books with raised letters, out 
of which principles of anatomy and physiology 
might be learned. In France the blind have been 
used, but not extensively, yet with some success. 
In Brussels there is a free school for the teaching 
of the practice of massage for the blind. In Den- 
mark a ten-months" course »s considered sufficient 
to prepare the blind for massage, and a reasonable 
amount of success has been met with in the teach- 
ing. At Briinn, in Austria, there is a successful 
school for the teaching of massage to the blind. 
The only place in Germany where a special effort 
has been made in this direction is at Leipsig, and 
here a certain amount of success has been ob- 
tained. 

Faculties Necessary for the Work. — If the blind 
are to successfully pursue the avocation of mas- 
sage, care must be taken in selecting proper indi- 
viduals for training. They should have strong hands 
and soft fingers, and, as a rule, should be such per- 
sons as readily learn to use their hands for almost 
anything — that is, they should be what are called 
handy persons. In Germany and in Denmark and 
in Russia it has been noted over and over again 
that the blind themselves seem to improve in health 
as the result of the exercise and the occupation of 
mind consequent upon this employment. Great 
Britain has more recently succeeded admirably in 
establishing an institute for the teaching of mas- 
sage to the blind. Women seem to do even better 
than men in becoming self-supporting after gradua- 
tion. In looking up the records of graduates of 
massage institutions, not a few of them are found 
to have engaged in sonic other employment. 

Preliminary Education.— It is important that can- 
didates should bo selected with due reference to 
their preliminary education. The more they know, 
the better are they likely to get along in this em- 
ployment. Only such blind should be taken for 
training as are especially neat in their habits. This 
is a rather difficult matter, because many of the 
blind are slovenly. As a rule, they should have 
good health and a good appearance. Their teeth 



should be carefully looked to, for if they have an 
offensive breath, they will find it difiicult to secure 
constant employment. Pupils should be between 
twenty and forty years, for at later years they do 
not learn well and do not secure the necessary 
dexterity. 

Massage for the Blind in America. — In Boston 
something has been accomplished in opening up 
this new avenue for the blind. In Philadelphia ex- 
cellent work has been done in connection with the 
Pennsylvania Institution for the Blind at Over- 
brook. About a dozen graduates are making a good 
living out of the profession of masseur. It seems 
too bad that more is not done in this matter, for 
in Japan it has been made a decided success. In 
this country very few of the blind are self-support- 
ing. A certain allowance is made to all blind per- 
sons by many of the States in certain cities. If this 
occupation co-uld be opened up to them, a great 
benefit would be conferred on them, and, at the 
same time, massage would be made available for 
man}' more patients than at present. 

Need for Masseurs. — The chairman of the sec- 
tion. Dr. Lewis, in discussing Dr. Potter's paper, 
said that at the present time it not infrequently 
happens that patients who need massage do not 
have it because of the expense attached to it. Many 
patients, for example, convalescent from typhoid 
fever, would reacquire their muscular energy much 
sooner if given massage. Few use it, however, be- 
cause of the expense attached to it, in considering 
the large bill for medical attendance that is likely to 
accumulate. For many other conditions in which there 
is relaxation of muscular tissue, as after intestinal 
toxemias, massage would add to the speed of re- 
covery. In such conditions as pseudoparesis and 
in the various forms of hysterical paralysis mas- 
sage would often be of the very greatest service. 
.Atlways it is the expense attached to it that con- 
stitutes the main objection against its employment. 

Electricity and Inflammatory Exudates. — Dr. 
Margaret A. Cleaves discussed the continuous 
current in relation to inflammatory exudates. She 
said that as the human body contains in its tissues 
six-tenths of 1 per cent, of common salt, it may be 
considered to be a good conductor of electricity and 
consequently definite chemical effects must be ex- 
pected from the use of the continuous current. Un- 
doubtedly there are electrolytic effects, though lit- 
tle electrolytic gathers at the poles. The electro- 
lysis would seem to be of a destructive nature. 
This is what is especially noted in certain low- 
grade new growths and in inflammatory exudates. 
Undoubtedly the disappearance of fibroids can in 
many cases be brought about by the use of the 
continuous current. What happens is that the 
fluids and salts are removed from the morbid 
growth, and, as a consequence of the contraction 
thus secured, less blood is brought to the region 
and as a consequence a further diminution in size 
until .-irlual disappearance may result. 

Gynecology. — It is in gynecology especially that 
the use of the continuous current has proved of ser- 
vice. When the pelvis has become roofed in by 
exudate, the use of the currout may produce a di- 
minution of circulation in this material, and so 
bring about relief of symptoms due to traction and 
compression. It is in exudative inflammations that 
the continuous current has given especially good 
satisfaction. Its benefits, however, are not confined 
to the genital tract, but have been seen in the nose 



April is, 1905] 



PHILADELPHIA COUNTY MEDICAL SOCIETY. 



713 



and throat and in the intestinal tract. Hepatic con- 
gestion of inflammatory origin are also relieved, 
and in general whenever there is a low-grade in- 
flammation, if the continuous current can be made 
to act directly upon an organ, then good will re- 
sult. Where fully formed connective tissue bands 
have come into existence, then the electric current 
will not prove beneficial; but for masses of exudate 
surrounding articular surfaces or clogging tendon 
sheaths so as to prevent movement, the results ob- 
tained are preeminently satisfactory. 

Phlebitis. — Dr. Cleaves has found the continuous 
current of excellent service in bringing about the 
reabsorption of such exudative masses as cause 
phlebitis after so many different forms of infection. 
She has had cases under treatment in which the 
phlebitis occurred as the result of vaccination, of 
typhoid fever, of uterine curettement, and all of 
them have been improved, though for many months 
beforehand all remedies have been tried without 
success. In cases where massage and passive 
movements had failed, in postseptic conditions, in 
joints, continuous current did not fail to give relief 
and produce a state of affairs within the joints 
which allowed much freer movement than before. 

Electricity and Nutrition. — Dr. Rockwell said 
that the influence of electricity depends upon nu- 
tritive processes as well as its mechanical effects. 
The galvanic current especially, because of its 
chemical effects, may encourage absorption that 
would otherwise be either very slow or perhaps 
not take place at all. Any one who has seen the 
continuous current faithfully and properly applied 
in pelvic disease can scarcely fail to realize how 
much may be accomplished by this means. The 
physical effects of electricity, and especially the 
modification of what we now know to be the im- 
portant processes of endosmosis and exosmosis, 
are undoubtedly responsible for some of these ef- 
fects. Unfortunately there is a tendency to neglect 
the good that may be thus obtained, or to use 
electrical treatment with so little consideration that 
it is sure to prove ineffectual. 

Chylous Ascites. — Dr. J. Finley Bell, of Engle- 
wood, N. J., presented the fluid from a case of 
chylous ascites. The patient was a German, fifty- 
seven years of age, who came under treatment suf- 
fering from severe dyspnea and from ascites in- 
volving not only the peritoneal cavity, but also the 
scrotum. There was rather deep pigmentation of 
the cutaneous surface and considerable cyanosis of 
the tips. He suffered from these attacks some few 
months ago and his case was called malaria. It 
seemed to be benefited somewhat by the use of 
Warburg's tincture. Three years ago he was ex- 
amined for life insurance and pronounced perfectly 
healthy. Eight months ago, as the result of an ac- 
cident, he suffered from a broken rib, but there 
seems to be no sign of this accident left. When 
he first began to suffer from accumulation of fluid 
in the abdomen, he was treated for obesity by a 
homeopath. 

Present Condition. — He has never suffered se- 
verely from constipation and does not now, but the 
intra-abdominal pressure has increased so much 
that his diaphragmatic breathing is almost abol- 
ished. Besides, some crepitant rales are to be heard 
at the base of the lungs and he has developed 
stubbed fingers, which have come on quite recently. 
The circumference of his abdomen at the umbilicus 
is 118 centimeters. As there were no parasites to 



be found in his blood, the diagnosis made was 
hepatic cirrhosis, with consequent ascites. Accord- 
ingly he was tapped for this condition, when, to 
his physician's surprise, the fluid obtained was of 
milky hue and consistency. It is slightly pinkish 
in color and does not coagulate on standing. 
Four thousand c.c.'s were removed at this time, 
and though it was easy to demonstrate that more 
fluid was present, no more could be tempted to 
come out. The emptying of the abdomen had very 
little effect upon the scrotum, and this accordingly 
was tapped the next day and proved to contain 
only clear serum. This is evidently due to the 
mechanical interference with the circulation by the 
intra-abdominal pressure. Every ten days since the 
tapping has had to be repeated. 

Possible Etiology. — The fluid obtained is always 
of the same chylous nature, so that there is evi- 
dently some obstruction in the chylous system. 
The man has not been outside of the United States 
for many years and no parasites have been found 
in his blood. An area of dulness, however, is 
demonstrable in the upper part of the thorax on 
the left side, and it seems clear that there is some 
sort of intrathoracic growth — whether of inflam- 
matory or neoplastic nature is not clear — pressing 
upon the thoracic duct not far from its entrance 
into the veins. Whether this has had anything to 
do with the broken rib seems extremely doubtful. 
Absolutely no deformity can be found where the 
rib is said to have been broken, and there are no 
tender spots any place over the thorax. The temp- 
tation is to believe that there is a thoracic new 
growth, which is interfering more and more with 
the function of the duct. In that case the prog- 
nosis is not at all favorable, since such cases are 
likely to be of malignant nature; and then, besides, 
interference with the flow of the chyle is of itself 
likely to cause such serious interference of nutri- 
tion as will eventually lead to fatal issue. 



NORTH BRANCH PHILADELPHIA COUNTY MEDICAL 
SOCIETY. 

Stated Meeting, held December 9, 1004. 
The President, Samuel Wolfe, AI.D., in the Chair. 
Case of Pancreatic Cyst. — The paper was read by 
Dr. M. J. Karpeles, who reviewed in detail the litera- 
ture of the subject, particularly the writings of Dick- 
lioff, Filger, Lazarus, Korte, Moynihan, Hemmeter 
and Senn. The case reported was a male, sixty-eight 
years of age, with a negative family history, without 
specific history and temperate in the use of alcohol 
and tobacco. He first complained of discomfiture in 
the left side, insisting that his side had been sprained, 
the principal sj'mptoms being marked nausea with 
occasional vomiting of a dark green, thin, watery 
fluid, without perceptible odor and in an amount out 
of proportion to that ingested; general pruritus, 
especially of the hands, dyspnea upon least exertion, 
profound weakness, epistaxis, colicky pains, frequent 
attacks of diarrhea and insomnia. The stools were 
submitted to a careful analysis and were found to be 
free from fat, the urine showed a low specific grav- 
ity, a trace of albumin and the presence of bile. Upon 
physical examination a tender area was elicited at 
the costal margin in the left mammary line. Ten 
days later it was possible to outline in this region a 
" mass " the size of an egg, which, at the time of the 
patient's death, about three weeks later, involved the 
left half of the epigastrium, the left hypochondrium. 



714 



PHILADELPHIA COUNTY MEDICAL SOCIETY. 



[Medical News 



the umbilical and the left lumbar regions. As this 

fluctuating mass, which was diagnosed a pancreatic 
cyst, enlarged, the gastro-intestinal symptoms proved 
more rebellious, the jaundice became more marked, 
the insomnia required hypnotics and the general dis- 
comfiture increased. In view of the marked pros- 
tration and jaundice operation was not deemed ad- 
visable. At autopsy a large pancreatic cyst was 
found, containing about two liters of a grayish col- 
ored fluid with little consistency and no blood. The 
cyst wall was thin and the inner lining smooth. It 
was impossible to determine the part of ihe gland in 
which the cyst originated. 

Dr. David Riesman stated that he had never seen 
a case of this condition on the autopsy table and this 
was the first case he had seen recognized during life. 
In the differential diagnosis he felt that (i) cystic 
gall-bladder; (2) hydronephrosis; (3) echinococcic 
cyst; (4) and in women ovarian cyst should be con- 
sidered. He stated that jaundice is not as prominent 
in cases of cystic gall-bladder but may be present. 
In hydronephrosis with renal crises and long history 
of pain, floating kidney should be taken into con- 
sideration; ovarian cyst should be differentiated by 
vaginal examination and echinococcic cyst by the 
patient's habits. He stated that in the above case 
reported exhaustion and epistaxis rendered operation 
inadvisable, although he felt possibly tapping of the 
sac, after sewing or stitching it to the abdominal 
wall might have been of value, if the epistaxis had 
not been so great. In the treatment of pancreatic 
cysts the surgical treatment was the one that should 
be employed. In regard to diagnosis he stated that 
where the tumor occurs in the epigastrium extend- 
ing into the left hypochondrium and is accompanied 
by pains in the celiac plexus, these symptoms are 
sufficient to warrant a provisional diagnosis of pan- 
creatic cyst. The danger of fat necrosis occurring 
by reason of the fluid getting into the abdominal 
cavity he felt to be quite small, and also believed 
that cases had occurred in which the tumor had 
evacuated itself into the intestinal cnual. 

The Etiology and Diagnosis of Cholelithiasis. — 
This paper was read by Dr. William Ruoff, in which 
he stated that no common etiological factor could be 
assigned to all cases. Age he considered an im- 
portant factor, the majority of cases occurring be- 
tween the ages of forty and sixty years: and the 
more frequent occurrences in females he laid to the 
mode of dress and pregnancy. The influence of age 
he felt might be manifested through the loss of con- 
tractile power of the bladder, thus favoring reten- 
tion and the lack of resisting power of the body 
fluids. He felt that too mucli impf)rtance was at- 
tached to temperament, gluttony, excessive indid- 
gencc in meats and fats, heredity and climate. He 
discussed in detail the different varieties: (l) Pure 
cholesterin stone; (2) laminated choleslerin stone; 
(3) ordinary gall-stones; (4) mixed bilirubin cal- 
cium stones; (5) the rarer forms, such as (a) amor- 
phous stones, rcsenil)ling pearls; (b) chalk stones: 
(c) concretions surrounding foreign bodies; (d) 
casts of bile ducts. He then considered in detail the 
infective causes through the medium of the portal 
circidation and through an ascending infection from 
the common duct, and the influence of appendicitis, 
salpingitis, peritonitis, etc. The diagnosis was con- 
sidered under three heads: Ct) Cases in which no 
symptoms have been produced and which are usually 
discovered at antf)psy table; (2) trau'iitory symp- 
toms of dyspepsia and abdominal and liver symp- 



toms; (3) those cases causing severe, and at times 
almost fatal illness, which are most frequently met 
with. The symptoms of jaundice, vomiting, hepatic 
and cystic infection were considered, as was also 
llif symptoms of impaction. 

Gall-Stone. Disease Remote Effects and Treat- 
ment. --This paper was read l)y Dr. Samuel P. Ger- 
hard, who reviewed the literature on the subject 
and stated that efforts should be mainly surgical, 
lie stated that gall-stones, so long as they remained 
in the bladder, were perfectly harmless, but that the 
danger was due to the liability of accidents in their 
passage through the common duct, considering 
under this head, the infectious conditions, such as 
cholecystitis, with its train of fatal effects, as em- 
pyema and gangrene; pancreatitis, caused by pres- 
sure upon the head of this organ, fistula into a 
neighboring organ, peritonitis, etc. He stated that 
while a few years ago the condition was almost en- 
tirely within the domain of internal medicine, it wa.s 
now almost eijually monopolized by surgery, which 
he attributed to the advance in the results obtained 
by this method. The medical treatment, he believed, 
should be prophylactic, directed to preventing the 
formation rather than curing the disease. He re- 
ferred to the cases of biliary colic, which, if recur- 
rent, should call for careful consideration of the 
cause thereof and advisability of operation. Par- 
ticularly should those cases be watched which have 
no janudice, the symptimis are vague, and there is 
only slight recurring pains over the region of the 
gall-bladder, owing to their liability to run on to 
suppuration and deceive the attendant. 

Dr. David Riesman, in the discussion, referred to 
the rarity of this condition in the colored race, and 
stated that, althougli he had had considerable ex- 
perience in autopsy work, he had never seen a sin- 
gle instance. He stated that the youngest patient he 
had ever seen was eleven years, and the oldest sev- 
enty years, and referred to the comparative frequency 
of the condition in the male and in the female. He 
stated that the essential features in the diagnosis 
were, pain in the region of the gall-bladder, below 
the costal cartilage in the right peristerual line, al- 
though the location of the jiaiii was not absolutely 
necessary. He referred to the case of a man. thirty- 
seven years of age, who had suffered from cramj)- 
like pains in the abdomen for a number of months, 
chiefly in the epigastric and left hypochondriac 
regions, and unassociated with vomiting. He had 
been treated in various ways and had lost 20 pounds 
in weight. At operation, gall-stones were found 
in the cystic duct; there was no jaundice and no 
tenderness in the gall-bladder region. He also re- 
ferred to several other cases in which the charac- 
teristic symptoms were not present. He stated in 
his experience the X-ray had not been of value in 
the diagnosis of these cases, and referred to the 
method of Dr. DaCosta of placing a cylindrical 
pad under the patient, so that the patient forms an 
inclined plane with the table, and then by gently 
rubbing with the hand, an enlarged gall-bladder 
may be felt. Referring to the pathogenesis, he 
stated that, without infection, the passage of the 
stone would cause infl.-inimation of the gall-bladder 
and ducts, and believed that many of the cases 
which were called biliousness were really due to 
gall-stone attacks. He referred to the occurrence 
of the condition after infectious diseases, and re- 
ported a case diagnosed as duodenal ulcer, which 
oil operation proved to be an infected gall-bladder. 



RIL 1$. I90S] 



NEW YORK ACADEMY OF MEDICINE. 



715 



e persistence of jaundice sliould suggest stone 
malignant disease. In regard to treatment, he 
ted he had tried the sodium salts and also the 
icylates, and that in some cases the attacks had 
;n prolonged, but did not cease entirely, and he 
jressed the belief that the surgical treatment 
uld assume the same place it had in appendicitis. 
Dr. John B. Deaver also stated that he had never 
in nor operated upon a case of gall-stones in a 
ored subject. He divided the condition into two 
sses: Cholelithiasis of the gall-bladder and af- 
tions of the common duct. The pain and tender- 
is in the epigastrium are less frequent in disease 
the common duct than in the gall-bladder in- 
mmation. He believed that the pain in the ma- 
ity of instances is inflammatory, and due to in- 
ition. He felt that the question of jaundice was 
■y misleading as a diagnostic factor, and stated 
It personally he never operated on acute cases, 
t if the attacks continue, and the symptoms and 
mdice persist, then the value of operation must 
considered. He did not consider the X-ray of 
ich value in diagnosis. He referred to the im- 
rtance of the physicians thoroughly understand- 
f palpating, which method, if properly applied, he 
ieved, would enable them to differentiate between 
ll-bladder disease and appendicitis, floating kid- 
Y, etc. After reviewing the history of several 
ies, he took up the subject of gall-bladder sur- 
ry, dealing particularly with the technic. He did 
t recommend operation in cases of acute common 
ct obstruction. In patients on which the opera- 
n is performed, it should be done early. He did 
t approve of the performance of such operations 
private houses, and emphasized the value of care- 
preparation of the patient prior thereto, includ- 
; careful urinalysis, but did not believe that stom- 
i analyses are much value except in cases of acute 
icocytosis. He favored drainage of the gall- 
dder more than its removal, unless there was some 
lication for the latter procedure. 
Dr. Wilmer Krusen referred to the case of a 
iman thirty-two years of age, who had suffered 
;ht years with gall-bladder disease, but had been 
amined by four phj'sicians, without the true con- 
ion being suspected, and the X-ray failed to re- 
al the seat of the trouble. At the operation for 
; removal of a cystic ovary, 43 stones were re- 
)ved from the gall-bladder and the woman made 
good recovery. Another case was reported, in 
lich an operation was done by another surgeon 
■ appendicitis, and the appendix found not to be 
.eased, and the wound was closed up. Two days 
er he was called in to see the patient, who had a 
se of 140 and a temperature of 103° to 104° F. 
marked enlargement over the gall-bladder was 
md. Operation showed empyema of the gall- 
dder, and 420 stones were removed therefrom, 
t the patient died within twenty-four hours from 
neral peritonitis. He expressed the belief that 
1-bIadder disease was as much a surgical pro- 
lure as appendicitis, and that the sooner the op- 
tions were done the better for the patient. 



Jrain Collection. — Ten leading American anato- 
Us Iiave been appointed as an advisory board to 
VVistar Institute of Anatomy of the University of 
nnsylvania, and they have appointed a committee 
five to cooperate with the committee on brain in- 
tigation of the international academies. 



NEW YORK ACADEMY OF MEDICINE. 

Orthopedic Section. 

Regular Meeting, held January 20, 1903. 

The President, Homer Gibney, M.D.. in the Chair. 

Fracture of Right and Left Femur. — Dr. Homer 
Gibney presented this case from his service at the Hos- 
pital for Ruptured and Crippled, with X-ray. Girl, aged 
live years, admitted to hospital January 11, 1905. The 
diagnosis was fracture of right femur and old fracture 
ol left femur. Left fenuir fractured two years ago. 
Found not to have united. Had no pain. Four days 
before entrance fell and had fracture of right thigh. 
Had no pain at entrance. The physical examination 
showed fracture of right thigh, anterior bowing at mid- 
dle and upper thirds. Linear scar four inches long 
over outer side of same thigh. Also marked anterior 
and lateral curvature of left thigh at same level ; bone, 
hiwever, is very firm. 

Treatment. — January 17, 1905, right leg by use of 
traction and local force straightened and bones got in 
good apposition, and put up in plaster spica, as at pres- 
ent. Subcutaneous osteotomy was done on the posterior 
half of the left femur at site of old fracture. The bone 
was then broken backward and plastic spica applied to 
that side. 

Double Coxa Vara. — Dr. Gibney also presented a 
case of double coxa vara admitted by Dr. Whitman and 
operated on by him. Girl, four years old. The pro- 
gressive scissors deformity was not present ; the waddle 
peculiar to congenital dislocation was present in this case, 
but the tibial curve h^d been corrected. Physical ex- 
amination on admission showed marked evidence of 
rickets, waddling gait and lordosis, as in double con- 
genital hip. Trochanters above Nelaton's line both 
sides. Right and left legs same on measurement. Soon 
after admission Dr. Whitman did osteoclasis (manual) 
at the middle of both tibiae ; union firm ; put up in plas- 
ter-of- Paris in overcorrected position. Firm union ; de- 
formity corrected, and the child was measured for 
braces which she now wears. 

The Chairman said that the interesting feature of this 
case is that the X-ray shows the right angle deformity 
of both femoral necks to be a rather unusual bilateral 
coxa vara. 

Dr. Whitman said that now that the bow legs had 
been corrected he should proceed to treat the coxa 
vara with the idea of replacing the neck of each femur 
in the normal position, for, in his opinion, the de- 
formity might later on become progressive. The char- 
acter of the operation he had described on several oc- 
casions, namely, a cuniform osteotomy at the base of 
the trochanter, of sufficient size to permit full abduc- 
tion of the limb. 

Osteitis Deformans. — Dr. Whitman presented an 
X-ray picture showing thickening, softening and slight 
deformity of the right femur. This illustrated so-called 
local osteitis deformans. The patient, a man fifty-eight 
years of age, had noticed slight discomfort about the 
thigh for twenty years. For three years this had be- 
come more troublesome. There was a slight limp, slight 
outward and forward bowing of the middle of the fe- 
mur and one inch of shortening. No treatment other 
than the avoidance of overstrain seemed to be indi- 
cated. 

Epiphysitis. — Dr. C. N. Dowd presented a boy 
who had had epiphysitis of the upper end of the hu- 
merus, which healed after operation two years ago. 
The abscess which had followed the epiphysitis had 
pointed just back of the deltoid insertion. The joint 
had not been involved, .■\bout half the head of the 



7i6 



NEW YORK ACADEMY OF MEDICINE. 



[Medical Ni 



liumcriis was removed without touching the articular 
surfaces. HeaUng was complete in about two and a 
half months. The speaker particularly callid attention 
to the condition of the shoulder-joint, which was nor- 
mal ; also to the growth of the bone, which al.so was 
normal. A second patient, of a similar kind, which 
was announced on the card, but which had not come 
to the meeting on account of whooping-cough, showed 
also a normal joint and normal bone growth, although 
the interior of the head of the bone had been completely 
removed, leaving simply a thin hard shell. He asked 
the experience of the members of the Section on the 
cfTect of epiphysitis on the growth of the bone. He 
had seen a number of cases in which only a small shell 
of bone was left and in which the subsequent growth 
had been normal. 

Dr. Dowd also presented a case of epiphysitis of the 
lower end of the tibia with an X-ray picture which 
showed a cavity in the bone leading upward from the 
epiphysis about an inch to the bone surface. The 
bone below the epiphysial line was cloudy and showed 
a lack of detail in the picture, but there was no evi- 
dence of involvement of the ankle-joint itself. The 
motion in the ankle-joint was free and not painful. 
The wound was practically healed. The outer shell 
of bone above the epiphysial line having been removed 
for about two inches healing had taken place in five 
weeks. The speaker also presented a case of fracture 
of the external condyle of the humerus, admitte<l in 
September, having the ordinary appearance of such a 
fracture. The arm was put up in plaster in flexion ; 
was inspected in two weeks and put in plaster again 
for two weeks more. He was unable to gain exten- 
sion after healing had taken place. He was seen again 
about December I and the fragment could be distinctly 
felt ; very slightly tnovable, the arm was still flexed 
at about 90 degrees. This fragment was removed by 
Dr. Mathews and was found to consist of a part of 
the external condyle and about half the capitcllum 
It had rotated about 90 degrees. Motion was good 
after this removal. The arm was again immobilized 
in flexion for three and a half weeks. Motion was 
now nearly normal. He has been carrying a light 
weight on his wrist, and extension has rapidly increased 
in that way. He referred to a similar case which had 
previously been treated in the hospital, and to several 
which were reported by Kochcr and others. Dr. Dowd 
said that he had been interested in this case on more 
than one account, particularly from having read in one 
of the most recently and widely circulated systems of 
surgery the following statement concerning fracture 
of the external condyle. " The prognosis is unfavor- 
able as the fracture lies partly within the joint and 
callus production and adhesion may cause permanent 
impairment of motion; for this reason it is important 
lo begin passive motion as soon as possible. — that i^. 
:it the end of the second week." He believed that the 
best way to prevent callus formation was to immobili/r 
the arm until the fragments were firmly united, and 
f|uf)ted his own experience of about 50 cases with only 
line in which good extension did not result. On the 
olhcr hand, the surgeons who advocated early passive 
motion were the same ones who were also removing 
the fragments of bone frequently because their results 
were so poor. He felt that it would l)e advisable for 
the Orthopedic Section to express an opinion as to 
the desirability of imraohilizing such joints in order to 
prevent callus formation and thus gain a good result 

Talipes Equinovalgus. — Dr. Dowd also presented 
a case of paralytic talipes equinovalgus. treated by the 
tnethod which Dr. Whitman advised. The tendon of 



the extensor hallucis was divided near its insert 
carried through a hole in the scaphoid bone, the 
being then brought up and sewed to the upper ] 
of the tendon, making a lirm fastening to the cei 
and to the side of the hone. Synarthrodesis of 
astragaloscaphoid joint was also done. A small 
mcnt of the tendon of the extensor hallucis, which 
separated from the rest, was left in this patient, 
foot had been kept in plaster for three months. He 
now walking with a brace, which limited the plai 
flexion of the ankle-joint and prevented eversion 
the foot, and walked very well. 

Fracture of the Middle of the Femur. — Sucl 
case was al.so presented by Dr. Dowd with practic 
a perfect result. The X-ray picture showed an obli 
fracture, with good apposition. A similar picture, ta 
after a healing, showed the position was maintaii 
and there was a slight callus about the fracture, 
case had been treated with Buck's extension for 
weeks, then kept in plaster for five weeks. He 1 
that he had noticed that four weeks had been suggei 
as a time in which bony union is firm in a child a 
fracture of the femur, but it did not seem to him \ 
to permit use of such a femur under seven or e 
weeks. 

Dr. Whitman said that accurate ajiposilion and 
would assure union with the least callus formation 
illustrated by the X-ray picture of the fractured fei 
presented by Dr. Dowd. He had sujjposed that c: 
passive motion in cases of fracture involving a j 
had been employed rather to push away bone or ca 
that might prevent motion than with the aim of 
sening its formation. Massage, after union was 
sured, had of course a very different object. Dr. W 
man said, regarding Dr. Dowd's case of tendon tr; 
plantation, that it was difficult to assure firm anchyl 
in children so that in doing this operation he se' 
the astragalus and scaphoid with strong silk and fi 
the foot invarus and slight dorsal flexion (oven 
rection). As soon as possible the patient was encc 
aged to walk about and the longer the attitude was 
taine.O, the better, in order that varus should be 
pressed on the foot by accommodative changes. 
Dr. Dowd's case there was slight flatfoot which mi 
Ik- corrected by a fool plate. 

Dr. Whitman said that in correcting deforniitic- 
the elbow following fracture, the attitude of comii 
extension was of advantage. This was best as.si; 
by a plaster bandage which included the thorax as ^ 
as the arm Complete extension was an awkward 
titnde for ambulatory treatment, but was not unc 
fortable if the patient remained in bed, as was u' 
after the open operation to which he especially refer 

Dr. Myers said he thought the amount of shortei 
would depend upon how nnich of the epiphysis h.id 1 
destroyed by operation or disease; the amount of mo 
on whether the joint was involved or not. though 
rule was not absolule. These cases are quite freq 
in tuberculous children following strains and the 
suits usually much better than in the hip. The spe 
remembered two cases about twelve years old now, 
it would he impossible to say anything had occn 
at that joint, whereas, in another the limb had 
shortened at lea.st three inches in its developn 1 
This case had undergone two scraping operation 1 
that region, and iirobably most of the epiphysis 1 
been destroyed. 

Dr. Sayre said that in his experience if the di' 
has been so extensive as to cither obliterate the epi 
sis of itself or to cause it to be removed by sur 
intervention there has been verv material redii 



April 15, 1905I 



NEW YORK ACADEMY OF MEDICINE. 



in the growth of that limb. It docs not at all times 
follow when the disease is sitnatcd in the neighborhood 
of the epiphysis that by removal of the diseased tissue 
the epiphysis is .sacrificed. In those cases he thought 
we still had sometimes, the same rate of growth in the 
leg. He had operated on an ankle in a boy a little 
older than the one presented this evening, scooping 
out the lower end of his tibia to remove a tuberculous 
locus. At the present time the patient is a medical 
student, with legs of absolutely normal length. About 
live years ago the speaker had scooped out the head of 
the humerus in a girl twelve years of age. The last 
lime he liad seen the case there had been no appreciable 
diminution in the length of that humerus. In a good 
many other cases seen there had been very marked 
diminution in the growth of the bone after such opera- 
lions. In some cases of hip disease one sees a very 
marked atrophy of the femur, very marked shortening, 
although the case has been rather a mild one and the 
acetabulum and the tip of the femur have been very 
little involved, but the epiphysis evidently very much 
<lcmoralized both from appearance as shown in X-ray 
and diminution in growth of the leg. A very much 
-.hortened femur on that side was sometimes accom- 
Ijanied by very excellent functional result. 

Dr. Sayre said Dr. Dowd showed that case of elbow, 
as he understood, to get the opinion of the Section 
as to the result of movement of fragments soon after 
fracture in regard to the production of callus. It 
seemed that the irritation of the two extremities of 
broken bone was one of the surest ways of producing 
callus. Judging from practical results he had seen, 
there was much freer motion in fractures of the joint, 
when left severely alone after fracture, placing frag- 
ments in as nearly normal position as possible, keeping 
them quiet to get good union, rather than taking them 
down at the end of a fortnight to move them. It has 
lieen fashionable in recent years to take fractures down 
very soon after the injury, in a fortnight, we will say, 
and begin to move them, and that was the plan a 
number of years ago. Then it became less fashionable 
in this country and the doctrine of rest after replace- 
ment was preached very forcibly by a great many gen- 
tlemen. Abroad they recently have become enamored 
of the idea of manipulating the fragments and moving 
the joint very soon after fracture with the idea of pre- 
venting anchylosis. The reason for inoving these frag- 
ments in the neighborhood of the joint as given by 
those practising in this country was not to prevent the 
formation of extra callus in the joint, but to keep the 
joint itself limber so it would move, and the ligaments 
would not set up fibrous anchylosis. The idea of mo- 
tion of the broken part diminishing the formation of 
callus was new to the speaker and he was surprised 
;it Dr. Dowd having said that Von Bcrgmann gave 
that as the ground work of his treatment. 

Dr. Fiske said he did not know of any more difficult 
fracture to treat than that of the external condyle 
of the humerus. In those cases involving joint sur- 
faces there is generally a good deal of displacement, 
for that reason we have poor results due to the amount 
(if callus which is large because it is almost impossible 
in some cases, to effect perfect apposition of the frag- 
ments. It seemed to the speaker that any such frac- 
ture with fragments displaced should be reduced while 
llie patient is under an anesthetic. He said he made 
it a rule in attempting to effect reduction. In many 
cases, it is impossible in spite of the greatest care in 
manipulating, to effect e.xact reduction. In most cases 
he placed the arm in the right angle position. In two 
weeks, when changing the dressing, he attempted to 



drop the arm 20 or 30 degrees. He thought this metJ 
eventually gave a better result than when the arm \ 
kept in one position four or five weeks. He said 
was not in favor of early massage, but thought the jc 
-hduld have twenty-eight days of ab.solutc fixation. 

Dr. Fiske said that several cases had been trea 
with the arm in extension with fair result. He p 
sented a man who, about eight days ago, attempted 
perform an athletic feat by which the Achillis tenc 
on the left side was put under great strain. A ph; 
cian called in to look at the case decided that noth 
very much was the matter. Dr. Fiske, after a i 
days, saw the man for the first time, and discove 
that he had practically complete rupture of the up 
portion of the Achillis tendon, but had good functi 
It was an unique case. He had attempted to jump 
against a wall and placed his foot against the w 
The shoe he had may have caused pressure, cutl 
him. 

Dr. Whitman said this case brought up a joint 
favor of subcutaneous tenotomy in that it demonstra 
how one may divide a tendon and leave the sheath 
preserve continuity. He said he would fix the f 
in slight equinus until the tendon had united, the < 
muscle would meanwhile accomodate itself to the elo 
ated tendon. The man, in his opinion, should 
walk without support, for fear of breaking the sheall 

Dr. Sayre said a number of years ago this quest 
of immobolization of the tendon after tenotomy oc 
pied a great part of orthopedic literature. Mr. Ads 
wrote a long work on the subject of tenotomy wh 
received a prize, in which he proved successfully, 
thought, that it was necessary to immediately apprc 
mate the fragments after a tenotomy, in order to 
union. In the appendix he spoke of Mr. Rolfe Co 
veterinary surgeon, who operated on race horses v 
had equinus. He cut the flexor perforans tendon, 
off the overgrown part of the hoof and allowed 
horse to stand on his foot and run about the field 
once. He soon recovered with a good tendon, vi^inn 
a race the next year. This showed that the approxii 
tion of fragments as argued in the first part of 
book, was not necessary in quadrupeds. It is 
necessary, either, in bipeds. If one divided a teni 
and covered the gap between the ends with a f 
dressing and thus left a space to be filled in with blc 
it would afterward organize in a good piece of tend 
After eighteen days, in rabbits, it is difficult to see w 
the naked eye that there has been a break. In th 
months one cannot detect the union under a mic 
scope. On the contrary, if one put a tight band 
around the part with a protecting roof over the % 
and keep it there, the space would be occluded so 
opportunity was allowed for effusion into the gap, ; 
cases thus treated might result in non-union. 

Dr. Ogilvy cited a case in which a heavy woman 1 
allowed to walk in seven days after the snapping 
the tendon. She could not raise herself on her t( 
and the tendon was not half so strong as before r 
ture. The result, he thought, was due to the fact t 
she had been allowed to walk too soon. 

Dr. H. W. Frauenthal showed a girl, aged ten, 
whom both hip-joints were anchylosed at right an: 
He asked for suggestions. Her trouble started in 
right hip at three years of age. Had had all kinds 
treatment. For the past three years no treatment at 
It was a case of neglect, sent to the speaker to se( 
anything could be done for her. 

Dr. Charles Ogilvy presented a case of congen 
dislocation of the hip operated on in October, 1901, 
Dr. Phelps, open method. The patient was admit 



CHICAGO SURGICAL SOCIETY. 



[Medical News 



weeks before operation, during which time between 

and eight pounds' weight was put on the leg. The 
ffa open operation was done except that the Duyon 
avator was used. The neck of the bone had an an- 
or twist. The head set more perfectly in the 
tabulum by having the leg rotated inward and the leg 
; put up in plaster, remaining three months, after 
ch time a Phelp's hip .splint was applied. This 
. kept on for six months, making nine months of 
tion altogether, after operation, after which time 

child was allowed to walk without further ap- 
atus. The result is perfect. Dr. Ogilvy showed 
ther case operated on by Dr. Phelps, open method, 
December, 1901. For six weeks a plaster-of-Paris 
:a was applied : after that the plaster was removed 

a hip brace was applied as in the other case. The 
:e was kept on for six months. In July the brace 
; removed. On December 12, 1902, Dr. Lorenz 
rated on the other side. At the time of the opera- 
1 he mentioned the fact of the acetabulum being 
ticularly shallow, and said it was wiser to keep on 

plaster-of-Paris as long as possible, even if it had 
De renewed — that it should be kept on for at least 
: months. She was treated as he advised with the 
jlts as shown. 

>r. Whitman said that he was glad to see such good 
]lts from the open method. He thought that it 
uld follow the Lorenz operation when that had 
ed. He did not think the Lorenz attitude the cause 
anterior displacement ordinarily, but rather the de- 
iiity of the neck and head of the bone. In the 
teral cases shown there was slight anterior displace- 
it on both sides. On the side in which the acetabu- 
I was excavated there was a bony outgrowth which 
e the femur a more secure support. Dr. Whitman 
1 that in a number of instances he had operated 

this twist of the upper extremity of the head of 

bone. He had opened the joint, enlarged the 
:abulum when necessary and replaced the head of 

bone by rotating the limb inward. Subsequently 

normal relation was restored by osteotomy of the 
ft of the femur. After the joint is open one can 

the relation of the neck and head of the bone to 

condyles of the femur, and can demonstrate that 
manent replacement is impossible unless the de- 
nity of the bone is corrected. Dr. Sayre said he 

heard an expression from Dr. Lorenz in regard 
this technic. Dr. Sayre had asked him what his 
ctice was in cases where the anterior twist of the 
k of the femur is so great that when one puts the 
d in the acetabulum the toes are turned inward, 
these, if one succeed in placing the head in the 
tabulum the foot must be turned inward and could 
f be straightened by subsequent osteotomy in the 
ft of the femur: Dr. Lorenz replied that this was 

logical mode of procedure, but it did not seem to 
I to be necessary. What he was looking for was a 
d functional result rather than perfect anatomical 
lacement and' in his experience he had obtained re 
s functionally satisfactory to the patient by anterior 
osition in these cases. He cited a case in which 

of his colleagues had followed out partially the 
itment just outlined by Dr. Whitman. When he 
1 arrived at the stage where osteotomy should be 
le the parents threw up their hands at the idea of 
operation and went to Vienna where the non-bloody 
ration was performed, with double transposition, 
erior, to the great delight of the parents. In both 
the patients on whom Dr. Lorenz operated for Dr. 
're at the New York University and Bcllevue Mcdi- 

CoUege, he obtained anterior transpositions. He 



said that the head of the bone was not in the acetabu- 
lum — he did not pretend to have it in there — did not 
think it necessary to do so, but he said the children 
would have very excellent, useful legs the way he left 
them, and that was what all were anxious to have. 
One case was single, the other double. The " double " 
child walks a good deal as the " double " child did this 
evening. The child with " single " hip walks very 
excellently — runs up and down stairs with hardly a 
trace of limp. One can see she has not an absolute 
reposition when her clothes are off, and motion is 
slightly limited, and there is a tendency to turn the 
toe too much outward unless she thinks of it. Several 
people have guessed wrongly when asked which leg, 
as she ran up and down the room. Dr. Sayre said he 
had a case of double congenital dislocation of the dor- 
sum of the ilium, which he saw when the girl, now 
nineteen years old, was a small child. The child fell 
downstairs, thrusting one leg through the banister, 
severely wrenching the hip. This fall converted the 
posterior luxation into anterior. That leg was one inch 
longer than the other, solid and stable, the other 
slipped around the dorsum of the ilium. She said: 
" This leg has been all well since I fell downstairs. 
If you can make the other as good as this, it is all 
I want." That was the attitude of Lorenz. Dr. Sayre 
said neither of the cases Lorenz had operated on for 
him had so good a functional and anatomical result 
as that of the single open operation shown this evening. 
The speaker said he thought Dr. Whitman had stated 
the case as tersely and as exactly as possible, and he 
considered it the logical and sensible thing to do in the 
majority of these cases. 

Dr. Ogilvy said he had noticed in looking over 
statistics of cases operated on by Dr. Lorenz. that the 
majority resulted in anterior displacement. In several 
cases he distinctly remembered, operated on b\- the open 
method, he found the head and neck of the bone twisted 
anteriorly. It is easily understood that if these cases, 
with the neck and head of the bone twisted anteriorly 
be treated by the Lorenz method, the head of the bone 
will be anterior and we will have as a result, an anterior 
displacement. Dr. Ogilvy asked if that were not the 
reason why there are so many anterior displacements, 
the result of the Lorenz method — Why will not internal 
rotation rather than outward rotation obviate this 
result? 

Dr. H. C. Frauenthal presented the case of a young 
man who came under observation on the tenth of the 
month. He said he had not opened his jaw for ten 
days — perimaxillary abscess. An attempt was made 
seven days ago to excise the abscess, which broke. The 
patient was admitted to hospital for observation. Since 
the breaking of abscess the jaw can be opened three- 
eighths of an inch. Has been on soft food for twenty- 
one days. No temperature, no pain, no septic chills or 
anything of the kind. A wisdom tooth extracted nine 
or ten days ago may have been the cause of the trouble. 



J 



CHICAGO SURGICAL SOCIETY, 

Regular Meeting, held January 16, iQOf,. 

The President, L. L. Mc.\rthur, M.D., in the Chair. 

Stricture of the Esophagus, — Dr. Daniel N. 
Eisendrath presented a patient who began to have 
difficulty in swallowing, with regurgitation of food, 
about one year ago, necessitating eventually a gastros- 
tomy. This operation was done in New York, with 
apparently a good result. An esophageal bougie could 
not be passed beyond the level of the junction of the 



Al'RIL 15, 1905 1 



CHICAGO SURGICAL SOCIETY. 



manubrium with the gladiolus. He had the patient 
swallow a large amount of bismuth, and then made a 
radiograph, which showed the obstruction and to the 
left of it a tumor. The obstruction was a saccular one. 
After the passage of steel sounds, the man was able 
to swallow milk, but at present was feeding himself 
through the gastrostomy wound. This case showed 
the value of the X-ray and bismuth for diagnosing 
these conditions. 

Actinomycosis of the Jaw. — Dr. William Hessert 
presented a young woman, aged fifteen years, who a 
few months ago presented a history of toothache and 
a swelling of the right jaw. A decayed tooth was 
visible, and the trouble seemed to be a necrosis of the 
jaw, with cellulitis in the surrounding tissue. Opera- 
tion failed to disclose pus. There was a hard indurated 
mass, the bone being denuded. The wound healed, 
but the tumor increased in size. Later small areas of 
softening appeared, three or four of which were incised 
and in the discharge was found the ray fungus. The 
patient was put on large doses of iodide of potassium, 
and had improved steadily. The mass had diminished 
in size about one-half, and she could now open her 
mouth better than ever before. 

Metastatic Renal Abscesses. — This patient con- 
sulted Dr. Hessert because of a necrosis of the right 
jaw. Some years ago the patient had necrosis of the 
right femur necessitating its amputation two inches 
below the trochanter. Later he had some abscesses of 
the back. The trouble in the jaw was diagnosed as an 
osteomyelitis. .An incision was made and a small amount 
of pus was evacuated. The patient did well for about 
ten days, when he began to complain of pain in the right 
lumbar region. Repeated examinations of the urine 
finally showed a small amount of pus. The right kid- 
ney was increasing in size, and became tender. The 
general condition of the patient was indicative of 
sepsis, and a diagnosis of suppurating right kidney 
was made. Tlie kidney was removed, and showed a 
number of abscesses in the cortical portion. The pus 
was found to contain Staphylococcus ['yojiciics aureus. 
The patient did well for a while, but finally complained 
of pain in the left kidney, which became large and 
tender. The pus showed in the urineT An incision 
was made, and many abscesses were found in the 
cortex of the kidney. These were evacuated with the 
finger, the wound was packed, and the patient made a 
slow but uneventful recovery. 

Dr. A. E. Halstead, in the discussion, stated that the 
tumor which showed in the radiograph of Dr. Eisen- 
drath's case probably was a diverticulum, although it 
might be an aneurism. Skiagraphing these diverticuli 
with bismuth was not so good as passing a soft rubber 
tube filled with shot, and then skiagraphing. 

Dr. Eisendrath extirpated a kidney about five years 
ago for ascending pyelonephritis with multiple abs- 
cesses, and later doubted whether he did not make a 
mistake in doing so. Fortunately, the patient recovered. 

Dr. A. H. Ferguson referred to a case he reported 
some years ago of multiple abscesses of the right kid- 
ney, where he excised some of the abscesses and 
opened others. The other kidney became involved two 
years later, but the patient refused operation and died 
from sepsis. In the kidney operated on no abscesses de- 
veloped subsequently, adding strength to the practice 
of not extirpating such kidneys. 

Dr. W. W. Harsha mentioned two cases of actinomy- 
cosis he had observed in the past year, saying that the 
tissue around the broken-down masses was very hard, 
almost gristly. This condition was so marked that he 
considered it a valuable diagnostic sign. 



Dr. D. A. K. Steele favored instituting conservat 
treatment in multiple embolic abscesses. Nephrectoi 
however, should be the rule in tubercular cases. 

Dr. Eisendrath said he had failed to find any e 
dence of aneurism or tumor in his case, after repea 
examinations, and he was unable to diflferentiate 
present between aneurism, tumor, or diverticulum. 

Brain Tumor. — Dr. John E. Owens reported 
interesting and instructive case of cerebral tumor 
moved in two stages by the osteoplastic method, w 
subsequent wiring of the bone flap, and the introd 
tion of a gold plate. The primary result was excellf 

Dr. Eisendrath mentioned the difficulties met w 
in performing these operations, one of them be 
hemorrhage from the scalp. In a case of Jackson 
epilepsy operated upon by him, the hemorrhage \ 
so severe the patient was almost exsanguinated, 
had observed a number of cases in which it was aim 
impossible to keep the bone flap in apposition with 
remaining portions of the skull. 

Dr. Ferguson had operated on a number of si 
cases, but in none of them had he any, such favora 
results as Dr. Owens had in his case. He succee( 
merely in securing temporary relief from the headac 
The hernia cerebri became enormous. He depended 
tirely on a sufficient number of hemostats and press 
to control hemorrhage from the scalp in these ca: 

Dr. A. E. Halstead had found that hemorrhage co 
be controlled with artery forceps and pressure. A 1 
years ago he operated on a case of brain tumor at 
base of the skull for the purpose of relieving press 
symptoms. He made trephine opening and evacuated 
ventricles. The intracranial pressure increased en 
mously, so much so that the brain tissue was forced 
through the small opening, through which the fluid \ 
withdrawn from the ventricli^. By tapping the v 
tricles, the patient's condition was improved and 
pressure was relieved. 

Dr. D. A. K. Steele stated that while the ultim 
outcome of Dr. Owens' case was still in doubt, 
temporary relief and the prolongation of the patiei 
life were of value. Reference was made to an int 
cerebral sarcoma, about two inches in diameter, wli 
he published about two years ago. The location of 
tumor in the motor area was easy, and its remc 
was not difficult. While there was no difficulty 
controlling the hemorrhage from the scalp, hemorrh 
from the longitudinal sinus was severe. He pad 
in an abundance of iodoform gauze, and succeedcil 
controlling the hemorrhage. The patient was still ai 
after twelve years. 

Dr. Owens, in closing, stated that hernia of the bi 
could be prevented by making the opening in the d 
at the base of the flap when this was possible. 1 
could not be done in his case because of the nati 
opening at the top made by the tumor. 

Hydrocele in the Female. — Dr. A. E. Halsti 
and Dr. Chas. P. Clark reported jointly a case 
hydrocele in the female. 

Dr. L. L. Mc.Arthur presented a case with a hist 
of calculi in the common duct and biliary passaj 
One hundred and forty stones were removed, 
patient died on the third day after the operation ft 
sepsis. On section of the liver, stones were found in 
the biliary ducts. He showed a gross specimen of 
liver. He also exhibited a skiagraph showing stone; 
the kidney. 

Dr. Eisendrath exhibited a specimen which ill 
trated the mechanism of rotary dislocations of the a' 
upon the axis. He also showed a boy, sixteen ye 
of age, with syphilis hereditaria tarda. There wa; 



BOOK REVIEWS. 



[Medical News 



irked enlargement ot the left tibia, greatly resembling 
riosteal sarcoma. Investigation revealed the proba- 
ity of syphilis in the parents. He also exhibited an 
ray of the pelvis and both femora, in which the head 
the left femur was entirely destroyed through the 
isence of a metastasis from a primary tumor of an 
descended testis. 



BOOK REVIEWS. 



■c Eleme.\t.\ry Tre.\tise on the Light Tre.\t.\ient 
KOR Nurses. By J.\mes H. Sequeir.^^ M.D., Lond., 
M.R.C.P.Lond., F.R.C.S.Eng.. Physician in Charge of 
the Skin Department and Lecturer on Dermatology at 
the London Hospital. The Scientific Press, London, 
The therapeutic use of light depends so largely for its 
ccess upon the technic with which it is handled that it 
extremely iinportant for any nurse called upon to em- 
5y this agent to be familiar with the inatter presented 
this little book. A brief summary of the more general 
pects of the question is followed by a careful descrip- 
m of the apparatus and its use which cannot fail to be 
assistance. 

[.\CTicAL Dietetics. By .\. L. Benedict, A.^L, M.D,. 
Councillor American Gastro-enterological Association ; 
Fellow .American Academy of Medicine; Consultant in 
Digestive Diseases, City Hospital for Women, and 
Riverside Hospital, Buffalo. G. P. Engelhard & 

Co., Chicago. 

This volume of some 400 pages deserves its title, for 
lile not neglecting the chemical and physiological prin- 
)les upon which the science of dietetics is based, it ex- 
unds them so simply and applies them so directly that 
e epithet " practical " is the one which occurs inost 
adily in any comment upon it. How to supply the 
eds of the body for growth and repair, for heat and 
€rgy, in conditions of health and of various types of 
;ease is discussed thoroughly and clearly, but without 
idue length, and with a certain pleasantness of style 
licli, although not generally considered essential in a 
irely instructive work, is nevertheless apt to render 
at instruction more effective. 

lET IN- He.m.th .\nd Disease. By Julius Friedex- 
WAi.D, M.D., Clinical Professor of Diseases of the 
Stomach in the College of Physicians and Surgeons. 
Raltimorc; and John Ruhrah, M.D., Clinical Pro- 
fessor of Diseases of Children in the College of Physi- 
cians and Surgeons, Baltimore. Octavo volume of 689 
pages. W. B. Saunders & Co., New York, Philadel- 
phia and London. 

This text-book of dietetics is sure to prove helpful 
cause of its eminently practical character. Besides 
aplers on the chemistry and physiology of digestion 
id on foods and stimulants, special dietaries are given 
r each of the infectious diseases, for various forms of 
sease of the stomach and intestines and in general for 
e many types of organic diseases. Besides this there 
e chapters on such special subjects as army and navy 
tions, dietaries in public institutions such as prisons 
id hospitals and recipes and diet lists. In a word, there 
ems to be nothing that the ordinary practitioner of 
edicine is expected to know with regard to food that 
)C5 not find a place in this manual. There is scarcely 
page of the book that does not contain eminently sug- 
;stive material. There is very little of theory and 
'idcntly much that lia- Ikcu gleaned from practical 
tperiencc. Wc ff)resee for the bonk a well-deserved 
)pularily 



International Clinics. A Quarterly of Illustrated 
Clinical Lectures and Especially Prepared Original 
.\rticles on Treatment, Medicine, Surgery, etc. By 
leading members of the Medical Profession Through- 
out the World. Edited by A. O. J. Kelly, A.M., M.D. 
J. B. Lippincott Company, Philadelphia. 
The present number of the International Clinics be- 
gins with an excellent article by Prof. George Hayem, of 
the University of Paris, on the Excessive Use of Drugs 
ill the Treatment of Chronic Diseases, with Reference to 
.Medical Intoxications. Another excellent article from 
a French source is that on Indications for the Dechln- 
ridation Treatment, by Adolph Javal. As is well kno\\ n 
now, certain French clinicians have succeeded by lessen- 
ing the amount of chloride of sodium consumed by pa- 
tients, in reducing cardiac edema and checking the de- 
velopment of certain kinds of ascitic effusions, besides 
moderating hyperclilorhydria and even favorably affect- 
ing some cases of exudate dermatitis. It is in cases 
of Bright's disease particularly that the indication fnr 
the reduction of the amount of common salt are to he 
found. 

There is a suggestive article from Sir Dyce Duck- 
worth on the Incidence of Gout in the United States 
of America and in new communities generally. The pres- 
ent volume is well up to previous issues in general in- 
terest of practical clinical import. 

First annual Report of the LIenry Phipps Insti- 
tute FOR the Study, Tre.\tment and Prevention or 
TuBERCULOSLS. February I, 1903. to February i, 1904. 
Published by the Henry Phipps Institute, Philadelphia. 
This first annual report is noticeable principally as 
containing the lectures delivered by distinguished au- 
thorities on tuberculosis at the Phipps Institute during 
the past year .•\mong these are Trudcau's article, The 
History of the Tuberculosis Work at Saranac Lake, N. 
Y., Professor Osier's address on the Home and Its Re- 
lation to the Tuberculosis Problem, Prof. G. .Sims Wood- 
head's address on The Morbid Anatomy and Histology 
of Pulmonary Tuberculosis, Prof. Hermann M. Bigg^ 
on the Administrative Control of Tuberculosis and Prof. 
Maragliano on Specific Therapy of Tuberculosis and 
Vaccination against the disease. 

Besides these, however, there is an excellent resume 
of the work of the Phipps' Institute during the past 
year, of which especially the chapter on neurological 
work in connection with tuberculosis is interesting and 
suggestive. 

BOOKS RECEIVED. 



One Hundred Years of Publishing. 121110, 29 pages. 
Illustrated. Win. Wood & Co., New York. 

The Houseboat Book. By Dr. W. F. Waugh. i2mo, 
209 pages. Illustrated. Clinic Publishing Co., Chicago. 

How to Study Literature. By B. A. Heydrick. Third 
Edition. i2mo, 150 pages. Heinze, Noble & Eldredge, 
New York. 

Dictionary of New Medical Terms. By Dr. G. M. 
Gould. Quarto, 571 pages. P. Blakiston's Son & Co., 
Philadelphia. 

Being Done Good. By Dr. E. B. Lent. Second edi- 
tion. 8vo, ,^45 pages. Illustrated. Brooklyn Eagle 
Press, Brooklyn, N. Y. 

Clinical Hematology. By Dr. J. C. DaCosta, Jr. 
Second Edition. 8vo. 591 pages. Illustrated. P. 
Blakiston's Son & Co.. Philadelphia. 

Ten Lectures on HinrnEMisTRY of Muscle and 
Nerve. By Dr. W. D. Halliburton. 8vo, 160 pages 
Illustrated. P. Hlakistnn'< .Son & Co.. Philadelphia. 



THE MEDICAL NEWS. 

A WEEKLY JOURNAL OF MEDICAL SCIENCE. 



Vol. 86. 



New York, Saturday, April 22, 1905. 



No. 16. 



ORIGINAL ARTICLES. 

ALCOHOL AS FOOD.' 
BY RUSSELL H. CHITTENDEN, PH.U.. I.L.I)., 

OF NEW HAVEN, CONN.; 

DIRECTOR OF THE SHEFFIELD SCIENTIFIC SCHOOL OF YAI.E 

UNIVERSITY. 

Alcohol and alcoholic fluids have been the 
subject of so many studies and of so many es- 
says that it threatens to be somewhat difficult to 
find a new point of view, until additional facts 
are discovered. Yet I shall venture upon a line 
of reasoning that may perhaps place the matter 
in a somewhat different light from that usually 
presented, though basing my argimient upon 
facts that are only in part at least comparatively 
new. 

Does alcohol, when taken into the healthy body 
in moderate quantities, serve as food, i.e., can it 
be oxidized with liberation of its energy in the 
form of heat or work, and can it play the part 
of a true non-nitrogenous food in replacing the 
fat and carbohydrate of the daily diet? In the 
literature of the subject we find many answers 
to these questions, but if we confine our atten- 
tion to the results obtained by the more accurate 
methods of recent days, especially the painstak- 
ing results reported by Prof. Atwater and his co- 
workers in this country, Rosemann and Rosenfeld 
in Germany, and many others, there seems to Le 
no doubt that alcohol when taken in moderate 
doses can be oxidized in the body and its energy 
made available for the needs of the system. It 
is of course understood that this statement does 
not carry with it the idea that alcohol is to be 
recommended for its food value, or that prior 
to its oxidation it may not exert some physio- 
logical effect the reverse of beneficial. Still, 
there is no question to-day that alcohol can be 
burned in the body and that the system may de- 
rive energy therefrom, as in the oxidation of 
sugar or fat. 

It is to be noted, however, that in the preced- 
ing statements " moderate doses of alcohol " are 
referred to, for it is well understood that when 
alcohol is introduced in compartively large quan- 
tities, considerable of the alcohol is excreted un- 
changed through the lungs and through the 
kidneys, implying quite plainly that the bodv can- 
not conveniently handle large quantities. Fur- 
ther, when comparatively large amounts of alco- 
hol are taken, not only is alcohol itself excreted, 
but there may appear in the urine and in the 
expired air aldehyde and acetic acid, products 
of the partial oxidation of the alcohol, indicative 
of the incomplete combustion of the ingested 
foodstuff. 

I Read at the New York Academy of Medicine, February 

20, 1905. 



In view of these facts, we need to know what 
is meant by moderate quantities, that we may 
form some estimate of the extent to which alco- 
hol can be burned in the body. If the system is 
capable of oxidizing only a small fraction of a 
small dose of alcohol, leaving the bulk of the 
substance to be excreted unchanged, then ob- 
viously the food value of alcohol must be rated 
very low. In an article, published recently in the 
Lancet.^ Dr. W. H. Goddard records some ex- 
periments made to determine the amounts of al- 
cohol that can be taken into the system and be 
practically all burned up, i.e., without any ap- 
preciable amount being excreted unchanged, or 
only partially oxidized. His experiments were 
conducted on dogs, and appear to have been 
most carefully planned. I will give briefly the 
results of two experiments : 

A dog weighing 12.4 kilograms, after a 
twenty-four hours' fast, was given 16 grams of 
absolute ethyl alcohol, mixed with an equal 
amount of pure water. The animal was then 
placed in a respiration chamber for five and a 
quarter hours and the expired air collected. This 
air on analysis was found to contain 2.14 per 
cent, of the alcohol administered, but no alde- 
hyde. The urine, drawn by a catheter, was 
found to contain 2.89 per cent, of the alcohol 
introduced. The animal being killed, no alco- 
hol or oxidation product of the alcohol could 
be detected in the organs or tissues. 

When 32 grams of absolute alcohol were given 
to a dog of 12. 1 kilograms body-weight, the ex- 
pired air collected for nine and one-quarter hours 
contained 2.23 per cent, of the alcohol admin- 
istered, and in addition there was present alde- 
hyde equal to 2.2 per cent, of the alcohol intro- 
duced. Further, the urine contained alcohol to 
the amount of 2.21 per cent, of the alcohol intro- 
duced into the body, while the tissues of the ani- 
mal were found to contain a mere trace only. In 
the liver, however, acetic acid was present, equal 
in amount to 2.1 grams of alcohol, corresponding 
to 6.5 per cent, of the original alcohol. Increase 
in the dosage of alcohol was followed by a cor- 
responding diminution in the extent of its oxi- 
dation. 

From these data it is evident that, with the in- 
troduction of 16 grams of absolute alcohol there 
was complete oxidation of 95 per cent, of the al- 
cohol, showing an excellent utilization of the sub- 
stance, while with an introduction of 32 grams 
of alcohol 13.2 per cent, escaped complete oxi- 
dation, showing a utilization of onlv 86.8 per 
cent, of the alcohol introduced. Dr. Goddard, in 
his conclusions, states that when alcohol to the 
amount of i/750th part of the body-weight of 

I The Physiological .-\ction of Ethyl .Alcohol considered as a 
Food: .\ Research. The Lancet. \'ol. CLXVIL No. 4234. p. 1132. 



CHITTENDEN: ALCOHOL AS A FOOD. 



[Medical News 



the animal is given, nearly 95 per cent, of the 
alcohol is made use of as food. Again, he 
states " ill small doses only alcohol is most un- 
doubtedly a food." 

It is of course to be remembered that these 
experiments were conducted upon dogs, and we 
cannot be quite certain that alcohol would un- 
dergo oxidation at exactly the same rate per kilo 
of body-weight in man. But. assuming that such 
is the case, we may query whether a utilization — 
up to 95 per cent. — of i6 grams of absolute al- 
cohol per 12.4 kilograms of body tissue is such 
a poor utilization as would at first glance appear, 
or whether such a dosage, when figured to the 
average body-weight of man would prove so 
verv small, especially if calculated in terms of 
a strong alcoholic beverage like whisky, or a still 
milder alcoholic fluid, like wine. 

The dog weighing 12.4 kilograms oxidized 
completely in five and one-fourth hours 95 per 
cent, of 16 grams of absolute alcohol, i.e., 15.2 
grams. This means that 1.2 grams of absolute 
alcohol per kilo of body-weight can be com- 
pletely oxidized. Therefore, a man of 70 kilo- 
grams body-weight (about 160 pounds) would 
o.xidize completely 84 grams of absolute alco- 
hol under like conditions. The strongest whisky 
contains, as a rule, not more than 50 per cent, of 
absolute alcohol. Consequentl}\ the above quan- 
tity of alcohol would correspond to at least 168 
grams of pure whisky. Further, it is to be re- 
called that in these experiments the absolute al- 
cohol given was diluted with an equal amount of 
water and introduced at one time. In other 
words, if this is a safe line of reasoning, the tis- 
sues and organs of a healthy man of 160 pounds 
body-weight are capable of oxidizing the alco- 
hol of 168 grams of pure whisky (even if taken 
at one time) completely into carbonic acid and 
water in the course of a few hours, like any other 
non-nitrogenous foodstuff. This amount of 
whisky equals 175 cubic centimeters or approxi- 
mately six ounces, and would fill two large wine 
glasses. Obviously, such a dosage of whisky, if 
taken at one time, would produce uncomforta- 
ble results with the ordinary individual, but the 
illustration will serve to indicate the degree to 
which alcohol can be oxidized in the body and 
thus serve as fuel. It must be remembered, 
however, that the experiments which we are 
using as the basis of our calculation were made 
upon dogs in a fasting condition, and further, 
they had been previously purged, so that their 
tissues were in a semi-hungry condition, and 
consequently they were doubtless able to utilize 
a larger proportion of alcohol.. 

These figures certainly indicate that the body 
is quite capable of burning and using as food 
fairly large amounts of alcohol, or, perhaps we 
should say, of alcoholic drinks. If we apply this 
same line of reasoning to wine, say of the claret 
tyi)e (claret containing 10 per cent, of alco- 
hol), we find that a man of 160 pounds body- 
weight would be able to oxidize completely the 



alcohol contained in approximately one quart of 
wine of this type. 

These general conclusions are essentially in 
accord with the results of the experiments re- 
ported by Professors Atwater and Benedict on 
men in the respiration calorimeter, where 72 
grams of absolute alcohol were given in the 
course of the day, i.e., six ounces of whisky, the 
only difference being that the alcoholic fluid 
was taken in six equal doses, three with meals 
and three between meals. On an average. Prof. 
Atwater found that over 98 per cent, of the alco- 
hol so introduced was burned or oxidized, thus 
showing indeed even a better utilization than the 
bodv ordinarily manifests toward the carbohy- 
drates or fats of the daily diet. 

Again, we can make this matter somewhat 
clearer perhaps by a comparison of the relative 
value as fuel of alcohol and carbohydrate, such 
as sugar or starch. One gram of absolute alco- 
hol yields the same amount of energy as 1.73 
grams of carbohydrate, or, in other words, 4 
grams of alcohol are isodynamic with 7 grams 
of sugar or starch. Consequently, it would ap- 
pear that the oxidation of 84 grams of abso- 
lute alcohol or 168 grams of whisky is the equiv- 
alent of the oxidation of 147 grams of pure 
sugar or starch, or about one-third of a pound, 
i.e., would yield the same amount of energy in 
the form of heat or work and with less expendi- 
ture of energy on the part of the body in accom- 
plishing it. 

This conclusion, however, may not be strictly 
correct in the sense that the above quantity of 
alcohol is the exact equivalent of the isodynamic 
quantity of carbohydrate in the body of the 
healthy man, or would serve the purpose of food 
in the same degree. We may indeed take differ- 
ent positions as to the proper definition of a food. 
The physiologist is ordinarily inclined to say 
that food serves two distinct purposes, viz., to 
build up and repair the tissues of the body and to 
yield energy. To build up muscle tissue (the 
nitrogenous part of the tissye) only proteid food 
is available. Starch and fat even have no power 
in this respect, except so far as they may protect 
the combustion of proteid. Carbohydrates and 
fat, however, are the chief reliance of the body 
as sources of energy, and as a consequent pro- 
tection for the more essential proteid or albumin- 
ous materials of the tissues. The fact that alco- 
hol can be burned in the body in fairly large 
quantities, and that its combustion insures a cor- 
responding amount of energy, renders plausible 
the view that alcohol can replace fat and carbo- 
hydrates as a source of energy ; an idea which 
is reinforced by experimental evidence. Hence 
the view that alcohol must be ranked as food. 
Further, it is equally evident that, like carbohy- 
flrate, alcohol can protect tissue proteid and tissue 
fat, jjcrhajis even to the extent of its isody- 
namic equivalent. On the question of saving pro- 
teid, however, we have to contend with another 
action of alcohol, viz., its well-recognized power 



April 22, 1905] 



CHITTENDEN: ALCOHOL AS A FOOD. 



723 



of stimulating proteid metabolism, under some 
conditions, apparently more marked in some in- 
dividuals than in others. Still, in a general way, 
it is safe to say that alcohol does tend to protect 
the proteid of food or body tissue, acting in this 
respect much as carbohydrate foods do. 

With these facts before us, and with a conse- 
quent recognition of the ability of the body to 
burn moderate amounts of alcohol with utiliza- 
tion of the resultant energy, thereby placing al- 
cohol as a foodstuff on the same level as fat and 
carbohydrate, I wish to present certain reasons — 
purely physiological, why it is quite misleading 
to rate alcohol as a non-nitrogenous food, the 
equal of fat and carbohydrate ; and here again 
let me say that all physiologists clearly recognize 
the possible pharmacological action of alcohol 
prior to its combustion, which action necessarily 
introduces many other factors to be considered 
in any estimate of the wisdom of utilizing alco- 
hol as a foodstuff'. It is not with these questions, 
however, that I wish to deal, but with certain 
facts regarding the action of alcohol on metab- 
olism, which tend to diff'erentiate alcohol as a 
foodstuff very sharply from both fat and car- 
bohydrate. 

Some eighteen years ago experiments were car- 
ried out in the writer's laboratory by Messrs. 
Charles Norris, Jr., and E. E. Smith on the in- 
fluence of alcohol upon proteid metabolism.' 
These experiments were conducted upon dogs 
in nitrogenous equilibrium and led to the con- 
clusion that alcohol, in such doses as we used, 
can serve as a non-nitrogenous foodstuff, pro- 
tecting in a measure the proteids of the tissue 
much as carbohydrate foods do. At the same 
time, we observed a very striking change in the 
output of uric acid in these dogs under the influ- 
ence of alcohol, i.e., the excretion of uric acid 
was greatly increased, while the output of total 
nitrogen was diminished. In other words, al- 
cohol, while it lowered the rate of proteid catab- 
olism, exercised a special influence upon the 
rate of production or elimination of uric acid, in- 
creasing very notably the output of this sub- 
stance through the urine. We immediately rec- 
ognized the significance of these results and saw 
the necessity of a careful study of the question on 
man, but for a long time we were unable to ar- 
range for an experimental study of the matter, 
under suitable conditions. Recently, however. 
Dr. S. P. Beebe, while in our laboratory, has 
carried out a most thorough series of experi- 
ments on man, and the results, published- a short 
time ago, afford a most interesting and important 
series of data bearing on this question. 

The experiments were all conducted upon 
young men, five in number, of good health and 
regular habits, none of whom was accustomed 
to the use of alcoholic fluids. The results of the 
many experiments all lead to the conclusion that 

1 Journal of Physiology. Vol. XIT, p. 220. 

2 The Effect of .Mcohol and Alcoholic Fluids upon the Ex- 
cretion of Uric Acid in Man. .American Journal of Physiology. 
Vol. XII, p. 13. 



alcohol, even when taken in very moderate 
amounts, causes a noticeable increase in the 
amount of uric acid and of purin bases excreted 
in the urine. This increase in the amount of uric 
acid excreted is not connected in any way with 
the marked diuresis which the alcohol produces, 
i.e., it is not due to a simple sweeping of urates, 
already formed and circulating in the blood, out 
of the system. Further, it was noted that alco- 
hol does not cause this change in the output of 
uric acid when taken without food or with a 
purin-free diet. The increase of uric acid ap- 
pearing in the urine, under the influence of alco- 
hol, is not then of endogenous origin, but is un- 
questionably associated with some change in the 
rate of oxidation in the liver of uric acid of exo- 
genous origin, or else there is a change in the rate 
of production of uric acid from the precursors of 
uric acid contained in the food. 

In following out the rate of increase in the out- 
put of uric acid by hourly analyses of the urine, 
Dr. Beebe found that the maximum increase oc- 
curs at the same time after a meal as it does when 
purin food without alcohol is taken. The obvious 
conclusion from Dr. Beebe's experiments is that 
absorbed alcohol reaching the liver influences at 
once the metabolism of the proteid cleavage prod- 
ucts, especially those which come from the 
breaking down of nuclein compounds. If we as- 
sume, as stated by Dr. Beebe, that the increased 
output of uric acid under the influence of alcohol, 
is due to an impairment of the o.xidative powers 
of the liver, then we have to consider not only 
the influence of alcohol in diminishing the de- 
struction of uric acid, but also the possibility of 
other oxidative processes in the liver being af- 
fected. It is to be remembered that the liver per- 
forms a large number of oxidations and syn- 
theses, all tending toward the destruction of 
toxic substances which would otherwise be dis- 
tributed through the system, hence it would 
seemingly follow that alcohol may not only cause 
an increased amount of uric acid and other purin 
compounds in the system, but it may also inter- 
fere with other processes normally occurring in 
the liver and thereby lead to the presence of 
other undesirable substances. 

However this may be, it is, I think, quite plain 
that while alcohol in moderate amounts can be 
burned in the body, thus serving as food in the 
sense that it may be a source of energy, it is 
quite misleading to attempt a classification or 
even comparison of alcohol with carbohydrates 
and fats, since, unlike the latter, alcohol has a 
most disturbing effect upon the metabolism or 
oxidation of the purin compounds of our daily 
food. Alcohol, therefore, presents a dangerous 
side wholly wanting in carbohydrates and fats. 
The latter are simply burned up to carbonic 
acid and water, or are transformed into gly- 
cogen and fat, but alcohol, though more easily 
oxidizable, is at all times liable to obstruct, in 
some measure at least, the oxidative processes 
of the liver, and probably of other tissues also. 



724 



PEABODY: ALCOHOL L\ DISEASE. 



[Medical News 



tliereb} throwing into the circulation bodies, 
such as uric acid, which are inimical to health ; 
a fact which at once tends to draw a distinct line 
of demarcation between alcohol and the two non- 
nitrogenous foods, fat and carbohydrate. 

Lastly, 1 am inclined to emphasize another ob- 
servation made by Dr. Beebe, viz., that certain 
alcoholic drinks, such as port wine, for example, 
e.xert a much greater influence upon the excretion 
of uric acid, than a corresponding amount of al- 
cohol, thus suggesting that even moderate drink- 
ing of alcoholic beverages may be attended with 
even greater disturbance of the metabolic phe- 
nomena of the body than prevalent ideas would 
lead us to believe. In this connection, however, as 
a matter of clinical significance, it is to be re- 
membered that this deleterious influence of alcohol 
and alcoholic drinks is exerted noticeably only 
in connection with exogenous uric acid ; hence, 
the use of alcoholic fluids, in many diseases 
where a light or non-purin diet is used, would 
not be followed by an increased output of urates. 
In other words, under these conditions the bene- 
ficial effects of alcohol might be looked for with- 
out the accompaniment of the disturbed purin 
metabolism. As an adjunct to the ordinary daily 
diet of the healthy man. however, alcohol can- 
not be considered as playing the part of a true 
non-nitrogenous food. 



ALCOHOL IN DISEASE.* 
BY GEORGE L. PE.\BODY, M.D., 



OF NEW YORK. 



When your alluring president asked me to 
contribute a paper not to occupy longer than fif- 
teen minutes in the reading, to the subject of the 
therapeutic uses of alcohol I was sufficiently 
audacious to tell him that the evening would 
be entirely filled without touching upon that 
branch of the subject. When the hour arrived 
for the preparation of the paper it seemed a 
little difficult to occupy so much of your time 
as the president graciously placed at my dis- 
posal ; and then very soon the subject seemed 
to grow, as I progressed, so that to keep within 
the limits of the president's condition and of your 
I)atience, will be a little difficult. 

Most of the recent work upon alcohol relates 
to its food-value and its toxicity, to alcoholism 
and the pathological conditions which it induces, 
and to the legislation bearing upon it : but very 
little work has been done and very few publica- 
tions have appeared of late years upon its thera- 
peutic uses. 

.\ little that is new has been ascertained with 
regard to its local uses, both its interstitial in- 
jection into inoperable or recurrent uterine car- 
cinomata' and angiomata- and also its power 
to permeate the ejiiderniis and even the skin itself 
and to disinfect the skin and bring about local 
changes in the blood-supply and thus relieve cer- 

• Read at a meeting of the New York State Medical Asso- 
ciation, New York County, February 20, 1905. 



tain symptoms, even in regions that cannot be 
considered to be entirely superficial. 

Rielander-' made an e.xperiment upon himself, 
which seems to explain this latter point, per- 
haps more heroically but not more satisfactorily 
than has been done by using guinea-pigs. He 
cleaned the skin of the extensor side of one 
forearm very carefully by diligent scrubbing with 
hot water and soap for five minutes. Then he 
rubbed it for five minutes with a 20 per cent. 
solution of copper nitrate in 96 per cent, alcohol 
and then subsequently bathed the part with a 
10 ]5er cent, solution of potassium ferro-cyanide 
for ten minutes. After this the skin was in- 
cised without anesthetic to the depth of the 
superficial fascia. The red coloring produced 
by the chemical reaction was found not only 
through the entire thickness of the epidermis 
but also in the connective tissue of the skin. 
It was very abundant in and about the hair.- 
follicles: on the other hand, the sweat-glands 
and their neighborhood were usually free from it. 

( )ther local uses of a surgical kind, as in dis- 
infection of hands and treatment of hernia* de- 
serve to be mentioned in passing. This power 
of alcohol to penetrate the epidermis and reach 
the skin even in its deeper layers is of very 
great practical use in conditions of superficial 
inflammation. The contiinied application to the 
abdomen of compresses soaked in alcohol and 
covered by gutta percha and cotton wool has 
given great relief in peritonitis," and to one writer 
has seemed to cure" the disease where operation 
has been declined or is impossible. 

I'YiUowing out these ideas I have found it of 
great value in various painful conditions when 
applied in this way such as peripheral neuritis and 
])hlebitis. In herpes zoster" there is probably no 
better application to relieve the pain, which effect 
may be confidently predicted. 

Many kinds of local infection are amenable* 
to this local use of alcohol. If alcohol is care- 
fully and persistently used suppuration can often 
be averted in inflammation of lymphatics as of 
buboes, for example, and in threatened abscess 
of breast, in carbuncle, furuncle, paronychia and 
other allied conditions, if only its application be 
made sufficiently early and with sufficient per- 
sistence. 

(Jne of the earliest local uses was in phleg- 
monous" inflammation involving the external 
ear and temporal and mastoid regions. Many 
of these cases are illustrations of its antiseptic 
power: its power to relieve pain when used in 
this local way is probably to be explained by 
its causing a dilatation of blood-vessels and 
tluis diminishing congestion and consequent pres- 
sure. 

The alcohol is to he ajiplied on a compress 
consisting of six or eight thicknesses of cheese- 
cloth soaked with it and this covered with gutta- 
])ercha pajjer and cotton wool. 

Alcohol is to be renewed several times a day, 
the frequency depending upon the location, and 



April 22, 1905] 



PEABODY: ALCOHOL IN DISEASE. 



72s 



the thoroughness with which it is covered by 
impervious dressings. The object is to keep the 
skin saturated with it. 

It is well to remember that where the epi- 
dermis is thin this treatment, if employed at all, 
must be resorted to very cautiously. I should 
not apply it to regions like the scrotum or to 
very young children anywhere unless it is con- 
siderably diluted. I once knew a deep slough 
to follow its too energetic use over the coccyx 
in a case of coccydynia, by a surgeon noted for 
his thoroughness. The suggestion to use it in 
this case was made by me ; and it is an inter- 
esting commentary on the relative standing of 
medicine and surgery before the communit}" that 
he got the credit of curing the coccydynia and 
I of causing the slough ! 

Another modern use of alcohol is as an anti- 
dote to poisoning by carbolic acid.^" The dis- 
covery of this relation was accidental. A woman 
swallowed an ounce of carbolic acid in whisky 
with suicidal intent. The doctor found her un- 
conscious, her extremities convulsed, pupils tight- 
ly contracted, breath smelling of carbolic acid. 
He was astonished to find that in spite of the 
size and concentration of the dose her mouth, 
lips and tongue showed no evidence of burning 
by the acid. He washed out her stomach freely 
until the washings no longer smelt of carbolic 
acid. She became conscious and subsequently 
recovered completely. 

This experience led the doctor to try alcohol 
locally in treating painful burns caused by the 
acid. The whitened areas on the skin ceased to 
burn and the pain entirely disappeared from them 
when they were covered with cotton soaked in 
alcohol Others soon confirmed this power of 
alcohol.'^ Since then whisky has been looked 
upon as an agent of great value in poisoning by 
carbolic acid. 

In spite of these additions to its range of ap- 
plicability the purely therapeutic uses of alcohol 
have been gradually reduced to very few ; and 
it is gratifying to note that there has been, dur- 
ing recent years a distinct tendency to recede 
from the very liberal, almost reckless adminis- 
tration of it by the doctors of a former time. 
As a reaction against that time many modern 
medical writers are inclined to throw it away 
altogether as being either useless or toxic under 
all circumstances. Among these may be men- 
tioned I-Cassowitz,'- Bunge, Rosemann, C. Fran- 
kel," as perhaps the most conspicuous of its op- 
ponents. 

That very large doses of it render animals less 
able to resist infections of various kinds has been 
shown by FrankeU* and his pupils as well as 
by others ; but Meltzer^^ very properly criticizes 
all the experimental work which leads to this 
conclusion on account of the size of the doses 
employed. He says : " They do not throw any 
light upon the question whether conservative 
doses of alcohol properly given to a patient sick 
with an infectious disease, and under proper 



management and care, are harmful, indifferent 
or useful." 

Meltzer, in the valuable paper just quoted, 
strongly favors the use of alcohol in diseases 
like typhoid fever and pneumonia and quotes 
an imposing array of modern clinicians of vast 
experience in favor of it. Among them are 
Curschmann, Pel, Juergensen von Jaksch and von 
Noorden. 

Its use in disease is still strongly advocated by 
\'. Leiden^* who thinks that in acute febrile dis- 
eases it cannot be dispensed with and that in 
them it is capable of arousing the heart to a 
more energetic performance of its function. He 
regards the disposition to discard it as fanatical 
and wholly without justification. 

Binz" also strongly urges its usefulness in 
disease, while admitting, as most thoughtful 
writers do, its uselessness in conditions of health 
and of normal nutrition. He still claims for it 
two attributes, namely its food-value and its 
value as a stimulant both of heart and of 
respiration and believes that its utility is not 
open to question in conditions of weakness and 
collapse. 

His opinion as to food-value is based upon the 
conclusion so generally received as to its under- 
going oxidation in conditions both of health and 
of disease, and thus saving waste of other tissues, 
both carbohydrate and nitrogenous. 

George Bonne, ^'^ of Holstein, published a work 
in Tiibingen, in 1899, in which he advocates total 
abstinence on the part of doctors, but very clearly 
sets forth the value of alcohol in certain patho- 
logical states which he restricts to a very small 
number. 

Unbiased clinical experience seems to justify 
the belief that in alcohol we have still the best 
means of stimulating the heart and thus in- 
creasing a low blood-pressure in many patho- 
logical states.'" Necessity for its use in this way 
may arise both in conditions of primary weak- 
ness or syncope, and in enfeeblement due to acute 
febrile disease. 

It is not intended to deny that it is often 
prescribed carelessly, unjustifiably and inap- 
propriately. I have seen patients, both adults 
and young children, that had been kept in a 
condition of semi-intoxication for days, whose 
head-symptoms promptly disappeared when this 
drug was inhibited. The very evident evils at- 
tending its misuse do not justify us, however, 
in going to the extreme of abolishing it from our 
list of therapeutic weapons. 

Although many cases of pneumonia and the 
acute fevers never need alcohol in any form 
or at any time, nevertheless it must be admitted 
that many of these cases do need stimulation, 
and that for them there is no known substitute 
that will quite replace alcohol. Conditions of 
feeble circulation with all the alarming symp- 
toms that indicate them, may sometimes be 
helped by digitalis, strophanthus, strychnine, 
adrenalin, caffeine and the rest, but there is no 



726 



WYMAN: HEALTH OF THE NATION. 



[Medical News 



one of tlieiii upon which so much rehance can 
be placed as upon this one — indeed in many 
cases it is worth more than all of them put to- 
gether. 

1 am <]uite willing to admit that all of the 
symptoms of intoxication, even the very earliest 
of them are to be ascribed to a paralytic effect 
e.xerted by it upon the cerebral cortex and are 
no part of its stimulating influence, and that there 
is no justification for the causation of them under 
any circumstances ; but when all has been said 
against alcohol (and no hospital doctor of ex- 
perience in any city in the world will minimize 
its ])ower for evil) it still remains, in my opinion, 
imique in its general applicability to the ac- 
complishment of the clinical ends to which I have 
referred. 

As an antipyretic its powers are too feeble 
to make it of value : but it is of very great 
importance that the presence of fever does not 
interfere with its usefulness. Practically it often 
seems as if fever did decidedly interfere with 
the therapeutic activity of digitalis and others 
of its class. 

To decide on the case that needs it and the 
tlose that should be given is by no means always 
•easy even for the experienced practitioner. .A. 
combination of high temperature, especially if 
persistent, with delirium and other signs of pro- 
found nervous prostration, together with a pulse 
which is rapid, easily compressible, possibly di- 
crotic, or of irregular force — this combination 
always calls for alcohol. But this special series 
of symptoms may not always be present when 
alcohol is needed. Thus the pneumonia and gen- 
eral bronchitis of old age may, without fever, 
loudly call for such stimulation. 

If one were compelled to depend upon the 
indications supplied by a single organ, reliance 
should be placed upon the heart : and its in- 
vestigation should include a careful study of 
the pulse and of the heart-sounds, especially the 
second aortic sound. 

In these acute conditions, the aid of alcohol 
may often be reenforced by combining it with 
•one or more of the others that have been men- 
tioned, but there is not one among them that can 
be depended upon to replace it. 

In the later stages of these diseases there may 
I)e no fever at all and yet the heart-symptoms 
may be urgent enough to demand alcohol. In 
all of these conditions in adults a half ounce of 
whisky every three, four, five or six hours is 
a good dose to begin with, and it may be in- 
creased or diminished according to its effects : 
and pcrliaps more important still is the fact that 
it should be a matter of conscience with the doctor 
to see tliat its administration is discontinued as 
soon as it is no longer needed. 

There is little practical danger of engender- 
ing the alcohol habit by giving it to a fever 
Itatient : but it is well to bear in mind the fact 
that this danger increases progressively as the 
patient a])i)roaches a condition of health. 



In general it is not unusual to see numer- 
ous obvious beneficial eft'ects follow its judicious 
administration. The tongue becomes less dr\ . 
the pulse becomes slower and fuller, the skin 
more moist, the wakefulness and delirium less 
marked, the powers of digestion and assimilation 
improved. 

Brunton has called attention to the fact that 
useful indication regarding the effects of alcohol 
and the regulation of its dosage may be ob- 
tained by the doctor if he will remain at the 
Ix'dside occasionally for a quarter of an hour 
after the administration of a dose and watch 
tlie pulse, tongue, respiration, skin and general 
conditions. He will thus be able to see whether 
benefit is really resulting from it and to regulate 
the dose according to the needs of the individual 
case more intelligently then if he merely pre- 
scribes it in routine fashion and allows a day to 
elapse before he sees his patient again. 

I am quite willing to subscribe to the closing- 
statement of Meltzer's paper : " Alcohol in health 
is often a curse ; alcohol in disease is mostly a 
lilcssing." or possibly, it might be safer to say 
that in disease it is a blessing when it is properly 
used. 

REFERENCES. 
I. Therapeutisclie Monatshefte, 1895, S. =13; 1896, S. 566. 
-'. 1'.. llousell. lieilragc 7.ur kl. Chir.. X.KXIl, 1, p. 251, 1901. 

3. Zeitschr. f. (Jeb. u. Gyn., Bd. 47, S. 4. 

4. Brodnitz. Miinchen. med. Wochcnschr., No. 41, 1906. 

5. Sehrwald. Therap. Monatshefte, 1900, S. 243. 
b. Meyer. Loc cit., 1901, S. jo. 

7. Loc. cit., 1901. .S. .13;. 

S. Loc. cit., 1900, S. 6ii. 

9. Loc. cit., 1S98. S. 692. 
10. Loc. cit., 1S96, S. 409. 
I 1. Loc. cit., 1899 S. 408. 
ij. Schmidt's Jahrbucher. 1901, Cd. 27J, S. 213. 

13. Therap. d. Gegenwart, N. F.. Ill, i, 1901. 

14. Schmidt's Jahrbiicher, 1901. Bd. 272, S. 212. 

15. Am. Medecine, Voh I^^ No. 2, pp. 60 to 65. 
j(>. Krankenpf.. IL i. 1902. 

17. Berliner kl. Wochcnsclir., 1903, Nos. 3 u. 4. 
IS. Die Alkoholfrage in ihrcr Bcdcutnng fiir die iirztlichc 
Praxis. 

10. Bin:^, Loc. cit. 



THE HEALTH OF THE NATION.' 

EV WALTER WYMAN^ M.D., 

OF WASHINGTON, D. C; 

srRGI:Qi\-GENER.\L, U. S. PUBLIC HE.\LTU AND MARINE-HOSPITAL 

SERVICE. 

The health of the nation seems rather a large 
topic, yet not too large for hopeful and practi- 
cal consideratioiL nor yet so large as would be 
a kindred topic, the health of all nations, which 
is likewise one for serious and hopeful considera- 
tioiL Indeed, these two subjects have a direct 
bearing one upon another, and one cannot be ade- 
quately consiilered without considering the otlier. 

It is a somewhat trite idea, but one whose sig- 
nificance is of great present import, that the na- 
tions of the earth to-day arc more nearly related 
than ever before in the world's history. " Not 
only has the ' narrow frith ' been practically abol- 
ished," says a recent writer, " but the wide ocean 
is traversed by passenger shi])s in five days, and 
by thoughts put into words in a few seconds. All 
the world has become one neighborhood so far 

I .\ddrcss hcforc the New York State Medical Association. 
New York County, at tlic New York Academy of Medicine, 
January 16. 1905. 



April 22, 1905] 



WYMAX: HEALTH OF THE NATION. 



727 



as relates to distances." In no manner has this 
been more strikingly shown than in the warfare 
against contagious disease. But a few years ago 
a violent epidemic of yellow fever in Cuba would 
excite no more than passing notice, while to-day 
the ne\fs of two cases in the far-otT neighbor- 
hood of Santiago is immediately wired through- 
out the United States and foreign countries. A 
few cases of bubonic plague in the Urient, which 
a few years ago would receive no attention, are 
instantly reported and published throughout the 
L'nited States, and one case of cholera on a ship 
in the Mediterranean is likewise immediately tele- 
graphed to the jjrincipal cities of the world. In- 
ternational congresses, conferences, and conven- 
tions, are frequent, bringing the nations togetliL-r 
as one family in the struggle against these foes 
of mankind. As in 1892 when a case of cholera 
appeared in Jersey City, the New York Board of 
Health took active interest therein, so is the 
L'nited States Government interested when epi- 
demic disease is reported in England, France, Ger- 
many, Turkey, Egypt, or any port in the Orient, 
for communication therewith is now swift and 
frequent. And so closely related are wc in health 
matters to our neighbors of Mexico, Central antl 
South America that periodical international sani- 
tary conventions have been agreed upon by the 
several republics, and a permanent international 
sanitary bureau of American republics has been 
established and is maintained. I need further 
to refer only to the international congresses of 
medicine, of hygiene and demography, of tuber- 
culosis, leprosy, and other allied subjects, to show 
how closely the nations are getting together in the 
effort to prevent and suppress disease. 

We hear much at the present time of interna- 
tional peace conferences and arbitration treaties. 
Is it too much to expect, as a corollary or parallel 
movement, the cooperation of nations to prevent 
and suppress communicable disease? There is at 
present pending before the Senate of the United 
States a convention — practically a treaty — sub- 
scribing to the findings of the international con- 
ference of Paris, 1903, embodying the principles 
and practice necessary on the part of all nations 
for successful warfare against plague and cholera. 

The International Sanitary Conventions of 
.\merican Republics, previously mentioned, were 
instigated by the obvious advantage of an agree- 
ment for the sanitation of all yellow fever in- 
fected seaports. Seaports being the points of 
contact between nations, would properlv be the 
first objective points in international sanitation, 
and their undoubted consequent prosperity would 
cause the sanitary movement to extend to other 
cities. 

International sanitation might well be consid- 
ered as adjunctive to the movement for univer- 
sal peace. I believe it would be less difficult of 
achievement than absolute arbitration, or at anv 
rate it could be made a powerful influence in 
establishing the latter. A former president of 
the French Republic. Monsieur Casimir Perier, 



at the opening of the Hygienic Conference in 
Paris, in 1894. said: "The international princi- 
ples, which had their origin in the laboratory and 
are based on science, are the only ones which 
bind nations together with strong ties, and estab- 
lish equitable and immutable laws." 

This principle may well be considered by those 
who are seeking universal peace, and international 
responsibility with regard to disease is a subject 
worthy of the attention of all interested in the 
development of international law. So far as 1 
know there is no mention in the treaties on inter- 
national law of the responsibilities of govern- 
ments to one another in matters of public health, 
but the time is ripe for adding such a chapter. 

I quote from a recent writer : It seems " that 
nations are beginning to develop a conscience 
and a sense of justice for the rights of other na- 
tions. As a whole, the peace movement is another 
step toward the actual attainment of the ideal 
perfection of government." With this growing 
sentiment of harmony and fraternity among the 
nations there should be developed an interna- 
tional sentiment regarding sanitation and sup- 
pression of disease. If, as Tolstoi says, the onl_\- 
substitute for war is religion, international sani- 
tation would be a po^'erful weapon in the hands 
of religion, if indeed it could not in itself be made 
a substitute for war. It surely would furnish 
a plain upon which nations might meet. It sug- 
gests a common enemy — disease — against which 
all might combine without fear of international 
complications, and would furnish a more worthv 
object than war for the expenditure of energy 
and money. 

As to the health of this nation, the subject may 
be considered under two heads, the exclusion of 
disease and the extinction of disease. The for- 
mer, which embraces the subject of quarantine, 
I will not discuss, as it may be considered by the 
distinguished gentleman who is to address you 
on the health of the port. As to the extinction 
of the ordinary communicable disease, is the idea 
one that is visionary or has it a good basis in 
scientific achievements and in practical results 
already attained? 

It is not my purpose to burden you with statis- 
tics, but surely enough has been widely published 
to show a marked diminution as the direct re- 
sult of special effort, and to encourage the belief 
that in the future most of these diseases mav be as 
rare as they are now common. Their subsidence 
or disappearance will be due chiefly to good laws 
and eft'ective administration. Good laws imply 
goixl organization, and it may be profitable to 
consider for a moment the health organization of 
the United States as it exists to-day. 

In general, I believe, this organization is a 
proper one, but defective in many of its de- 
tails. The United States Public Health and Ma- 
rine-Hospital Service has, under various acts of 
Congress, certain maritime quarantine functions 
and interstate quarantine functions. It has also 
a hygienic laboratory " for the investigation of 



728 



WYMAN: HEALTH OF THE NATION. 



[Medical News 



contagious diseases and matters pertaining to 
the public health." 

This last is generous and broad legislation, but 
is limited to laboratory investigations. Therefore, 
certain other investigations, which are desirable, 
cannot be made; for example, an investigation 
into the sanitary conditions at certain health re- 
sorts where tuberculosis patients are gathered in 
great numbers. I mention this simply as an il- 
lustration, but efforts will be made to meet this 
difficulty. The epidemic appropriation under 
which investigations other than laboratory can be 
made, is limited to certain specified diseases, 
namely, cholera, yellow fever, smallpox, typhus 
fever, and bubonic plague. The laboratory has 
an advisory board through which it is brought 
into relation with the medical departments of the 
armv and navv, the Bureau of Animal Industry of 
the Agricultural Department, and through five 
distinguished scientists with the laboratories of 
leading institutions of learning. Thus the scien- 
tific pulse of the service is brought in contact 
with the profession. 

In the practical administrative work of a sani- 
tary character, the service is brought into rela- 
tion with State boards of hpalth and quarantine 
officers, through annual conferences required by 
law, and occasional conferences called either by 
the Surgeon-General or by the State health au- 
thorities. 

Every State and Territory has a health de- 
partment consisting either of a health commis- 
sioner, or of a State board of health, which has 
about the same relation to county and municipal 
boards of health as the national service has to 
the State organizations. 

The chain of organization, therefore, seems 
theoretically a good one, and it would appear to 
be the part of wisdom to perfect and strengthen 
every link in the chain. The chain has not been 
forged all at once. Link after link has been 
added, and the several links strengthened as the 
occasion seemed to demand. In a growing 
country this seems to be the natural and proper 
method. The other method has been tried and 
failed.^ So that our sanitary system must be one 
of gradual growth. 

Thus far I have spoken only of the official 
health organizations, which are, of course, the 
most potent of all, based upon the statutes of the 
States and the nation, continuous in their opera- 
tions and not dependent upon spasmodic effort 
or ephemeral enthusiasm. Yet it is impossible 
to ignore the valuable results of auxiliary organ- 
izations, voluntary in character, but inspired by 
noble and patriotic motives. They are too nu- 
merous to mention in detail, but I mav refer to 
sucli organizations as the great American Medical 
Association, the American Public Health Associ- 
ation. State, county, and city medical societies, 
and the auxiliary sanitary associations that exist 

I A Xational Board of Health was established in 1879, but 
after four years its operations were discontinued and later the 
law creating it wat repealed by Congress. 



in so many of our States and cities. Through 
these public sentiment is developed which crystal- 
lizes into statutory laws and organizations. 

One of the most common pleas of the sanitarian 
of to-day is for a wider diffusion of knowledge 
of hvgienic and sanitary principles. It has been 
frequently said that sanitary science is far in 
advance of its practical application. The facts 
are known, but not to a sufficient number, and 
appeals are often heard for the introduction into 
schools and colleges of more instruction in these 
essential and easily comprehended subjects. The 
plea is justified by every consideration, but I 
should like to call attention to the necessity of the 
spread of sanitary information among intelligent 
adults, among the learned, and the wise ; among 
the men who govern our cities and our States, and 
among our legislators. The knowledge I would 
seek to have impressed upon them is the value 
of sanitation in the advancement of the individual 
happiness and national. State, and municipal wel- 
fare. Too many regard sanitation as an id,eal 
matter, efficacious theoretically. They shotild 
be impressed with the knowledge that improved 
conditions can and must be attained, and that bad 
sanitary conditions indicate sloth, a willingness to 
endure and ignore, characteristic of the least civ- 
ilized and cultivated communities.- The possibility 
of sanitation in the advancement of civilization 
should be impressed upon them, so that in addition 
to their high ideals of civil government they may 
also entertain ideals of sanitary advancement far 
beyond their present standards. Their influence 
and aid will then be more readily giveii when 
measures are brought before them for consider- 
ation or action. 

There is one method of popular diffusion of 
knowledge which I have referred to on pre- 
vious occasions, and which seems worthy of fur- 
ther consideration. It is the making of sanitation 
an issue in local politics. Issues might be made on 
efforts to suppress the ordinary diseases by nnuii- 
cipal improvements, particularly in the worst por- 
tions of a city. I am aware that these improve- 
ments are liable to be unpopular among those 
whose excessive profits on investments would 
be unfavorably affected thereby, and even among 
those whose individual physical welfare is to be 
improved. ?,ut these difficulties can be overcome 
if the political movement is shrewdiv and fairly 
managed : and these issues being the subject of 
popular discussion, hygienic and .sanitary knowl- 
edge would be brought out and broadly diffused. 

This idea has already been given expression by 
an association great in numbers and influence. 
At the recent annual meeting in San Francisco 
(last November) of the American Federation of 
Labor three hundred delegates were present, rep- 
resenting one hundred national and international 
labor unions, with a membership of about twO' 
million. In that convention was passed the fol- 
lowing resolution, which seems to me significant 
of tiic earnest and laudable attitude of these 
unions toward the sanitarv movement. The reso- 



April 22, 1905] 



WYMAN: HEALTH OF THE NATION. 



729 



» 



lution was referred to the committee on resolu- 
tions and adopted by the convention on the tenth 
day of its session. (Resohition No. 157.) 

Whereas, In the proper embelhshment of our 
towns and cities, by parks, monuments, ornamen- 
tal buildings, boulevards, and driveways, there 
is too frequently an utter neglect in the removal 
■of insanitary and unhealthful conditions in the 
Jess favored localities, and 

Whereas, In our opinion one of the first duties 
of town and city governments is to make whole- 
some, by good drainage, paving, water supply, 
and correct tenement house construction, those 
portions of cities and towns that are now neg- 
lected in these respects, thus imperilling the health 
and happiness of the working people; therefore, 
be it 

Resolved, In the interest of the poor and well- 
to-do also, town and municipal councils should 
give greater legislative attention with adequate 
appropriations to the removal of these evil con- 
ditions in the less favored localities, and be it 
further 

Resolved, That the labor unions by supporting 
candidates pledged in advance to the support of 
necessary and wise ordinances, according with 
the foregoing principles, will advance the health 
conditions and material prosperity of the coun- 
try ; and the American Federation of Labor in 
this convention assembled recommends these 
principles to its affiliated national, State, district, 
and local bodies. 

The foregoing resolutions seem to confirm the 
ideas I have endeavored to express as to inject- 
ing sanitation as a live issue in municipal poli- 
tics, and you will recall that one eiifect of such 
injection would be a wider diflfusion of sanitary 
knowledge among the working people, and a 
deeper impression of its importance among the 
more highly educated. 

But there is more in these resolutions than the 
spread of sanitary knowledge. They express 
what seems to me to be a cardinal principle for 
guidance in practical measures to improve health 
conditions in the United States. They practically 
assert that the low, unsewered, unpaved, filthiest 
parts of our cities should receive the very first 
consideration in all plans for municipal improve- 
ments. 

It should be the ambition of all those who take 
special interest in the health of the nation to bring 
about a slumless country. I have given expres- 
sion to these views before, but they require re- 
peated iteration. As stated in a former address, 
" there is no adequate reason why slums should 
exist anywhere, and by slums I mean places where 
through bad drainage, imperfect sewerage, in- 
adequate air space, lack of pure water, and lack 
of sunlight, human beings are subject to disease 
and crime-inducing conditions." 

Following this all sanitary administration 
would be much easier and more effective. 

Now. in the elimination of slums, there are one 
or two principles involved, which should be care- 



fully considered lest fatal mistakes be made. 
Such mistakes have been made, as may be seen in 
the reports of the commission on the housing 
])roblem in London. The right of the owner of 
the insanitary dwelling should be considered, and 
whether compensation should or should not be 
allowed him seems to be a matter dependent upon 
local considerations. But the rights of the ten- 
ants, however poor, must also be considered, and 
ordinarily it would seem wise to defer their 
ejectment until provision is made for their hous- 
ing in quarters equal in size, no greater in rent, 
and as convenient in locality, as they have been 
occup_\-ing. 

The bureau of which I have charge is. now re- 
ceiving, through the State Department, from the 
L^nited States consuls abroad, and is collating the 
experiences and laws in foreign countries relating 
to these matters. The statement from one city 
contained a confession of mistake in that, while 
buildings are being put in sanitary condition re- 
spectable workmen are driven into localities for- 
eign to their trades and among a foreign element, 
all of which is detrimental to their self-respect. 
This difficulty suggests the possibility of a coor- 
dination of effort between the municipalities and 
our wealthy philanthropists. The municipalities 
can well afford to pass ordinances for the destruc- 
tion or reconstruction of insanitary dwellings, 
with a proviso for a possible delay of execution 
until proper quarters, as before indicated, are 
provided. 

I would not undertake to say whether or not 
a plan of this character is applicable to a great 
city like New York, but with regard to other 
cities I believe it is. If municipal ownership of 
tenement houses is objectionable, then would 
be available the efforts of the milionaire philan- 
thropist, who, not as a giver of charity, but as one 
willing to accept a very moderate return on his 
investment, would erect the necessary buildings. 

I have said that the health of this nation might 
be considered under two heads, the exclusion of 
disease and the extinction of disease. There is 
another consideration worthy of attention, name- 
ly, the development of a healthy and robust in- 
dividual organism. The elimination of the or- 
dinary diseases and the development of a higher 
average of individual health and strength would 
practically mean life on a higher plane in all its 
features. It would mean a greater average of 
mental aptitude for work in the higher fields of 
human activity — in all the arts and sciences. 

When thus we review the good results of sani- 
tation, and survey the field and realize that im- 
proved conditions are within our reach, we cer- 
tainly must feel a desire to hasten the dav when 
they may be realized. 

In dealing with my topic. The Health of the 
Nation, I have preferred to express these gen- 
eral ideas and principles, rather than to go into 
those details and statistics of disease and sanitarv 
work which are narrated elsewhere in medical 
journals, reports of State and citv boards of 



■30 



DOTY: HEALTH OF THE PORT 



[Medical News 



health, and of the Public Health and Marine- 
Hospital Service. 

Knowing that other speakers are to follow, 
whom we are all anxious to hear, I feel that I 
have fully occupied all the time due me, and. in 
closing. I wish to say that it is a rare pleasure and 
an opportunity greatly appreciated to meet and 
exchange ideas with the members of this society. 
I wish to thank your president for his kind 
invitation for this evening, and to thank you all 
heartilv for vour kind attention. 



THE HEALTH OF THE PORT OF NEW YORK.' 

BY .\LV.\1I H. DOTY, M.D., 

OF KEW YORK; 
HEALTH OFFICER OF THE PORT OF NEW YORK. 

The health of the port of New York, which 
has been assigned to me as the title of a paper 
to be presented at this meeting can best be con- 
sidered in connection with a description of the 
diseases which are dealt with at the New York 
Quarantine Station, and the methods emplo}ed 
to prevent their entrance into this country. 

Quarantine ofificers, while expecting to deal 
with almost any form of infection, usually regard 
some one disease as the most constant visitor 
which comes under their observation. The 
character of this depends upon the ports 
with which the various quarantine stations 
are in frequent and direct communication. For 
instance, yellow fever, which has been almost 
continuously present in South American and 
L^uban ports, is looked upon as a special menace to 
this country, particularly the southern portion of 
it, where ports of entrv have made unusual and 
extensive preparation for the detection and care 
of this disease. Although New York and its 
vicinity have little or nothing to fear from yel- 
low fever, it is necessary to bear in mind that a 
case in its early stage, or in a mild or ambulant 
form, if allowed to pass the New York Quaran- 
tine Station unrecognized, may reach a Southern 
town and possibly cause an outbreak of this dis- 
ease. For this reason great care is taken at this 
])ort to detect the presence of yellow fever on in- 
coming vessels. It may be truthfully said that in 
the past no disease which has visited the United 
."states has caused such consternation and great 
loss of life or has been responsible for such 
stringent rules and regulations on the part of 
health authorities as yellow fever. Not only 
just but unjust means have been employed to pre- 
\ent its extension. This has been carried to such 
an extent during the presence of epidemics in 
the .South that the commerce of that section has 
been at times practically paralyzed. The enforce- 
ment of drastic measures was largely due to the 
belief that yellow fever was transmitted by per- 
sonal contact with the patient, by discharges, the 
clothing and effects of the sick, cargoes of ves- 
sels, merchandise, etc. — even iron rails have been 

I Read before the New York County Medical Association, at 
le New York .Academy of Medicine, New York, February 16, 
J 905. 



regarded as a medium of infection and have been 
subjected to disinfection. To-day w-e know that 
such regulations are unnecessary, as it has been 
conclusively proven by the most careful and thor- 
ough investigations that yellow fever is conveyed 
from one person to another by the mosquito. It is 
but pr()])er to say that there are still some who be- 
lieve that there may be other means of transmit- 
ting the disease. However, there is at present no 
reasonable proof of it, and for practical purposes 
it may be regarded as safe to assume that the 
mosquito is the only means by which the disease 
is conveyed. The importance of this knowledge 
cannot be overestimated, inasmuch as it ])laces in 
our hands means by which formidable and dan- 
gerous epidemics of yellow fever can be pre- 
vented. The means to which I refer consist 
principall}' in confining the patient sick with yel- 
low fever in an apartment completely protected 
by screens to prevent the entrance or exit of 
mosquitoes. This measure of protection is easily 
carried out, and in order to be eminently suc- 
cessful it is required that cases of yellow fever 
shall be very early detected. Aside from the use 
of agents such as sulphur dioxide in apartments 
to destroy the Stcgoinyia fasciafa, the variety of 
mosquito which transmits yellow fever, disinfec- 
tion is now regarded as unnecessary. Exhaust- 
ive experiments which were made at the New 
York Quarantine .Station conclusivelv proved 
that the mosquito will not live in closed trunks, 
bags and other receptacles more than twenty- 
four or thirty hours; therefore the disinfection 
of baggage which has been in transit more than 
two days would seem to be uncalled for. This 
not only simplifies the methods employed in the 
treatment of outbreaks of yello^v fever, but re- 
lieves commerce of the long delays and great 
expense which general disinfection has heretofore 
involved. No one welcomes this change so ear- 
nestly as the quarantine officer, inasmuch as the 
proljlem of securing a thorough and safe disin- 
fection without imnecessary delay to vessels and 
their passengers is now practically eliminated. 

.\nother factor which has recently made con- 
siderable change in quarantine methods, particu- 
larly at the Port of New York, are the means em- 
ployed to prevent the entrance of bubonic plague 
into this country. The appearance of this disease 
in European and South -American ports during 
the ])ast five or six years has caused consider- 
able apprehension, as it was believed that these 
outbreaks would be followed by results similar 
to those reported from India, where the mortality 
from this disease is very great. This anxiety was 
largely due to the meager knowledge heretofore 
possessed of the character and habits of this dis- 
ease. Furthermore modern methods of sanitation 
are not in force in India, and the sanitary au- 
thorities not only do not receive the support of 
the people in efforts to enforce proper regula- 
tions, but have their opposition instead. The 
people there are extremely poor and ignorant, 
and ar« herded together in great ntiinbcrs, thus 



April 22, 1905] 



DOTY: MF.ALTII OF THE PORT. 



7.n 



I 



giving any infectious disease every opportunity 
to extend. In Santos and Rio Janeiro, where out- 
breaks of plague assumed an epidemic form, and 
where sanitary regulations, although fairly good, 
are far inferior to our own, the disease was soon 
Ijrought under control. In efforts to detect the 
])resence of this disease, it is necessary to bear in 
mind that it may appear either as the " bubonic " 
form, which is associated with enlargement of 
the superficial glands, particularly the inguinal 
and auxiliary ones, or the " pulmonary " form, 
in which the symptoms are principally refer- 
able to the lungs. Aside from the trans- 
mission of the disease by personal conta- 
gion, it is necessary that proper consideration 
be given to the rat, which has been regarded as a 
common means of conveying the disease from 
one person to another. Although there is no 
doubt as to the truth of this, there is also no 
doubt that the importance of the rat in the trans- 
mission of the bubonic plague is overestimated. 
In addition to vermin we have yet to consider 
the probability of the disease being conveyed by 
insects. During the past four or five years a 
number of cases of bubonic plague have been 
removed at the New York Quarantine from ves- 
sels arriving from South American and Indian 
ports. In no instance did secondary cases occur 
among those who were in contact with the pa- 
tient, either on shipboard or on Swinburne 
Island. This tends to show that bubonic plague, 
when modern sanitary regulations are in force, is 
not easily transmitted. The pulmonary form, 
which is very fatal, is not usually seen away from 
India. 

In vessels arriving from cholera ports great 
care is taken to detect the disease in its various 
manifestations. The ship's log is carefully ex- 
amined, and all cases recorded as heart disease, 
diarrhea, dysentery, etc.. which may either have 
died or recovered in transit to this country, are 
regarded as suspicious, and as a rule justify the 
detention of the crew, besides a thorough dis- 
infection of the vessel. Fortunately, vessels 
coming from cholera and plague infected ports 
do not as a rule carrv passengers. 

Typhus fever and smallpox, which complete 
(he hst of five diseases that are specially subject 
to quarantine regulation, are also carefullv 
watched for, particularly if there is any reason 
lo believe that these diseases exist at the ports ol 
departure. 

In order to insure the detention of infectious 
diseases in the stage of invasion all persons ar- 
riving at this port on foreign vessels having fever 
as indicated by the thermometer, and which can- 
not be satisfactorily accounted for, are subject to 
removal to Swinburne Island for observation. In 
this manner manv cases of infectious disease have 
been prevented from reaching the city. 

Success on the part of quarantine officials in 
the detection of infectious disease and the treat- 
ment of passengers, crews and vessels depends 
upon the character of inspection performed, and 



an intimate knowledge of the principles which 
govern modern and practical sanitation, which it 
can be said is now placed on a scientific basis. 
We are therefore dealing mainly with facts and 
not theories. Many of the latter which have long 
held sway have been repudiated by practical sani- 
tarians. 

I am confident that the clothing worn by well 
persons, textile fabrics, other than those used 
about the sick, merchandise, cargoes of vessels, 
etc., rarely act as a medium of infection. I 
am convinced of this as a result of careful investi- 
gation and practical experience. The theory that 
this material transmits disease undoubtedly re- 
ceives its chief support from the fact that it is the 
only plausible explanation of the presence in a 
community of a case of infectious disease, the 
origin of which cannot be satisfactorily accounted 
for. While this theory is apparently reasonable 
and easily accepted, it is associated with great 
danger to the public, inasmuch as it discourages 
a careful and thorough inspection to ascertain the 
real origin of the outbreak, which I believe is 
frequently due to the presence of mild, ambulant 
or unrecognized cases. This statement I am quite 
sure will be indorsed by many who have had long 
practical experience with infectious disease. In 
support of the statement which I have just made. 
[ will cite the following instances from my own 
experience: During the prevalence of typhus 
fever in New York City in 1893. a thorough in- 
vestigation was made as to the origin of each case 
brought to the notice of the Health Department. 
The investigation frequently covered over a pe- 
riod of a week or more, and in the great majorit)- 
of cases the most satisfactory and conclusive 
l^roof was obtained that the disease was contracted 
In- personal contagion and not through the me- 
dium of clothing, etc. Typhus fever also existed 
in New York during the previous year, 1892. Dur- 
ing the period referred to (1892-1893) there 
were 714 cases of typhus fever, and 814 cases 
of smallpox under the observation of the Health 
Department. The Bureau of infectious dis- 
eases at the time referred to consisted of 
from sixty to seventy-five officers and employees, 
including diagnosticians, vaccinators, ambulance- 
drivers, etc.. all of whom were more or less con- 
stantly in direct contact with the above cases and 
their apartments. It was frequently necessary 
for the diagnosticians to undress the patient in 
order to make a thorough examination. Ambu- 
lance drivers and other attendants carried the pa- 
tients from their apartments to the ambulance, 
and afterward from it to the hospital wards. 
Gowns were not used, and the officers and eni- 
ployees referred to went freely to and from their 
homes to the seat of infection ; yet in no instance 
(luring this entire period of almost two years was 
either typhus fever or smallpox transmitted to the 
families of these men, or to the other occupants 
of houses in which they lived. Fourteen of the- 
emplovees contracted typhus fever, and seven 
(lied. The fact that the fourteen men referred to 



732 



DOTY: HEALTH OF THE PORT. 



[Medical News 



were promptly removed to the hospital on the ap- 
pearance of the first symptoms of the disease 
will, I believe, explain why members of their fam- 
ilies and others were not infected, inasmuch as 
there is good reason to believe that typhus fever 
does not usually transmit infection during its very 
early stage. If infection were commonly com- 
municated by the clothing worn by well per- 
sons, it seems reasonable to infer that it would 
have been demonstrated in the instance just re- 
ferred to. 

During the past six or seven years a number 
of cases of bubonic plague have been brought to 
this station by vessels coming from South Amer- 
ican and Indian ports. In all but one instance 
the disease was in a mild or ambulant form, which 
under the ordinary inspection of passengers would 
have passed unrecognized. The persons affected 
were able to stand erect on the deck of the vessel, 
answer all questions, and presented no evidence 
of the disease. However, when their clothing was 
removed and a glandular inspection made, the dis- 
ease was recognized and the diagnosis confirmed 
by bacteriological examination ; moreover, at no 
time during their detention at Swinburne Island 
did their general condition or appearance indi- 
cate that they were affected with the plague. The 
presence of a case of this kind in a crowded 
sailor's boarding house in a large city would be 
likely to transmit the disease, and inasmuch as no 
record of a previous case was forthcoming, the 
infection would probably be attributed to clothing 
or cargo. Cases of the mild or ambulant form of 
yellow fever, or in the early stage of this disease, 
have been detected at this station by the use of the 
clinical thermometer, when the ordinary methods 
of examination would probably have allowed them 
to pass unrecognized. 

The opening of the school season largely in- 
creases the number of cases of diphtheria, scar- 
latina and measles, and it is the belief of many 
that they are transmitted by the clothing of well 
children who are members of families where in- 
fectious diseases exist. That this belief has not 
been well founded has been clearly demonstrated 
by the Health Department of New York and 
other cities. Inspectors connected with the school 
corps are constantly finding in the .schools mild 
and ambulant cases of the above diseases, which 
have not been recognized and which are unques- 
tionably principally responsible for the increased 
number of cases of infectious diseases which 
follow the opening of schools. 

What I have said regarding the necessity of a 
careful inspection in outbreaks of infectious dis- 
eases a])])lics in the most forcible way to quaran- 
tine insi)ection. inasnuich as after the release of a 
ship no further opportunity for e.xaminatit)n is. 
as a rule, afforded. 

In referring particularly to this part of the sub- 
ject, it is not my intention to discourage the use 
of every reasonable and sensible measure neces- 
sary to prevent the extension of infectious dis- 
ease, but rather to indicate in what direction our 



energies should be directed for this important 
purpose. I am certain that the full acceptance 
of the theory that the clothing worn by well per- 
sons, merchandise, cargoes, vessels, etc., com- 
monly transmit infectious disease militates against 
the careful inspection, which I believe is impera- 
tive in order to discover the true origin of out- 
breaks of infectious disease and to control them 
promptly and successfully. 

The inspection of passengers and crews at the 
New York Quarantine Station is of the most 
rigid character. Neither the bill of health, the 
statement of the ship's captain, or surgeon, or of 
anv one else is taken in lieu of a careful personal 
examination when called for by the regulations 
of the department. The use of carefully registered 
thermometers constitutes a part of the inspection 
of passengers and crews coming from infected 
districts. If plague is suspected all on board are 
subjected to a glandular examination, and special 
attention is given to the presence of any pulmo- 
nary affection. The use of the thermometer is also 
included in the inspection of plague suspects. \ 
]3assenger or member of the crew having aiT eleva- 
tion of temperature, which cannot be satisfactorily 
accounted for, is subject to removal to Swinburne 
Island for observation. Those who have been in 
contact with infectious disease on shipboard are 
also held for observation. So-called cases of ma- 
larial fever, particularly from Southern ports, are 
detained until an examination of the blood shows 
the presence of the malarial plasmodium, or until 
the disease has been shown not to be yellow fever. 
The clothing of the crew and passengers, bedding 
and forecastle, etc., of vessels coming from plague 
of cholera ports, which have been long in transit, 
are on their arrival here thoroughly disinfected ; 
not on the assumption that this material may have 
conveyed infection from the ports of departure, 
but on the ground that in the long voyage there 
may have been cases of infectious disease which 
have recovered and are not properly reported. 

When disinfection is necessary steam at a tem- 
perature of 230° F. with an exposure of fifteen 
minutes is used for the treatment of clothing, 
bedding, and other textile fabrics, inasmuch as it 
is the only agent which can be depended upon to 
thoniughly penetrate the material referred to. 
When furs, silks, .satins, and other delicate fab- 
rics, and also leather goods, etc., which are de- 
stroyed or injured by steam are to be disinfected, 
formaldehyde gas is employed. In these in- 
stances, however, every article is carefully hung 
up and spread out in order that all surfaces shall 
be exposed to the gas. Formaldehyde is also used 
in the disnfection of saloon apartments, which 
contain fine fabrics, gilding, etc. Hot water and 
soap, sulphur dioxide, bichloride of mercury and 
car])olic acid arc variously used in the cleansing 
and disinfecting of the ship's forecastle and other 
apartments after the removal of all textile fabrics, 
merchandise, etc. 

I lowever, the thorough use of soap and water 
liy scrubbing, followed by tlie generation of sul- 



i 



April 22, 1905] 



PETERSON: NEW YORK AND THE INSANE. 



733 



phur dioxide, or formaldehyde gas in the closed 
apartment, is as a rule all that is required to in- 
sure safety against infection. I am sure that the 
value of soap and water in the treatment of filthy 
and greasy woodwork, which is almost always 
found in the ship's forecastle, and commonly in 
schoolrooms, etc., is not properly appreciated. 
Under these conditions, the use of a solution of 
bichloride of mercury or carbolic acid certainly 
does not cleanse the woodwork nor can it be de- 
pended upon to insure disinfection. 

The disinfecting steamer, James W. Wads- 
worth, which is always under steam at the New 
York Quarantine Station, contains all the appa- 
ratus which is used in modern disinfection. In 
this way the treatment of vessels is properly car- 
ried out with very little detention. After the re- 
moval of a case of infectious disease, and also 
those that have been exposed to it, as in small- 
pox, or where all passengers and crews are sub- 
ject to removal, as in the presence of plague, 
cholera or typhus fever, thorough disinfection of 
the vessel is performed, and the latter promptly 
released. The further detention of a vessel is 
not only unnecessary, but it entails a serious ex- 
pense to the owners. The detention of a case of 
infectious disease on shipboard is in violation of 
one of the cardinal principles of marine sanita- 
tion, inasmuch as proper segregation and quaran- 
tine cannot be properly carried out, and the in- 
fection is apt to be further extended. Besides, 
under these circumstances, the time for the release 
of the vessel cannot be determined. 

In transatlantic mail steamships, the deposition 
of the captain and surgeon that the saloon passen- 
gers and crew of the vessel are well is under or- 
dinary conditions aijd where no epidemic or in- 
fectious disease is prevalent at the port of de- 
parture, accepted in lieu of an examination. 
However, under no conditions are steerage pas- 
sengers exempt from examination. Experience 
has shown that this procedure is safe. Further- 
more, the examination of two or three hundred 
saloon passengers and two to six hundred mem- 
bers of a crew, who are constantly needed in the 
movement of the ves;pel. would involve a deten- 
tion, which is not under ordinary circumstances 
justified. 

If success has attended the eflforts of the Health 
Officers' Department of the State of New York, 
to prevent the entrance of infectious disease into 
the United States, it has been due to a strict ob- 
servance of the principles which govern modern 
sanitation. 

Identification of the Body of Paul Jones. — Accord- 
ing to the newspaper reports the identification of the 
hody of Paul Jones, recently exhumed in Paris, is 
complete in every particular. Found where it was ex- 
pected, the body, remarkably well preserved, shows 
marked resemblance to the extant portraits and busts 
of the Admiral, and corresponds to the recorded meas- 
urements. As a finishing touch to clinch the identifica- 
tion, an autopsy " showed distinct proofs of the disease 
from which the .\dmiral is known to have died," 



WHAT THE STATE OF NEW YORK IS DOING FOR 

THE INSANE.i 
BY FREDERICK PETERSOX, M.l)., 

OF NEW YORK: 

PROFESSOR OF CLINICAL PSYCHI.\TRY IN COLUMBIA UNIVERSITY; 

EX-PRESIDENT OF THE STATE COMMISSION IN LUNACY. 

On the invitation of your President I have the 
honor to address you upon the subject of " What 
the State of New York is Doing for the Insane 
and for the Advancement of the Science of !Med- 
icine." 

Having left the busy ranks of the medical pro- 
fession for a few years, to be one of the Commis- 
sioners in Lunacy of the State, I feel that I have 
returned to my work with some news to tell of 
a medical domain outside of our common ex- 
periences. The isolated position of many State 
hospitals as well as private retreats, and the fact 
that the State in taking charge of the vast body 
of the insane, supplies its own physicians and that 
these physicians, by reason of their isolation and 
preoccupation with institutional duties, have not 
come into such active relations with their pro- 
fession as their more fortunate brothers in gen- 
eral practice, — all of these features have made the 
asylum system rather foreign country to the med- 
ical profession. I feel that I have been abroad 
and should tell you some of the matters observed 
in my travels. 

In the first place, there are between 26,000 and 
27,000 insane in the State's public and private 
asylums. These institutions tiow number 39. 
The annual increase in the number of the insane 
under State care is between 700 and 900, almost 
enough to suggest the construction of a new hos- 
pital each year. Every asylum is greatly over- 
crowded. The movement of population is rather 
rapid, about 6,000, in rough figures, being admit- 
ted to the hospitals yearly, and 5,000 discharged. 
The Lunacy Commission, consisting of one med- 
ical inan, one lawyer and one layman, have the 
entire supervision of all of these institutions, as 
well as the direction of the expenditure of some 
$5,000,000 yearly. I would say here — to forestall 
commentaries — that no member of the Lunacy 
Commission ever saw this money or handled it. 
It remains in the State Treasury until disbursed 
by the Comptroller, upon estimates made by the 
various hospitals subject to the approval of the 
Lunacy Commission. 

The chief duties of the Lunacy Commission are 
to visit all of the 39 ptiblic and private hospitals 
twice yearly, or oftener if necessary, to examine 
into their needs in the way of improvements, re- 
pairs, etc., to look over and revise the thousands 
of items of proposed expenditures in the esti- 
mates, to prepare plans for new construction, and 
to look to the welfare of the patients. In addi- 
tion to this, the medical commissioner must see 
and examine all of the new patients admitted 
each year. With such large administrative du- 
ties, you may be sure that in the work of the 
Commission inedical questions, as a rule, receive 

I Read before the Medical Association of Greater New York, 
January, 1905. 



734 



PETERSON: NEW YORK AND THE INSANE. 



[Medical News 



but small attention, and then only when forced 
upon the Commission by the one medical mem- 
ber. The innunierable hours of joint deliberation 
b\- the Lunacy Commission are devoted almost 
wholly to matters economic, mercantile and ad- 
ministrative. 

" The time ha? come." the wah'us said, 
" To talk of many things : 

Of shoes — and ships — and sealing wa.x — 

Of cabbages — and Kings — 

.\nd wh\' the sea is boiling hot — 

.\nd whether pigs have wings." 

I laving accomplished what I could in a med- 
ical way in the service, I was very glad to give 
up these arduous duties three years before the 
expiration of my term of office, in order to de- 
vote myself to more congenial, as well as more 
lucrative work. But my experience as a commis- 
sioner made me familiar with the nature of the 
work required of a superintendent of a hospital, 
which was exactly paralleled by mine. It is not 
the fault of a medical man who becoines a hospi- 
tal superintendent that his labors should tend to 
become more and more administrative, and less 
and less professional. It is the fault of the sys- 
tem, and the physician who undertakes this work 
sinipl}' falls a victim to the institutional Jugger- 
naut. The asylums are large aggregations of 
people, sometimes 3,000 or 4,000, and each ag- 
gregation presents the multiplicity of detail that 
may be observed in any village of like size. The 
medical superintendent is the Mayor of the town 
and has to do with its commerce, its agriculture, 
its bookkeeping, its sanitation, its water-supply, 
lighting, heating, road-making, street-cleaning, 
laundry-work, as well as the feeding, clothing and 
care of all the citizens. He has under him effi- 
cient aids in the persons of steward, farmer, a 
corps of physicians, and a great staf¥ of other 
em]5loyccs. The assisting physicians take the 
superintendent. as their model, and while they are 
brought more closely into contact with the pa- 
tients and the medical work, the system is ])rone 
tu make them also more and more administrative 
officers, and less and less medical in their tenden- 
cies. Having once been an assistant physician 
for some years in a large a.sylum I have a fellow- 
feeling for these young men, who are often iso- 
lated from professional life by the distance of the 
hospitals from medical centers. They find them- 
selves confronted with innumerable duties of a 
non-medical character. They have ])laced before 
them an enormous mass of medical material, but 
they find the problems of psychiatry most ab- 
stru.se and difficult. They fall into a dull and 
dispiriting routine, which is only enlivened by the 
certainty of the cjuarterly salary. Many an eager 
medical mind, many an ambitious spirit, has been 
crushed by these conditions, 

'Hiese facts arc true of a hundred asylums in 
this country, and of a hundred or more in Clrcat 
r.ritain. Only the other day a Lancet leader 
dealt earnestly with this subject in coinicction 
with the London Countv asvlums. 



But I want to say on behalf of New York, that 
her efforts to change this state of affairs have 
placed her in the lead of all the American and 
British communities. There are no better public 
hospitals for the insane than ours, and there are 
no others where at the present time more purely 
scientific and medical work is being done. 

To Dr. Carlos F. Macdonald, one of my pred- 
ecessors in the office of Lunacy Commissioner, 
the credit is due of liaving established the first 
central laboratory in this country for the study 
of psychiatric problems. While there have been 
changes in the persomiel of this laboratory, ex- 
cellent work has been done in it since its first 
inception. During the past three years, under 
the direction of Dr. Adolf Meyer, a great deal 
of attention has been paid to the very matter just 
referred to, of stimulating new medical interest 
among the one hundred and thirty physicians 
constituting the staffs of the fourteen State hos- 
pitals. This central Pathological Institute occu- 
pies a building on \\"ard"s Island adjacent to one 
of the largest of the hospitals there. There" are 
some 4,000 patients on the Island. In addition 
to the Director, there is a staff' of workers in 
pathology, chemistry, psychology, clinical psy- 
chiatry and the like. \\'hile research work is an 
im])ortant function of the Institute, the instruc- 
" tion of the physicians in the State hospitals was 
felt to be of almost equal consequence. During 
the first year of Dr. Sleyer's incumbency all of 
the superintendents of the fourteen State hos- 
pitals gathered at Ward's Island for a brief 
course of lectures and demonstrations which 
should serve as an index of the character of the 
medical and scientific work to be carried out in 
each hospital. During the same year, 65 of the 
assistant physicians, from all parts of the State, 
were sent to the Institute for a longer course of 
instruction in clinical methods, and in neuro- 
pathology. Subsequently 16 physicians from 
various hospitals took three-months' courses at 
the Institute, while 25 others took shorter 
courses. In addition to this. Dr. Meyer and his 
assistants have spent some time at each asylum, 
working over clinical and pathological material 
with the staff. Particular stress has been laid 
uix)n the most careful study of the clinical side 
of all cases admitted. In my time of asyhnn 
service, histories appeared to be kept chietly as 
evidence of insanity, to be used in case of habeas 
cor])us ])roceedings. The elaborate histories now 
taken not only ]5resent a clear picture of the 
mental condition of the patients, but record so 
completely every physical abnormality that they 
have already become a treasure-house of import- 
ant data for reference. It is safe to say that there 
are over 10,000 histories of ])atients in the books 
better recorded than any ever before init down in 
asylum annals. The accunnilation of such ma- 
terial nnist become of incalcnlable value to in- 
vestigators in jisychiatry; but quite as important 
is the fact that the very work of their preparation 
is an education to the young men performing the 



April 22, 1905] 



PETERSON: NEW YORK AND THE INSANE. 



735 



services, stimulating their understanding, improv- 
ing their powers of observation, and sharpening 
tiieir scientific judgment. It makes them better 
[jhysicians. and in so doing directly profits the 
patients under their care, who must inevitably 
reap the benefits of better diagnosis and more 
expert treatment. 

The practice of having staff meetings once or 
twice weekly, for the discussion of conditions of 
patients and for' the presentation of new and in- 
teresting data in the domain of medicine, has 
become general. Each hospital has in effect its 
own medical society. The State has been liberal 
in allowance for medical books and scientific 
periodicals in all languages, so that a well- 
equipped working medical library exists in each 
institution. Every hospital desiring it. has been 
thoroughly fitted out with its own clinicopatho- 
logical laboratory and accessories with all sorts of 
instruments of precision, with fine operating- 
rooms, X-ray apparatus, electric machines, hydro- 
therapeutic apartments, and the like. Nothing 
has been spared to make each institution equal 
in facilities and appliances to any general hos- 
pital. Where asylums are located sufficiently 
near to large towns or cities, consulting boards 
of medical men, active in various specialties, have 
been secured in order to bring the members of 
the staff's into relation with all lines of medical 
])rogress. These boards of consultants have not 
been merely honorary associates in the work, but 
have proved singularly interested and efficient 
and often enthusiastic. The hospitals have been 
thrown open to recent graduates, who should 
take positions therein similar to those of internes 
in general hospitals. \\'ith their large population 
and laboratory facilities, these institutions offer 
great opportunities to ambitious young men un- 
able to secure the more coveted positions in gen- 
eral hospitals. The result of all this has been to 
make each asylum a nucleus for a large amount 
of genuine clinicopathological work, despite the 
difficulties that formerly beset the scientific path 
of the assistant physician, and in time the effects 
will become more and more apparent. I firmly 
believe that as time goes on. the superintendent 
of a large asylum in this State will be first of all 
a medical and scientific man. and only second- 
arily an administrative officer. He will find 
means to supervise the machinery of his hospital 
through efficient heads in the various departments 
under his control, without sacrificing his profes- 
sional ideals to matters wholly subsidiary. 

The asylums of New York were among the 
first institutions for the insane in this country to 
establish training schools for nurses. This was 
begun twenty years ago at Buffalo, and since 
then every hospital has had its training school in 
which instruction in all departments of nursing 
is given as in general hospitals. IMany of their 
graduates are now doing general nursing in all 
parts of the State, though, of course, the majority 
remain in the hospitals. Considerably over a 
thousand nurses have been graduated. 



There is a woman physician upon the staff of 
each of the State hospitals, as well as a salaried 
dentist and ophthalmologist. 

Patients are always sent for by the State 
hospitals when the request is made, nurses of the 
proper sex. and often a doctor too being dele- 
gated for this purpose. There is an ambulance 
service at the foot of East One Hundred and 
Sixteenth Street, which might be more used if 
the physicians of New York were more familiar 
with its existence. We have the habit of sending 
patients to Bellevue for examination, whence the\' 
are transferred to various asylums and retreats. 
But this is not necessary. The commitment pa- 
pers may be made out by any two exami